Author Question: While performing an assessment, the nurse auscultates a coarse low-pitched sonorous rattling in the ... (Read 77 times)

mckennatimberlake · **on:** Jun 25, 2018

While performing an assessment, the nurse auscultates a coarse low-pitched sonorous rattling in the left lower lobe. Based on the presence of this adventitious lung sound, which action should the nurse take next?

a. Instruct the patient to turn, cough, and deep-breathe.
b. Administer the diuretic as ordered.
c. Administer the bronchodilator as ordered.
d. Instruct the patient to blow into the incen-tive spirometer.

Question 2

The student nurse is ambulating with a blind patient. Which technique(s) indicate(s) that the student nurse requires further instruction? (Select all that apply.)

a. Holding the patient's dominant arm
b. Instructing the patient to put both hands on his shoulders
c. Allowing the patient to hold the nurse's arm
d. Holding the patient's hand
e. Walking just behind the patient

tmlewis4706 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

A
Low-pitched sonorous wheezing sounds are caused by secretions accumulating in the larger air-ways. Patients with pneumonia or chronic bronchitis often present with low wheezes (rhonchi). Coughing may help to partially clear the secretions. High-pitched wheezes result from narrowing of air passages, and a bronchodilator would be beneficial. Crackles are produced by air passing through moisture in the smaller airways; diuretics are beneficial. Proper technique for the incen-tive spirometer directs the patient to inhale through the mouthpiece, as if the patient is pretending to drink a thick milk shake.

Answer to Question 2

A, B, D, E
The safest and most effective technique when ambulating a blind patient involves allowing the patient to hold the nurse's arm, as the patient follows. The nurse should not hold the patient's arm, instruct the patient to place his hands on the nurse's shoulders, or hold the patient's hand, so these actions would require additional teaching.