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 C
Explanation
An Incentive Spirometer is a device that helps patients take deep breaths and improve their lung function. It encourages patients to take deep breaths and to hold them for a few seconds. The device also helps to monitor and measure lung volume. By using an incentive spirometer, MA can expand her lung volume as much as possible and allow for proper oxygen blood exchange within the alveoli. This is an important technique to help prevent pneumonia and other respiratory complications.
The other options mentioned, 4L of oxygen via Nasal Cannula, Fluter Valve, and Abdominal Binder, are not appropriate devices to help MA achieve proper breathing techniques and expand lung volume. 4L of oxygen via Nasal Cannula is used to provide supplemental oxygen to patients who have difficulty breathing. Fluter Valve is a handheld device used for airway clearance in patients with chronic obstructive pulmonary disease (COPD) or cystic fibrosis. An abdominal binder is a wrap that is placed around the abdomen to support the abdominal muscles and help reduce pain after surgery or injury. These devices do not help improve lung function and are not appropriate for MA's condition.
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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