Author Question: The shift report states that a client has crackles in both lungs. Which statement by the nurse ... (Read 54 times)

storky111 · **on:** Jul 23, 2018

The shift report states that a client has crackles in both lungs. Which statement by the nurse preparing to assess the client best reflects a thorough understanding of the recorded assessment finding?

1. I wonder if they are fine, medium or coarse.
2. I'll listen again and reassess after I ask him to cough.
3. That musical sound is hard to miss as they breathe out.
4. I wish it was recorded where in the lungs they were heard.

Question 2

A male nursing student is assigned to change the abdominal dressing of a 74-year-old female. The clinical nursing instructor asks that a female nurse assist him with the procedure. The primary reason for this decision is:

1. It diverts the client's attention during the assessment and procedure
2. It provides a third party to ensure proper conduct of all involved
3. It facilitates a comfortable, efficient environment for the client
4. It assists with the wound assessment and changing of the abdominal dressing

briezy · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 2
Crackles are most common in dependent lobes: right and left lung bases, Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during end of inspiration, usually not cleared with coughing. Medium crackles are lower, more moist sounds heard during middle of inspiration; not cleared with coughing and coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing. Reassessing and asking the client to cough provides the clearest understanding of this type of breath sounds. Musical sounds are representative of wheezes not crackles.

Answer to Question 2

ANS: 2
When the client and nurse are of opposite gender, it helps to have a third person of the client's gender in the room. The presence of a third person ensures the client that the examiner will be-have ethically. This person is also a witness to the examiner's conduct as well as the client's. While a second health care provider may be useful during the assessment and procedure, that is not the primary reason for their presence.