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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Using a helmet when riding a motorcycle:
Not a typical concern or screening priority for older adults, especially at age 75. It targets younger populations involved in high-risk activities.

B. Falls and loss of hearing and visual acuity:
These are age-related risks in older adults and are routinely screened to promote safety and prevent injury.

C. Injuries from rock climbing activities:
Unlikely to be relevant for most 75-year-olds; this focuses on a younger, more active demographic.

D. Literacy and communication skills:
While important, these are not primary screening focuses in elderly populations unless there is a specific concern noted.

A. Brief Pain Inventory B. Descriptor Scale C. Numeric rating scale D. Faces Pain Scale-Revised (FPS-R)

Correct Answer is D

Explanation

A. Brief Pain Inventory:
Designed for older children or adults to assess pain over time and its impact—not ideal for a 4-year-old.

B. Descriptor Scale:
Uses words to describe pain—better suited for older children and adults.

C. Numeric rating scale:
Typically used for children 8 years and older who can understand number scales.

D. Faces Pain Scale-Revised (FPS-R):
Ideal for children ages 3+; it uses facial expressions to help young children communicate pain intensity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What are some conditions for which the nurse would normally screen a 75-year-old patient?

Correct Answer is B

Explanation

A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain?

Correct Answer is D

Explanation

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