The practical nurse (PN) heard adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour. Which action should the PN take next?

Report the findings to the charge nurse.

Review the last balance of intake and output.

Slow the DSW infusion rate to 50 ml/hour.

Document the findings and monitor the client.

Answer and Explanation

The Correct Answer is A

The practical nurse (PN) who hears adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour should report the findings to the charge nurse.

Adventitious breath sounds can be indicative of respiratory problems such as fluid accumulation or infection in the lungs. In this case, it is important for the PN to report the findings to the charge nurse to ensure appropriate action is taken to assess and manage the client's respiratory status.

incorrect:

B- Reviewing the last balance of intake and output is important for overall assessment but may not directly address the concern of adventitious breath sounds. It can provide additional information about the client's fluid balance, but it is not the next immediate action in response to the abnormal lung sounds.

C- Slowing the DSW infusion rate to 50 mL/hour is not the most appropriate action to take based solely on the presence of adventitious breath sounds. The abnormal lung sounds may be an indication of an underlying respiratory issue that needs further evaluation and intervention.

Adjusting the infusion rate without a comprehensive assessment and appropriate medical orders could potentially overlook the underlying cause.

D- Documenting the findings and monitoring the client is necessary, but it should not be the sole action taken. Reporting the findings to the charge nurse is crucial to ensure prompt assessment and appropriate intervention.

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Free Nursing Study Resources

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

Explanation

Minimize the number of refined grains in the diet: Refined grains, such as white bread, white rice, and pasta, have had their bran and germ removed, resulting in a loss of fiber and nutrients. Including more whole grains in the diet, such as whole wheat bread, brown rice, and whole grain pasta, can help maintain stable blood sugar levels and reduce the risk of type 2 diabetes.
Eliminate sugary beverages and juices from the diet: Sugary beverages, including soda, fruit juices, and sweetened teas, can contribute to weight gain and an increased risk of type 2 diabetes. Encouraging the client to choose water, unsweetened tea, or other sugar-free beverages can help reduce the intake of added sugars.
Increase the amount of dietary fiber: Fiber-rich foods, such as fruits, vegetables, whole grains, legumes, and nuts, can help regulate blood sugar levels and improve insulin sensitivity. Encouraging the client to include these foods in their diet can be beneficial in reducing the risk of type 2 diabetes.

Incorrect:

D- Double the usual amount of protein in the diet: While protein is an essential nutrient, doubling the usual amount of protein in the diet may not be necessary or appropriate for everyone. It is important to follow individualized dietary recommendations and consult with a healthcare provider or registered dietitian for specific protein needs.

E- Only select food items with no fat: It is not necessary or advisable to eliminate all fat from the diet. Healthy fats, such as those found in avocados, nuts, seeds, and olive oil, are important for overall health. Choosing foods with healthier fats and moderating intake of saturated and trans fats is a more balanced approach to nutrition.

F- Take a cinnamon supplement: While cinnamon has been studied for its potential effects on blood sugar control, it is not a proven or recommended treatment for reducing the risk of type 2 diabetes. It's important to focus on overall dietary patterns and lifestyle factors rather than relying solely on supplements

A. "Are you planning to obey the voices?" B. "Have you taken any hallucinogens?" C. "When did these voices begin?" D. "Do you believe the voices are real?"

Correct Answer is A

Explanation

A. "Are you planning to obey the voices?" – This question is crucial as it assesses the immediate risk of harm to the client or others. Determining if the client intends to follow commands from hallucinations provides insight into potential danger, ensuring safety is prioritized.

B. "Have you taken any hallucinogens?" – While drug use can contribute to hallucinations, asking about substance use is less urgent than assessing potential harm from the voices. Immediate safety takes precedence over exploring potential causes at this stage.

C. "When did these voices begin?" – Knowing when the symptoms started is relevant for understanding the history of the hallucinations but is secondary to determining if the client intends to act on any commands from the voices, as safety is the first priority.

D. "Do you believe the voices are real?" – This question helps assess the client’s insight into the hallucinations but is not as critical as assessing the immediate risk of harm by determining if the client plans to follow any commands from the voices.

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The practical nurse (PN) heard adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour. Which action should the PN take next?

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Naxlex Comprehensive Predictor Exams

Discussed the DASH diet with the client and gave examples of appropriate portion sizes. Review H and P, nurse's note, and laboratory results. What other nutritional recommendations would be helpful for this client in reducing the risk for type 2 diabetes? Select all that apply.

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

Explanation

A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

Correct Answer is A

Explanation

The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility:

A client who had orthopedic surgery three days ago verbalizes difficulty in sleeping. Which initial intervention is best for the practical nurse (PN) to implement?

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The practical nurse (PN) is preparing for shift change. Which task has the highest priority and should be completed first?

56. The practical nurse (PN) is caring for a client who has a tracheostomy tube. After donning sterile gloves, in which sequence should the PN should implement these interventions? (Arrange from the first action on top to last on the bottom.)

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