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 B

Explanation

Choice A rationale
Turning the torso at the waist when reaching for objects can actually increase the risk of back injury. It’s important to keep the back straight and bend at the knees when lifting or reaching for objects.
Choice B rationale

Using ice packs intermittently for 48 hours is a common recommendation for acute lower back pain. Ice can help reduce inflammation and numb the area, providing relief. It’s important to use the ice packs intermittently, not continuously, to avoid frostbite.
Choice C rationale
Using 10 lb arm weights to start strengthening the back muscles is not recommended for someone with acute lower back pain. Heavy lifting can exacerbate the pain and potentially cause further injury. It’s better to start with gentle, low-impact exercises and gradually increase intensity as the back heals.
Choice D rationale
Staying in bed except for toileting during the first 24 hours is not typically recommended for acute lower back pain. While rest is important, prolonged bed rest can actually lead to muscle stiffness and increased pain. It’s generally recommended to stay as active as possible without exacerbating the pain.

A. Request a prescription for the insertion of an indwelling urinary catheter. B. Apply a moisture barrier ointment to the skin. C. Clean the skin and perineum with hot water after each episode of incontinence. D. Check the client’s skin every 8 hours for signs of breakdown. E. Check the client’s skin every 8 hours for signs of breakdown.

Correct Answer is B

Explanation

Choice A rationale
Requesting a prescription for the insertion of an indwelling urinary catheter is not the best option to prevent skin breakdown in a client with urinary incontinence. Catheters can increase the risk of urinary tract infections and should be used as a last resort.
Choice B rationale

Applying a moisture barrier ointment to the skin can help protect the skin from the damaging effects of urine. This can help prevent skin breakdown and is a common practice in the care of clients with urinary incontinence.
Choice C rationale
Cleaning the skin and perineum with hot water after each episode of incontinence is not recommended. Hot water can dry out the skin and cause irritation. It’s better to use warm water and a gentle cleanser.
Choice D rationale
Checking the client’s skin every 8 hours for signs of breakdown is important, but it’s not the only action the nurse should take. The nurse should also take proactive measures to protect the skin, such as applying a moisture barrier ointment.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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