Author Question: The nurse hears rhonchi when auscultating a client's lungs. Which nursing intervention would be ... (Read 41 times)

tnt_battle · **on:** Jul 23, 2018

The nurse hears rhonchi when auscultating a client's lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?

a. Have the client take several deep breaths.
b. Request the client take a deep breath and cough.
c. Take the client's blood pressure and apical pulse readings.
d. Count the client's respiratory rate for 1 minute.

Question 2

A patient's wife tells the nurse that she wants to be with her husband when he dies. The patient's respirations are irregular, and he is congested.

The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best?
a. Certainly, go ahead; your husband will most likely hold on until you return.
b. Your husband could live for days or a few hours; you should do whatever you are comfortable with.
c. You need to take care of yourself; go home and shower, and I'll stay at his bedside while you are gone.
d. Don't worry. Your husband is in good hands; I'll look out for him.

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

Answer to Question 1

B
Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to clear rhonchi. Taking the blood pressure and apical pulse readings and counting the respiratory rate are not effective for clearing rhonchi, and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi.

Answer to Question 2

B
The patient is exhibiting signs that typically occur days to a few hours before death. The nurse should provide information to the wife so she can make an informed decision about whether to leave her husband's bedside. The nurse should not offer false reassurance by stating that the patient will most likely be fine until the wife's return. The nurse should not offer her opinion by telling the wife that she needs to take care of herself. It is also unrealistic for the nurse to stay with the patient until his wife returns. The nurse would be minimizing the wife's concern by telling her not to worry because her husband is in good hands. The issue for the family member is not trust in the competency of the healthcare provider but rather wanting to be present with her spouse at the time of death.