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.

Answer and Explanation

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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Correct Answer is B

Explanation

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

A. Decrease ﬂuid intake. B. Take Tylenol for the secretions. C. Range -of-motion exercises as tolerated D. Increase ﬂuid intake.

Correct Answer is D

Explanation

Explanation: In clients with COPD, the secretions tend to be thick and sticky, which makes it difficult to cough up and clear the airway. To promote respiratory hygiene in this situation, the nurse should recommend increasing ﬂuid intake. Adequate hydration helps to thin the secretions, making them easier to expectorate. The client should aim to drink at least 8-10 glasses of water or other ﬂuids per day unless there is a medical reason not to do so.

Decreasing ﬂuid intake (option a) would make the secretions even thicker and more difficult to clear. Taking Tylenol for secretions (option b) is not a recommended intervention as Tylenol is not indicated for thinning of secretions. Range-of-motion exercises (option c) are important to prevent complications such as pneumonia, but they are not directly related to promoting respiratory hygiene in this situation.

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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

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Correct Answer is B

Explanation

A client suﬀering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and the secretions are thick and sticky. Which intervention will the nurse use to promote respiratory hygiene in this situation?

Correct Answer is D

Explanation

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