Abnormal Lung Sounds
Wheezes
A nurse is caring for a client with pneumonia. During lung auscultation, the nurse hears coarse crackles in the lower lobes. Which intervention should the nurse implement first?
a) Encourage the client to cough and deep breathe
b) Notify the healthcare provider immediately
c) Administer a prescribed bronchodilator
d) Place the client in a supine position
Correct Answer:
a) Encourage the client to cough and deep breathe
Rationale:
Coarse crackles are low-pitched, bubbling, or gurgling sounds that often indicate the presence of secretions in the larger airways. In conditions like pneumonia, these secretions can sometimes be mobilized and cleared with coughing and deep breathing. This is a non-invasive, immediate intervention that can help improve airway clearance. Notifying the healthcare provider is important if the client’s condition worsens, but it is not the first action. Administering a bronchodilator is appropriate if bronchospasm is present, but it is not the priority for coarse crackles due to secretions. Placing the client in a supine position is not recommended, as it may impair lung expansion and secretion clearance.
A nurse is performing a preoperative assessment on a client scheduled for abdominal surgery. Which finding should the nurse report to the healthcare provider immediately?
a) The client reports a history of seasonal allergies
b) The client states they have not had anything to eat or drink since midnight
c) The client reports taking warfarin daily for atrial fibrillation
d) The client expresses anxiety about the surgery
Correct Answer:
c) The client reports taking warfarin daily for atrial fibrillation
Rationale:
Warfarin is an anticoagulant that increases the risk of bleeding during and after surgery. This medication may need to be held or reversed prior to surgery, and the healthcare provider must be notified immediately. The other findings are important but do not require immediate intervention.
A nurse is caring for a client in the post-anesthesia care unit (PACU) following abdominal surgery. Which assessment finding requires immediate intervention?
a) Respiratory rate of 10 breaths per minute
b) Blood pressure of 110/70 mm Hg
c) Small amount of serosanguinous drainage on the surgical dressing
d) Client reports mild incisional pain (3/10)
Correct Answer:
a) Respiratory rate of 10 breaths per minute
Rationale:
A respiratory rate of 10 breaths per minute is below the normal range (12–20 breaths per minute) and may indicate respiratory depression, possibly due to anesthesia or opioid medications. This requires immediate intervention to prevent hypoxia and other complications. The other findings are expected or within normal limits in the immediate postoperative period.
A nurse is caring for a client 5 days after abdominal surgery. The client suddenly reports feeling a "popping" sensation at the incision site, and the nurse observes that the wound edges have separated with visible tissue. What is the priority nursing action?
a) Apply a dry sterile dressing and notify the healthcare provider
b) Instruct the client to ambulate to reduce pressure on the wound
c) Cover the wound with a sterile saline-moistened dressing and notify the healthcare provider
d) Reapproximate the wound edges with adhesive strips and document the finding
Correct Answer:
c) Cover the wound with a sterile saline-moistened dressing and notify the healthcare provider
Rationale:
Wound dehiscence is a surgical emergency. The priority is to cover the wound with a sterile saline-moistened dressing to keep the tissues moist and reduce the risk of infection, then immediately notify the healthcare provider. The other actions are either incorrect or not the priority in this situation.
A nurse is caring for a client with a history of peptic ulcer disease who reports sudden, severe abdominal pain, a rigid and board-like abdomen, and shallow respirations. Which action should the nurse take first?
a) Administer prescribed antacids
b) Notify the healthcare provider immediately
c) Place the client in a high-Fowler’s position
d) Obtain a stool specimen for occult blood
Correct Answer:
b) Notify the healthcare provider immediately
Rationale:
Sudden, severe abdominal pain with a rigid, board-like abdomen and shallow respirations may indicate perforation of the ulcer, a life-threatening emergency. The nurse should immediately notify the healthcare provider. Administering antacids, changing the client’s position, or obtaining a stool specimen are not priorities in this acute situation.
Rhonchi
A nurse is caring for a client with asthma who is experiencing shortness of breath. On auscultation, the nurse hears high-pitched, musical wheezing sounds throughout the lung fields. Which action should the nurse take first?
a) Encourage the client to cough forcefully
b) Administer the prescribed bronchodilator inhaler
c) Place the client in a supine position
d) Notify the healthcare provider immediately
Correct Answer:
b) Administer the prescribed bronchodilator inhaler
Rationale:
Wheezing is a high-pitched, musical sound usually heard during expiration and is caused by air moving through narrowed airways, as seen in asthma. The priority action is to open the airways by administering a bronchodilator as prescribed. Encouraging coughing is not effective for wheezing, placing the client supine may worsen breathing, and while notifying the provider is important if the client does not improve, the immediate action is to relieve the airway constriction.
