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. Assist the guest to the floor and begin mouth-to-mouth resuscitation. B. Perform the Heimlich maneuver on the guest. C. Observe the guest before taking further action. D. Slap the guest on the back several times.

Correct Answer is B

Explanation

Choice A rationale
Assisting the guest to the floor and beginning mouth-to-mouth resuscitation is not the appropriate initial response. The guest’s symptoms indicate choking, and the Heimlich maneuver is the recommended first aid response.
Choice B rationale

The Heimlich maneuver is the correct response when someone is choking. The guest’s symptoms of a weak cough, inability to speak, and grasping the throat are classic signs of choking.
Choice C rationale
Observing the guest before taking further action is not appropriate in this situation. Immediate action is required to clear the guest’s airway.
Choice D rationale
Slapping the guest on the back is not the recommended response for choking in adults. It can potentially cause the object to become more deeply lodged in the throat.

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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

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