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.
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.
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