The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

Stridor.

Pleural rub.

Wheezing.

Crackles.

Answer and Explanation

The Correct Answer is D

D. The short, rattling, high-pitched sounds heard in the lower lobes of the client with pneumonia are indicative of crackles. Crackles are abnormal respiratory sounds that occur when air moves through fluid or mucus in the small airways or alveoli.

A. Stridor refers to a high-pitched, wheezing sound that occurs during inspiration or expiration and is typically associated with upper airway obstruction, such as in conditions like croup or foreign body aspiration.

B. Pleural rub refers to a grating or rubbing sound heard on auscultation that occurs when inflamed pleural surfaces rub against each other during respiration. It is commonly heard in conditions such as pleurisy or pleural effusion.

C. Wheezing refers to a high-pitched, musical sound heard during expiration that is typically associated with narrowing or obstruction of the airways, as seen in conditions like asthma or chronic obstructive pulmonary disease (COPD).

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Correct Answer is C

Explanation

Restarting the IV line first ensures that the client has immediate access to intravenous fluids and medications, which is critical for maintaining hydration and treatment continuity. This is especially important if the client is receiving antibiotics or other medications that need to be administered continuously or urgently.

Following the IV line, performing tracheostomy care ensures that the airway is maintained and free from obstructions. This is essential, especially in clients with compromised respiratory function. By addressing the airway next, the nurse ensures that the client can breathe effectively and is stable.

Changing the coccyx dressing is important for wound management, especially with an infected wound. Performing this last minimizes the risk of contaminating the sterile field or the dressing while the nurse is managing other tasks. This also reduces the number of times the nurse enters and exits the room, adhering to contact isolation protocols.

A. Provide comfort measures such as topical warm application and tactile massage. B. Implement a 24-hour schedule of routine administration of prescribed analgesic. C. Assist the client to ambulate as much as possible during waking hours. D. Encourage increased fluid intake and measure urinary output every 8 hours. E. Determine client's subjective-measure of pain using a numerical pain scale.

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

Explanation

A. Provide comfort measures such as topical warm application and tactile massage. Comfort measures can help alleviate chronic pain symptoms and provide relief to the client.

B. Implement a 24-hour schedule of routine administration of prescribed analgesic. Consistent administration of prescribed analgesics helps maintain pain control and manage chronic pain effectively.

E. Determine the client's subjective measure of pain using a numerical pain scale. Assessing the client's pain using a numerical pain scale allows for quantification of pain intensity, which helps guide pain management interventions and evaluate effectiveness.

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The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

Correct Answer is C

Explanation

The nurse is reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in the client's plan of care? Select all that apply.

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

Explanation

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