When the nurse assessing the lung fields of a patient during the morning assessment, the nurse notes a short, popping and crackling sound. What is the priority action after this assessment?
Return to do a re-assessment in 30 minutes
Inform the co-assigned nurse
Ask the patient if he needs his puffer
Instruct the patient to take a few breaths and cough
The Correct Answer is D
A. Return to do a re-assessment in 30 minutes:
Delays addressing the finding. The nurse must determine if the crackles are transient or persistent.
B. Inform the co-assigned nurse:
Not a priority action. The nurse should reassess directly before involving others.
C. Ask the patient if he needs his puffer:
Puffers are used for bronchoconstriction; crackles are usually not treated this way unless wheezing is present.
D. Instruct the patient to take a few breaths and cough:
This helps determine if the crackles are transient (e.g., atelectasis) or indicative of a more serious issue (e.g., fluid overload). If they clear, it’s likely atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "How do other people treat you?":
Not focused on the patient’s safety or suicidal ideation-may divert from the urgent concern.
B. "People often feel hopeless, but the feeling resolves within a few weeks":
Minimizes the patient’s distress and offers false reassurance.
C. "Do you own any lethal weapon?":
Important later in risk assessment, but first establish if the patient has suicidal thoughts.
D. "Are you feeling so hopeless that you feel like hurting yourself now?":
Direct, therapeutic, and necessary. It assesses current suicide risk in a nonjudgmental and supportive way.
Correct Answer is A
Explanation
A. Bell of the stethoscope:
The bell is best for hearing low-pitched sounds like certain murmurs.
B. Palpation with the nurse's palm of the hand:
Palpation can detect thrills or vibrations but cannot auscultate murmurs.
C. Electrocardiography:
ECG records electrical activity but does not assess heart sounds.
D. Diaphragm of the stethoscope:
Best for high-pitched sounds like breath or bowel sounds, not low-pitched murmurs.
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