Author Question: The nurse recognizes that which of the following clients should be thoroughly assessed for their ... (Read 31 times)

elizabeth18 · **on:** Jul 23, 2018

The nurse recognizes that which of the following clients should be thoroughly assessed for their ability to be safely placed in the supine position?

1. An 18-year-old who suffered a fractured elbow playing football
2. A 20-year-old hospitalized with abdominal pain to rule out an appendicitis
3. A 74-year-old client who requires 3 L of continuous oxygen via nasal cannula
4. A 37-year-old reporting complaints of vaginal bleeding between menstrual peri-ods

Question 2

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.

Zack0mack0101@yahoo.com · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 3
Clients who are experiencing any degree of respiratory distress will not find this position com-fortable and should not be placed in this position because it will make breathing even more dif-ficult. If the client becomes short of breath easily, raise the head of the bed. The other clients may not prefer this position, but there is no medical reason for avoiding it.

Answer to Question 2

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 the end of inspiration and usually not cleared with coughing; medium crackles are lower, more moist sounds heard during the middle of inspiration and not cleared with coughing; and coarse crackles are loud, bubbly sounds heard during inspiration and not cleared with coughing. Reassessing and asking the client to cough provide the clearest understanding of this type of breath sound. Musical sounds are representative of wheezes, not crackles.