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Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Lobar pneumonia

Actions to take:

Auscultate the lungs for adventitious breath sounds
Inspect the chest for lag on the affected side

Parameters to monitor

Crackles
Respiratory rate and pulse

Rationale:

Potential Condition: Lobar pneumonia

The client presents with worsening breathing difficulty, a mild fever, elevated respiratory rate, and borderline hypoxemia, which are indicative of pneumonia. The chest X-ray order supports the suspicion of a lung infection, such as lobar pneumonia.

Actions to Take:

Auscultate the lungs for adventitious breath sounds: Lobar pneumonia often produces abnormal lung sounds, such as crackles or bronchial breath sounds, over the affected lobe. This assessment helps confirm consolidation in the lung.

Inspect the chest for lag on the affected side: Chest lag may indicate reduced ventilation of the affected lobe, a hallmark of pneumonia.

Parameters to Monitor:

Crackles: A common finding in pneumonia, crackles result from the movement of air through fluid-filled alveoli. Monitoring for resolution or worsening crackles can assess treatment efficacy.

Respiratory rate and pulse: Both are essential indicators of respiratory and cardiovascular status. An increasing respiratory rate or tachycardia may signal worsening oxygenation or sepsis.

Rationale for Incorrect Options:

Other Conditions

Pleural effusion: While it can cause respiratory symptoms, pleural effusion typically presents with dullness to percussion and diminished breath sounds, not crackles or lobar consolidation.

Atelectasis: Usually presents with diminished or absent breath sounds and often resolves with deep breathing exercises or incentive spirometry.

Acute bronchitis: This condition is associated with a productive cough, wheezing, and diffuse lung involvement, not localized findings like in lobar pneumonia.

Other Actions:

Assess for tactile fremitus: Fremitus is reduced in pleural effusion or pneumothorax, but pneumonia typically increases fremitus over the affected lobe.

Assess for muffled heart sounds: This is associated with cardiac tamponade, not pneumonia.

Assess for prolonged expiration: This is more relevant in obstructive conditions like asthma or COPD.

Other Parameters to Monitor:

Loud bronchial breathing: Although it may occur, it is less specific and not always present in pneumonia.

Cyanosis: This would indicate advanced hypoxemia, which is not present in this client (oxygen saturation is 94% on room air).

Wheezing: More commonly associated with bronchospasm or asthma, not lobar pneumonia.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Palpate the radial pulses: This may not reveal irregularities or provide an accurate heart rate, especially in clients with conditions like atrial fibrillation.

B. Feel the dorsalis pedis and posterior tibialis pulses: These assess peripheral circulation, not the heart rate.

C. Use the stethoscope over the carotid artery: While it assesses blood flow in the carotid artery, it is not the best method for determining pulse rate.

D. Auscultate the apical pulse: This provides the most accurate assessment of heart rate and rhythm, especially in clients with cardiac disease.

A. Review recent serum bilirubin levels. B. Assess conjunctival sacs of lower lids for pallor. C. Observe the client's urine for dark orange color. D. Examine client's sclera for icterus.

Correct Answer is D

Explanation

A. Review recent serum bilirubin levels: This is an indirect confirmation but not part of a physical assessment.

B. Assess conjunctival sacs of lower lids for pallor: This checks for anemia, not jaundice.

C. Observe the client's urine for dark orange color: This may suggest jaundice but is not definitive or diagnostic.

D. Examine the client's sclera for icterus: Scleral icterus is the most reliable physical sign of jaundice and directly reflects elevated bilirubin levels.

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Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

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