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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:

Telling the patient to “try to go as long as possible before you press the button” is not advisable. PCA devices are designed to allow patients to manage their pain effectively by administering medication as soon as they begin to feel discomfort. Delaying the use of the PCA can lead to uncontrolled pain, which can be more difficult to manage later.

Choice B reason:

“Instruct your family or visitors to press the button for you when you are sleeping” is incorrect and potentially dangerous. Only the patient should press the PCA button to ensure that they are receiving the medication when they actually need it. Allowing others to press the button can lead to overmedication and serious side effects.

Choice C reason:

“Push the button every 15 minutes whether you feel pain at that time or not” is also incorrect. PCA devices are intended to be used on an as-needed basis. Pressing the button at regular intervals without experiencing pain can result in unnecessary medication administration and potential overdose.

Choice D reason:

“Push the button when you begin to feel pain, instead of waiting until the pain becomes worse” is the correct instruction. This approach helps to manage pain more effectively by preventing it from becoming severe. Early intervention with pain management can lead to better overall outcomes and patient comfort.

A. Ask the client their date of birth and confirm it with the chart and name of surgery. B. Check the client’s medical record number and surgical consent form. C. Check the client’s armband and ask their name, date of birth, and site of surgery. D. Ask the client their name and social security number.

Correct Answer is C

Explanation

Choice A reason: Asking the client their date of birth and confirming it with the chart and name of surgery is a good practice, but it is not the most comprehensive method. This approach verifies only one identifier and does not ensure the correct surgical site.

Choice B reason: Checking the client’s medical record number and surgical consent form is important, but it does not involve direct interaction with the client. This method verifies the documentation but does not confirm the client’s identity through personal verification.

Choice C reason: Checking the client’s armband and asking their name, date of birth, and site of surgery is the best method. This approach uses multiple identifiers and involves direct interaction with the client, ensuring accurate identification and confirmation of the correct surgical site. The use of multiple identifiers reduces the risk of errors and enhances patient safety.

Choice D reason: Asking the client their name and social security number is another method of identification, but it is not as commonly used in clinical settings due to privacy concerns. Additionally, it does not confirm the surgical site.

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The nurse is assessing the client and notes fine crackles throughout the lungs bilaterally. This assessment finding is often associated with:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What information would be important for the nurse to reinforce when teaching a pre-operative client about the correct use of the patient-controlled analgesia (PCA) device to achieve the best outcome?

Correct Answer is D

Explanation

Which is the best method for the nurse to correctly identify a client prior to surgery?

Correct Answer is C

Explanation

The nurse recognizes that the client is manifesting early signs of hypoxia with findings of:

An older adult client with chronic respiratory disease tells the nurse it is unnecessary to receive the pneumococcal pneumonia vaccine because the influenza vaccine was just received two months ago. Which response by the nurse is most appropriate?

The nurse is performing a physical assessment on the respiratory system. Although the client is currently confined to bed, they have the strength and ability to move and reposition themselves. The nurse instructs the client to assume which position for the assessment?

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The client diagnosed with pneumonia develops pleuritic chest pain. Which nursing action should the nurse implement at this time?

The nurse has applied a client problem of ineffective gas exchange for a client diagnosed with chronic bronchitis. Which intervention would the nurse include in the plan of care?

The nurse must administer 1600 mL of total parenteral nutrition (TPN) over 24 hours. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest tenth, do not use trailing zeros, use a leading zero if it applies)

The nurse is caring for a client recently diagnosed with emphysema. What information, regarding health maintenance, would the nurse include in teaching sessions? (SELECT ALL THAT APPLY)