A nurse is completing a preoperative assessment for a client scheduled for elective surgery. Which statement by the client requires immediate follow-up by the nurse?
a) "I stopped eating and drinking at midnight as instructed."
b) "I am allergic to penicillin and get a rash when I take it."
c) "I took my blood pressure medicine with a sip of water this morning."
d) "I have a loose tooth in the front of my mouth."
Correct Answer:
b) "I am allergic to penicillin and get a rash when I take it."
Rationale:
A medication allergy, especially to antibiotics like penicillin, must be immediately communicated to the surgical and anesthesia teams to prevent a potentially life-threatening allergic reaction. The other statements are important but do not require immediate intervention.
A nurse is assessing a client 2 hours after abdominal surgery. Which finding should the nurse report to the healthcare provider immediately?
a) Temperature of 37.8°C (100°F)
b) Blood pressure of 128/76 mm Hg
c) Absent breath sounds in the left lower lobe
d) Small amount of serosanguinous drainage on the dressing
Correct Answer:
c) Absent breath sounds in the left lower lobe
Rationale:
Absent breath sounds in the left lower lobe may indicate a serious complication such as atelectasis, pneumothorax, or mucus plug, and requires immediate intervention. The other findings are expected or not immediately life-threatening in the early postoperative period.
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. Which nursing intervention is most appropriate to promote effective breathing?
a) Encourage the client to lie in a supine position
b) Instruct the client to use pursed-lip breathing during exhalation
c) Administer high-flow oxygen at 10 L/min via non-rebreather mask
d) Restrict the client’s fluid intake to prevent pulmonary edema
Correct Answer:
b) Instruct the client to use pursed-lip breathing during exhalation
Rationale:
Pursed-lip breathing helps keep airways open during exhalation, promotes carbon dioxide elimination, and improves oxygenation in clients with COPD. Lying supine can worsen breathing, high-flow oxygen can suppress the respiratory drive in COPD patients, and fluid restriction is not indicated unless there is another condition such as heart failure.
A client with a suspected bowel obstruction is NPO and has an NG tube to low intermittent suction. Which nursing intervention is most important to include in the plan of care?
a) Encourage the client to ambulate in the hallway every 2 hours
b) Irrigate the NG tube with 30 mL of tap water every 4 hours
c) Monitor the client’s electrolyte levels and replace losses as prescribed
d) Offer the client ice chips to relieve dry mouth
Correct Answer:
c) Monitor the client’s electrolyte levels and replace losses as prescribed
Rationale:
Clients with bowel obstruction and NG suction are at risk for fluid and electrolyte imbalances due to vomiting and gastric decompression. Monitoring and replacing electrolytes is a priority to prevent complications. Ambulation may be encouraged but is not the most important. NG tubes should only be irrigated with saline and only if prescribed. The client is NPO, so offering ice chips is not appropriate.
Crackles (Rales)
A nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who reports increased cough and difficulty breathing. On auscultation, the nurse hears low-pitched, snoring sounds (rhonchi) over the central chest. Which action should the nurse take first?
a) Encourage the client to cough and deep breathe
b) Notify the healthcare provider
c) Administer a prescribed corticosteroid
d) Place the client in a supine position
Correct Answer:
a) Encourage the client to cough and deep breathe
Rationale:
Rhonchi are low-pitched, snoring sounds caused by secretions or mucus in the larger airways, common in clients with COPD. The priority intervention is to encourage coughing and deep breathing to help mobilize and clear the secretions. This may resolve the rhonchi and improve breathing. Notifying the provider or administering corticosteroids may be necessary if symptoms persist, but the first action is to attempt to clear the airway. Placing the client supine is not recommended, as it may worsen breathing
A nurse is conducting a preoperative assessment for a client scheduled for a cholecystectomy. Which of the following findings should the nurse report to the healthcare provider before surgery?
a) The client reports mild anxiety about the procedure
b) The client states they removed their nail polish
c) The client reports using herbal supplements daily
d) The client has an identification band on their wrist
Correct Answer:
c) The client reports using herbal supplements daily
Rationale:
Some herbal supplements (such as garlic, ginkgo, or ginseng) can increase the risk of bleeding or interact with anesthesia. The healthcare provider must be notified so that appropriate precautions can be taken. The other findings are expected or routine in the preoperative period.
