While assessing breath sounds, a nurse hears crackles. What causes these lung sounds?

Moisture in air passages

Narrowed small air passages

Normal air passing through the airways

Narrowing of the upper airway

Answer and Explanation

The Correct Answer is A

The correct answer is choice A, moisture in air passages. Crackles, also known as rales, are abnormal lung sounds that can indicate a buildup of fluid in the lungs. The moisture in the air passages causes the sound of air moving through fluid or mucus, leading to a crackling sound. Crackles can be heard in conditions such as pneumonia, heart failure, and pulmonary fibrosis.

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Correct Answer is D

Explanation

A. Apply restraints to the hands or wrists to keep the patient in bed:Restraints should only be used when absolutely necessary and as a last resort, and the client in this scenario is oriented and can follow instructions. Restraints can also increase the risk of injury, agitation, and further falls.

B. Place a belt restraint on the client when they are sitting in a chair:Belt restraints restrict movement and should only be used when other measures are insufficient to protect the client. Since the client is oriented and can follow directions, this intervention is not warranted and could cause harm.

C. Keep the bed in the lowest position with all four side rails up:
Incorrect. Raising all four side rails is considered a form of restraint and can increase the risk of injury. Clients may attempt to climb over the side rails, leading to falls. Keeping the bed in a low position is appropriate, but using all four side rails is not.

D. Educate the patient on using the call light and make sure the call light is within reach.This is the most appropriate action as the client is oriented and can follow directions. Educating the patient on how to use the call light and ensuring it is easily accessible encourages them to ask for assistance when needed, reducing the risk of falls.

A. Complete the procedure and then report what happened. B. Apologize to the client and continue on with the procedure. C. Nothing because the client is on antibiotics. D. Gather new sterile supplies and start the procedure over.

Correct Answer is D

Explanation

The correct answer is choice D. Gather new sterile supplies and start the procedure over.

In order to maintain surgical asepsis during a urinary catheterization procedure, the nurse must ensure that all equipment used is sterile and that there is no contamination of the equipment during the procedure. If the catheter is contaminated, the nurse should stop the procedure, gather new sterile supplies, and start the procedure over to prevent the introduction of bacteria into the urinary tract. Reporting the incident and apologizing to the client are important, but not the first priority in maintaining surgical asepsis. The fact that the client is on antibiotics does not change the need for sterile technique during the procedure.

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While assessing breath sounds, a nurse hears crackles. What causes these lung sounds?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Correct Answer is D

Explanation

A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?

Correct Answer is D

Explanation

Which of the following scenarios would represent proper delegation as applies to delegating care to the right professional?

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