The nurse is assessing a 1-day post-operative client and discovers fine crackles at the bases of the right lung on inspiration. What does the nurse suspect is the cause of the adventitious lung sounds in the right lung?

Asthma

Pneumothorax

Atelectasis

Emphysema

Bronchitis

Answer and Explanation

The Correct Answer is C

A. Asthma typically presents with wheezing, not fine crackles.
B. Pneumothorax usually presents with decreased or absent breath sounds rather than crackles.
C. Atelectasis, which is common after surgery, can cause fine crackles at the lung bases due to collapsed alveoli reopening during inspiration.
D. Emphysema generally results in diminished breath sounds and hyper-resonance rather than crackles.
E. Bronchitis typically produces coarse crackles or rhonchi, not fine crackles.

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Correct Answer is B

Explanation

A. Venous insufficiency typically presents with swelling and pain that worsens with prolonged standing, not with exercise.
B. Claudication is the correct term, as it describes pain due to decreased blood flow to the muscles during exercise, often relieved by rest, which matches the patient's symptoms.
C. Muscle cramps may cause pain but are usually not consistently triggered by activity and relieved by rest.
D. Deep vein thrombosis would typically present with pain, swelling, warmth, and redness rather than exercise-induced pain relieved by rest.
E. Bruit from turbulent blood flow is an audible sound over an artery and not directly related to the type of pain described.

A. Have client use the incentive spirometer every hour B. Help client dangle legs off the side of the bed C. Encourage the client to ambulate as soon as possible D. Keep the client in bed with knees elevated E. Limit the amount of fluid the client drinks

Correct Answer is B

Explanation

A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.

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The nurse is assessing a 1-day post-operative client and discovers fine crackles at the bases of the right lung on inspiration. What does the nurse suspect is the cause of the adventitious lung sounds in the right lung?

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A 67-year-old client states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes, then he is able to resume his activities. How would the nurse document this finding?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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The nurse is assessing a 1-day post-operative client and discovers fine crackles at the bases of the right lung on inspiration. What does the nurse suspect is the cause of the adventitious lung sounds in the right lung?

The nurse is percussing over the lungs of a client with pneumonia. What sound will the nurse expect to hear?

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