A nurse is caring for a client who is 4 hours post-op following a total hip replacement. Which assessment finding should the nurse report to the healthcare provider immediately?
a) Urine output of 40 mL/hour
b) Temperature of 37.6°C (99.7°F)
c) Moderate swelling at the surgical site
d) Sudden onset of shortness of breath and restlessness
Correct Answer:
d) Sudden onset of shortness of breath and restlessness
Rationale:
Sudden shortness of breath and restlessness may indicate a serious complication such as a pulmonary embolism, which is a medical emergency after orthopedic surgery. The other findings are expected or require routine monitoring, but do not require immediate intervention.
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing hypoxemia. The healthcare provider prescribes oxygen therapy. Which nursing intervention is most appropriate?
a) Administer oxygen at 8 L/min via simple face mask
b) Maintain oxygen saturation between 88% and 92% as prescribed
c) Encourage the client to increase oxygen flow rate if feeling short of breath
d) Place the client in a supine position to improve oxygenation
Correct Answer:
b) Maintain oxygen saturation between 88% and 92% as prescribed
Rationale:
Clients with COPD are at risk for losing their hypoxic drive to breathe if given too much oxygen. The nurse should maintain oxygen saturation within the prescribed range (usually 88–92%) and use the lowest effective oxygen flow rate. High-flow oxygen and supine positioning are not recommended, and clients should not adjust their own oxygen flow rates.
A client with peptic ulcer disease is prescribed omeprazole and sucralfate. Which instruction should the nurse give regarding the administration of these medications?
a) "Take omeprazole and sucralfate together with breakfast."
b) "Take sucralfate 30 minutes before meals and omeprazole before breakfast."
c) "Take omeprazole after meals and sucralfate at bedtime."
d) "Take both medications on an empty stomach at bedtime."
Correct Answer:
b) "Take sucralfate 30 minutes before meals and omeprazole before breakfast."
Rationale:
Sucralfate should be taken on an empty stomach, ideally 30 minutes to 1 hour before meals, to coat the ulcer and protect it from acid. Omeprazole (a proton pump inhibitor) is best taken before breakfast to reduce gastric acid secretion. Taking them together or after meals is not recommended, as sucralfate needs to bind to the ulcer site before food or other medications are present.
Stridor
A nurse is caring for a child who is post-tonsillectomy. The nurse hears a harsh, high-pitched inspiratory sound (stridor) when the child breathes. Which action should the nurse take first?
a) Notify the healthcare provider
b) Assess the child’s throat for bleeding
c) Prepare for possible intubation
d) Administer oxygen and call for emergency assistance
Correct Answer:
d) Administer oxygen and call for emergency assistance
Rationale:
Stridor is a sign of upper airway obstruction and is a medical emergency, especially in a post-tonsillectomy patient who is at risk for airway swelling or bleeding. The nurse’s priority is to maintain oxygenation and call for immediate help to secure the airway. Notifying the provider and preparing for intubation are important, but the first action is to support the airway and get emergency assistance.
A nurse is preparing a client for surgery scheduled in one hour. Which preoperative intervention is most important to perform at this time?
a) Teach the client about postoperative exercises
b) Ensure that the client has signed the informed consent form
c) Discuss the expected length of the hospital stay
d) Provide the client with a clean hospital gown
Correct Answer:
b) Ensure that the client has signed the informed consent form
Rationale:
The most important preoperative intervention immediately before surgery is to verify that the client has provided informed consent. Surgery cannot proceed without documented consent. Teaching and providing information are important but should be completed earlier. Providing a gown is routine but not as critical as legal consent.
A nurse is caring for a client who is 8 hours post-op following abdominal surgery. Which intervention is most important to help prevent postoperative complications?
a) Encourage the client to use the incentive spirometer every hour while awake
b) Offer the client ice chips to relieve dry mouth
c) Provide a warm blanket for comfort
d) Allow the client to rest undisturbed for several hours
Correct Answer:
a) Encourage the client to use the incentive spirometer every hour while awake
Rationale:
Using the incentive spirometer helps prevent postoperative complications such as atelectasis and pneumonia by promoting lung expansion and clearing secretions. The other interventions may provide comfort but do not directly address the prevention of serious postoperative complications.
