Upon auscultating a client’s lungs, the nurse identifies crackles in the left posterior base. What action should the nurse take?

Prepare to administer antibiotics.

Instruct the client to limit fluid intake to less than 2,000 m/day.

Initiate bedrest in semi-Fowler’s position.

Repeat the auscultation after asking the client to breathe deeply and cough.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While antibiotics are used to treat bacterial infections, crackles in the lungs can be a sign of various conditions, not just bacterial infections. Therefore, administering antibiotics is not the appropriate action based solely on the finding of crackles.
Choice B rationale

Limiting fluid intake can be beneficial for clients with certain conditions such as heart failure, but it is not the appropriate action based solely on the finding of crackles.
Choice C rationale
Initiating bedrest in semi-Fowler’s position can help improve lung expansion and ease breathing in clients with certain respiratory conditions. However, it is not the appropriate action based solely on the finding of crackles.
Choice D rationale
Crackles can sometimes be cleared by deep breathing and coughing. Repeating the auscultation after asking the client to breathe deeply and cough can help the nurse determine if the crackles are transient (cleared by coughing) or persistent.

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Correct Answer is C

Explanation

Choice A rationale

Mycoplasmal pneumonia, also known as walking pneumonia, is typically not an airborne disease. Standard precautions, including the use of a surgical mask, are usually sufficient when caring for these patients.
Choice B rationale
Scarlet fever is caused by group A Streptococcus bacteria, which are spread through respiratory droplets. Standard precautions, including the use of a surgical mask, are usually sufficient when caring for these patients.
Choice C rationale
Tuberculosis is an airborne disease. Healthcare providers should wear an N95 respirator when caring for a client with tuberculosis to protect themselves from inhaling the bacteria.
Therefore, Choice C is the correct answer.
Choice D rationale
Scabies is caused by a mite and is spread through direct skin-to-skin contact. It is not an airborne disease, so an N95 respirator is not necessary when caring for a client with scabies.

A. Check that the client’s restraints are secured with a half-bow knot. B. Request that the provider prescribe the restraints as PRN. C. Ensure that the client’s wrists are padded. D. Loosen the restraints once every 4 hr. E. Document client care every 15 min.

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

Explanation

Choice A rationale
Checking that the client’s restraints are secured with a half-bow knot is a good practice. This type of knot is secure but can be easily untied, which is important for quick removal of the restraints if necessary.
Choice B rationale
Requesting that the provider prescribe the restraints as PRN is not a good practice. Restraints should only be used as a last resort and must be ordered by a healthcare provider. The order must specify the reason for the restraints and the duration of use.
Choice C rationale
Ensuring that the client’s wrists are padded is a good practice. Padding helps to prevent skin breakdown and nerve damage.
Choice D rationale
Loosening the restraints once every 4 hours is not a good practice. Restraints should be removed or loosened every 2 hours to allow for skin care and assessment, range of motion exercises, and to check for signs of injury.
Choice E rationale

Documenting client care every 15 minutes is a good practice. This includes documenting the client’s behavior, the type and location of restraints, the frequency of care (at least every 2 hours), and the client’s response to the restraints.

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Upon auscultating a client’s lungs, the nurse identifies crackles in the left posterior base. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients on an infectious disease unit. When should the nurse wear an N95 respirator mask?

Correct Answer is C

Explanation

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

Explanation

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