The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the
Auscultate bilateral breath sounds.
Obtain blood culture for tuberculosis.
Request pulmonary function studies.
Document the findings.
The Correct Answer is A
The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can affect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.
While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.
Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.
Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.
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Related Questions
Correct Answer is B
Explanation
Chest tubes are inserted to drain fluid, blood, or air from the pleural space, which is the space between the lung and the chest wall. It is important to ensure that the chest tube is secured properly and the drainage system is functioning properly before the patient is ambulated. Additionally, the patient may experience discomfort or pain during ambulation, so it is important to assess and manage the patient's pain before and after ambulation.
Option A is not appropriate because it disregards the patient's need to use the restroom and may make the patient feel helpless or dependent.
Option c is not appropriate because it does not address the patient's request for assistance and may make the patient feel neglected or uncared for.
Option d is not appropriate because it is a directive statement that does not take into account the patient's autonomy or individual needs. It is important to involve the patient in the decision-making process and provide appropriate care based on their individual needs and preferences.
Correct Answer is C
Explanation
c. Sip the water he is allowed to have slowly to make it last throughout the day.
Option a is not recommended as hard candies may contain sugar and artificial sweeteners, which can be harmful to the patient's health.
Option b is not recommended because caffeinated tea has diuretic properties that can increase urine output, leading to further dehydration.
Option d is not recommended as Gatorade is a sports drink that contains high amounts of sugar and electrolytes, which can lead to fluid overload and imbalances.
Sipping the water slowly can help the patient moisten his mouth without going over his fluid restriction. This approach can also help him pace his fluid intake throughout the day, which can be beneficial for maintaining proper hydration levels and managing fluid overload.
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