A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?
Delayed gastric emptying
Pulmonary edema
An upper respiratory infection
Atelectasis
The Correct Answer is D
A. Delayed gastric emptying is not associated with decreased breath sounds in the lower lobes of the lungs. It is more commonly associated with gastrointestinal symptoms such as bloating and nausea.
B. While pulmonary edema can cause respiratory symptoms, such as crackles and wheezes, decreased breath sounds in the lower lobes are not typically indicative of pulmonary edema. Pulmonary edema is more commonly associated with fluid accumulation in the lungs, leading to crackles and other signs of fluid overload.
C. An upper respiratory infection primarily affects the upper airways, such as the nose and throat, and typically presents with symptoms such as nasal congestion, sore throat, and cough. It is not typically associated with decreased breath sounds in the lower lobes of the lungs.
D. Atelectasis refers to the collapse or closure of a part of the lung, leading to decreased air entry and breath sounds in the affected area. In a client who has been on bedrest for several days, atelectasis can occur due to reduced lung expansion and ventilation. Decreased breath sounds in the lower lobes are a common finding in atelectasis, especially when the condition affects the bases of the lungs, as gravitational forces can exacerbate the collapse of lung tissue in dependent areas. Therefore, this finding is most consistent with atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will be sure to take the albuterol before taking the cromolyn": Taking albuterol before cromolyn is the correct sequence because albuterol is a bronchodilator that helps open the airways quickly, while cromolyn is a mast cell stabilizer that helps prevent asthma symptoms. Taking albuterol first allows for better penetration of cromolyn into the airways. Therefore, this statement indicates an understanding of the appropriate sequence for using the medications.
B. "I will use both medications immediately after exercising": While it is essential to use albuterol before exercise to prevent exercise-induced bronchospasm, using cromolyn immediately after exercise is not typically indicated. Cromolyn is more effective when used prophylactically to prevent asthma attacks triggered by allergens or exercise rather than as an acute rescue medication.
C. "If my breathing begins to feel tight, I will use the cromolyn immediately": Cromolyn is not indicated for the immediate relief of acute bronchospasm. It works best when used regularly to prevent asthma symptoms rather than as a rescue medication during an asthma attack. Albuterol is the appropriate choice for immediate relief of tightness or wheezing.
D. "I will administer the medications 10 minutes apart": While it's important to space out the administration of different medications to ensure proper absorption and effectiveness, the specific timing between albuterol and cromolyn may vary based on individual instructions from the healthcare provider. Generally, it's recommended to take albuterol first, followed by cromolyn after a brief interval.
Correct Answer is B
Explanation
A. "I will tell your family of your concern so that they can be here." This option involves the family in the client's care, which is important during end-of-life situations. However, it assumes that the client's primary concern is about the family's presence rather than exploring the underlying emotions or fears the client may be experiencing. While involving the family is beneficial, it may not directly address the client's emotional needs.
B. "I wonder if you are fearful of dying alone." This response demonstrates therapeutic communication by acknowledging the client's statement and exploring the underlying feelings or concerns behind it. It shows empathy and provides an opportunity for the client to express their emotions. Fear of dying alone is a common concern for many individuals facing the end of life, and addressing this fear can help alleviate distress.
C. "We will call your family in time for them to get here." While involving the family is important, this response primarily focuses on the logistics of family arrival rather than addressing the client's emotional needs. It may not fully explore or validate the client's feelings about dying alone.
D. "I will make sure a staff member is in your room at all times." While providing support and ensuring the client's comfort is essential, this response does not directly address the client's emotional needs or explore their concerns about dying alone. It also may not be feasible to have a staff member constantly present in the room. This option may not fully address the client's underlying fears or emotions related to dying alone.
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