The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? (Select all that apply)

Auscultating lung sounds

Obtaining the client’s temperature

Assessing the strength of peripheral pulses

Obtaining information about the client’s respirations

Asking the client about a family history of any illness or disease

Answer and Explanation

Correct Answer : A,B,D

A. Auscultating lung sounds:

Auscultating lung sounds is essential to assess for any abnormal sounds such as wheezing, crackles, or diminished breath sounds, which can provide information about the extent and nature of lung congestion.

B. Obtaining the client’s temperature:

Obtaining the client's temperature is important to assess for the presence of fever, which is a common symptom associated with respiratory infections.

C. Assessing the strength of peripheral pulses:

Assessing peripheral pulses is not directly related to cold, cough, and lung congestion symptoms. This type of assessment is more relevant in cardiovascular or peripheral vascular assessments.

D. Obtaining information about the client’s respirations:

Assessing the rate, depth, and rhythm of respirations is crucial when dealing with respiratory symptoms. This information helps determine the severity and nature of the respiratory distress.

E. Asking the client about a family history of any illness or disease:

Family history is important for a comprehensive health assessment, but for the focused assessment of a cold, cough, and lung congestion, obtaining information about the current symptoms and associated factors takes precedence.

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Correct Answer is ["A","D","E"]

Explanation

A. Client reports feeling dizzy when sitting up from a supine position.

Dizziness or lightheadedness when moving from a lying down to a sitting or standing position can be indicative of orthostatic hypotension.

B. Client reports feeling palpitations when rising from a supine to a standing position.

Palpitations (feeling of rapid or irregular heartbeat) can be associated with orthostatic changes and may indicate the heart's compensatory response to low blood pressure.

C. Erythema is present on the bilateral lower extremities.

Erythema (redness of the skin) is not typically associated with orthostatic hypotension. This symptom is more likely related to skin conditions or other causes.

D. The client has a temperature of 100.4 F.

Fever (elevated body temperature) is not a direct symptom of orthostatic hypotension. Orthostatic hypotension is primarily related to changes in blood pressure upon assuming an upright position.

E. The client states, “I feel lightheaded when sitting up.”

Lightheadedness upon sitting up or standing is a common symptom of orthostatic hypotension.

A. Place the client on bed rest in supine position. B. Repeat auscultation after asking the client to breathe deeply and cough. C. Prepare to administer antibiotics. D. Instruct the client to limit fluid intake to less than 2,000 mL/day.

Correct Answer is B

Explanation

A. Place the client on bed rest in supine position:

While bed rest might be appropriate for certain respiratory conditions, it is not a specific intervention for crackles. In fact, changing the client's position, such as having them sit up, may enhance lung function and help with breathing.

B. Repeat auscultation after asking the client to breathe deeply and cough:

This is the correct action. Repeating auscultation after having the client take deep breaths and cough can provide additional information about the nature of the crackles and may help clear the airways temporarily.

C. Prepare to administer antibiotics:

Administering antibiotics would be considered if the crackles are indicative of a respiratory infection. However, determining the need for antibiotics would require a more comprehensive assessment, including diagnostic tests.

D. Instruct the client to limit fluid intake to less than 2,000 mL/day:

Limiting fluid intake is not a direct intervention for crackles. This action is typically considered in conditions like heart failure where there is a risk of fluid overload. It is not the primary intervention for addressing crackles in the lungs.

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The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

Correct Answer is B

Explanation

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