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 D
Explanation
This outcome is the most appropriate because smoking can worsen COPD and lead to further respiratory complications, while oxygen is often used to help patients with COPD breathe more easily. Smoking while wearing oxygen can be very dangerous and increases the risk of fire and explosion. Therefore, the best expected outcome is for the patient to completely avoid smoking while wearing oxygen.
Option a is not a recommended solution since vaping may also worsen COPD symptoms and there is limited evidence of its safety in people with respiratory conditions. Option b is a good outcome, but it may not be achievable in such a short time frame. Option c is not an ideal outcome as even a few cigaretes can cause harm to the respiratory system, exacerbate symptoms, and slow down the healing process.
Correct Answer is D
Explanation
Explanation: The normal range of sodium (Na+) in the blood is 135-145 mEq/L. The patient's sodium level of 121 mEq/L is below the normal range, indicating a low sodium level, which is called hyponatremia.
Hyponatremia is a common electrolyte imbalance that can be caused by a variety of factors, including excessive sweating, vomiting, diarrhea, certain medications, kidney disease, and hormonal imbalances. It can cause symptoms such as nausea, headache, confusion, seizures, and coma, and it can be a medical emergency if the sodium level drops rapidly or severely.
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