The nurse is assessing the client and notes fine crackles throughout the lungs bilaterally. This assessment finding is often associated with:
Bronchitis
A pneumothorax
Asthma
Emphysema
The Correct Answer is A
Choice A reason: Fine crackles are often associated with bronchitis, particularly chronic bronchitis. These sounds are caused by the presence of mucus in the airways, which creates a crackling noise when air passes through. Chronic bronchitis involves inflammation and increased mucus production in the bronchi, leading to these characteristic lung sounds.
Choice B reason: A pneumothorax, or collapsed lung, typically presents with absent or diminished breath sounds on the affected side rather than fine crackles. The absence of breath sounds is due to the lack of air movement in the collapsed portion of the lung. Fine crackles are not a common finding in pneumothorax.
Choice C reason: Asthma is characterized by wheezing, which is a high-pitched whistling sound caused by narrowed airways. While crackles can occasionally be heard in asthma, they are not the primary lung sound associated with this condition. Wheezing is more indicative of asthma due to bronchoconstriction and inflammation.
Choice D reason: Emphysema, a form of chronic obstructive pulmonary disease (COPD), typically presents with decreased breath sounds and prolonged expiration rather than fine crackles. The destruction of alveolar walls in emphysema leads to reduced lung sounds overall. Fine crackles are not a hallmark of emphysema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Clients on tuberculosis (TB) medications, particularly those on isoniazid, rifampin, and pyrazinamide, are at risk for hepatotoxicity. Therefore, regular monitoring of liver function tests (LFTs) is crucial to detect any liver damage early and adjust treatment as necessary.
Choice A reason:
Liver function studies are essential for clients on TB medications. Drugs like isoniazid, rifampin, and pyrazinamide can cause liver toxicity. Monitoring liver enzymes such as ALT (alanine aminotransferase) and AST (aspartate aminotransferase) helps in early detection of hepatotoxicity, allowing for timely intervention to prevent severe liver damage. Regular LFTs ensure that any adverse effects on the liver are identified and managed promptly.
Choice B reason:
White blood cells (WBCs) are not typically monitored monthly for clients on TB medications. While WBC counts can be affected by various conditions and treatments, they are not specifically indicative of the side effects of TB medications. Monitoring WBCs might be necessary if there are signs of infection or other hematologic issues, but it is not a standard monthly requirement for TB treatment.
Choice C reason:
Coagulation studies are not routinely required for clients on TB medications. These tests are more relevant for patients on anticoagulant therapy or those with bleeding disorders. TB medications do not typically affect coagulation parameters, so regular monitoring of coagulation studies is not necessary unless there is a specific clinical indication.
Choice D reason:
Red blood cells (RBCs) are also not typically monitored monthly for clients on TB medications. While anemia can occur in TB patients, it is not a direct side effect of the medications used to treat TB. Monitoring RBCs might be necessary if there are symptoms of anemia or other hematologic concerns, but it is not a standard part of monthly TB treatment monitoring.
Correct Answer is C
Explanation
Choice A reason: Placing the client on cardiac monitoring is important, especially if there are signs of cardiac involvement or if the client is at risk for arrhythmias. However, it is not the primary intervention for hypernatremia. Hypernatremia primarily affects fluid balance and neurological status.
Choice B reason: Monitoring breath sounds every 4 hours is a good practice, particularly if there is a risk of fluid overload or respiratory complications. However, it does not directly address the issue of hypernatremia. The primary concern with hypernatremia is managing fluid balance and preventing further increases in serum sodium levels.
Choice C reason: Restricting fluids to 500 mL per day is a critical intervention for managing hypernatremia. Hypernatremia often results from a deficit in free water, leading to an elevated serum sodium level. Fluid restriction helps to prevent further increases in sodium concentration and assists in gradually correcting the imbalance. This intervention directly addresses the underlying issue of hypernatremia and helps to stabilize the client’s condition.
Choice D reason: Implementing safety precautions is important, especially if the client is experiencing neurological symptoms such as confusion or agitation. While safety precautions are necessary, they are not the primary intervention for correcting hypernatremia. The focus should be on managing fluid balance and serum sodium levels.
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