When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action?
a. Weak cough effort
b. Barrel-shaped chest
c. Dry mucous membranes
d. Bilateral crackles at lung bases
ANS: D
Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier.
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