A nurse enters the room of a client who is 6 days post-op from abdominal surgery and finds the client’s abdominal wound has eviscerated, with intestines protruding. Which action should the nurse take first?
a) Notify the healthcare provider
b) Cover the wound with a sterile saline-moistened dressing
c) Place the client in a supine position with legs straight
d) Obtain vital signs and assess for shock
Correct Answer:
b) Cover the wound with a sterile saline-moistened dressing
Rationale:
The priority action is to immediately cover the exposed organs with a sterile saline-moistened dressing to keep the tissues moist and reduce the risk of infection and tissue damage. After this, the nurse should notify the healthcare provider, position the client with knees bent (not legs straight) to decrease abdominal pressure, and monitor vital signs.
A nurse is caring for a hospitalized adolescent with cystic fibrosis who is colonized with Burkholderia cepacia. Which infection control intervention is most important to implement?
a) Place the client in a private room and use standard precautions
b) Place the client in a private room and require contact precautions
c) Allow the client to participate in group activities with other cystic fibrosis patients
d) Assign the same nurse to care for all cystic fibrosis patients on the unit
Correct Answer:
b) Place the client in a private room and require contact precautions
Rationale:
Burkholderia cepacia is a highly transmissible and drug-resistant organism that can cause severe respiratory infections in people with cystic fibrosis. Clients colonized with B. cepacia should be placed in a private room with contact precautions to prevent transmission to other vulnerable patients. They should not participate in group activities with other CF patients, and nurses should avoid caring for multiple CF patients to prevent cross-infection.
Pleural Friction Rub
A nurse is assessing a client who reports sharp chest pain that worsens with deep breathing. On auscultation, the nurse hears a grating, scratching sound (pleural friction rub) over the lower left lung field. Which action should the nurse take first?
a) Notify the healthcare provider
b) Encourage the client to take shallow breaths
c) Assess the client’s pain level and administer prescribed analgesics
d) Instruct the client to cough and deep breathe
c) Assess the client’s pain level and administer prescribed analgesics
Rationale:
A pleural friction rub is a grating sound caused by inflamed pleural surfaces rubbing together, often associated with pleurisy or pleuritis. The pain is typically sharp and worsens with inspiration. The priority is to assess and manage the client’s pain to promote adequate ventilation. Notifying the provider is important, but pain control comes first to prevent hypoventilation. Encouraging shallow breathing may reduce pain but can lead to atelectasis. Coughing and deep breathing may worsen pain and are not appropriate until pain is managed.
A nurse is caring for a client scheduled for surgery in the morning. Which preoperative nursing intervention is most appropriate to reduce the risk of aspiration during surgery?
a) Instruct the client to void before being transported to the operating room
b) Remove the client’s dentures and document their removal
c) Ensure the client has been NPO since midnight
d) Verify that all jewelry has been removed
Correct Answer:
c) Ensure the client has been NPO since midnight
Rationale:
Maintaining NPO (nothing by mouth) status before surgery is the most effective intervention to reduce the risk of aspiration during anesthesia. The other interventions are important for safety and comfort, but NPO status directly addresses aspiration risk.
A nurse is caring for a client who is 6 hours post-op after an open cholecystectomy. Which nursing intervention is most effective in preventing deep vein thrombosis (DVT) in this client?
a) Encourage the client to increase oral fluid intake
b) Instruct the client to perform leg exercises every hour while awake
c) Place a pillow under the client’s knees for comfort
d) Maintain the client on strict bed rest for 24 hours
Correct Answer:
b) Instruct the client to perform leg exercises every hour while awake
Rationale:
Leg exercises promote venous return and help prevent venous stasis, which is a major risk factor for DVT after surgery. Increasing fluids is helpful but not as effective as movement. Placing a pillow under the knees can impede circulation, and bed rest increases the risk of DVT.
A nurse is caring for a child with cystic fibrosis who is admitted for a pulmonary infection. Which nursing intervention is most important to include in the plan of care?
a) Encourage a low-sodium diet
b) Administer pancreatic enzymes with meals and snacks
c) Limit physical activity to conserve energy
d) Withhold chest physiotherapy during periods of infection
Correct Answer:
b) Administer pancreatic enzymes with meals and snacks
Rationale:
Children with cystic fibrosis have pancreatic insufficiency and require pancreatic enzyme supplements with all meals and snacks to aid digestion and nutrient absorption. A high-calorie, high-protein, and high-salt diet is recommended, not low-sodium. Physical activity is encouraged to help mobilize secretions. Chest physiotherapy should be continued, not withheld, during infections to help clear airway secretions.
A client with a history of peptic ulcer disease is admitted with complaints of weakness and dizziness. The nurse notes that the client’s blood pressure is 88/54 mm Hg, pulse is 118 beats/min, and the client has black, tarry stools. Which action should the nurse take first?
a) Notify the healthcare provider
b) Prepare to administer a proton pump inhibitor
c) Start an intravenous (IV) line with normal saline
d) Obtain a stool specimen for occult blood testing
Correct Answer:
c) Start an intravenous (IV) line with normal saline
Rationale:
The client is showing signs of acute GI bleeding (melena, hypotension, tachycardia, weakness, dizziness), which can lead to hypovolemic shock. The priority is to maintain circulatory volume and prevent shock by starting IV fluids. Notifying the provider and administering medications are important, but stabilizing the client’s hemodynamic status comes first. Obtaining a stool specimen is not the priority in an acute situation.
Kussmaul Respiration
A nurse is assessing a client with a history of type 1 diabetes mellitus who presents with deep, rapid respirations (Kussmaul respirations), fruity-smelling breath, and abdominal pain. Which action should the nurse take first?
a) Administer prescribed antiemetic medication
b) Check the client’s blood glucose level
c) Place the client in a supine position
d) Encourage the client to take slow, shallow breaths
Correct Answer:
b) Check the client’s blood glucose level
Rationale:
Kussmaul respirations are a compensatory mechanism for metabolic acidosis, most commonly seen in diabetic ketoacidosis (DKA). The nurse should first check the client’s blood glucose to confirm hyperglycemia and guide further treatment. The other options do not address the underlying cause or are not appropriate for this situation.
A nurse is preparing a client for surgery. Which preoperative nursing intervention is most important to prevent wrong-site surgery?
a) Ask the client to remove all personal belongings and jewelry
b) Confirm the client’s allergies with the surgical team
c) Participate in the surgical site marking with the client and surgeon
d) Instruct the client to deep breathe and cough after surgery
Correct Answer:
c) Participate in the surgical site marking with the client and surgeon
Rationale:
Participating in the surgical site marking with the client and surgeon is a critical intervention to prevent wrong-site surgery. This process ensures that the correct site is identified and marked before the procedure, following safety protocols such as the Universal Protocol. The other interventions are important for safety and postoperative care but do not directly prevent wrong-site surgery.
A nurse is caring for a client who is 12 hours post-op following abdominal surgery. Which intervention should the nurse implement to help prevent postoperative atelectasis?
a) Maintain the client in a supine position at all times
b) Encourage the client to ambulate as soon as possible
c) Restrict oral fluids until bowel sounds return
d) Apply a warm compress to the surgical site every 4 hours
Correct Answer:
b) Encourage the client to ambulate as soon as possible
Rationale:
Early ambulation promotes lung expansion and helps prevent atelectasis, a common postoperative complication. The other interventions do not directly address the prevention of atelectasis.
A nurse is assessing a child with cystic fibrosis. Which assessment finding should the nurse report to the healthcare provider immediately?
a) Weight loss despite a good appetite
b) Frequent, loose, fatty stools
c) New onset of wheezing and decreased breath sounds
d) Persistent, thick nasal discharge
Correct Answer:
c) New onset of wheezing and decreased breath sounds
Rationale:
A new onset of wheezing and decreased breath sounds may indicate airway obstruction or worsening respiratory status, which can be life-threatening and requires immediate intervention. Weight loss, fatty stools, and thick nasal discharge are common in cystic fibrosis but are not as urgent as acute changes in respiratory status.
A client is recovering from surgery for colorectal cancer and has a new colostomy. Which nursing intervention is most important during the initial postoperative period?
a) Encourage the client to look at and touch the stoma
b) Teach the client how to irrigate the colostomy
c) Monitor the stoma for color and viability
d) Instruct the client on a high-fiber diet
Correct Answer:
c) Monitor the stoma for color and viability
Rationale:
In the immediate postoperative period, the priority is to assess the stoma for adequate blood supply. The stoma should be pink or red and moist; a pale, dusky, or black stoma indicates compromised circulation and requires immediate attention. While client education and emotional support are important, ensuring the stoma is viable is the most critical intervention at this stage.