Upon auscultation of the chest, the nurse reports to the preceptor what is heard. What statement should cause the preceptor to be most concerned?
1. "I heard crackles earlier, but now I am not able to hear anything."
2. "I hear wheezing in the right lobes, but clear on the left."
3. "There are coarse crackles that clear with coughing."
4. "The patient was clear, but now there are scattered wheezes bilaterally."
Correct Answer: 1
The preceptor would be most concerned about the nurse not hearing anything. This statement needs immediate follow-up assessment as to whether the nurse hears nothing, or no adventitious breath sounds. The other options indicate adventitious breath sounds, but none is indicative of the need for immediate action.
You might also like to view...
Schools of nursing based on Florence Nightingale's model of classroom and clinical experience began to appear in the United States after the American Civil War. What influence did war have on nursing education?
1. no true influence 2. increased demand for trained nurses 3. increased paternalism 4. increased nursing shortages in the hospitals
A client with a history of depression tells the nurse that since she has taken yoga classes, the depressive episodes have decreased. The nurse realizes that yoga:
1. Increases blood flow to the brain. 2. Stimulates the production of serotonin. 3. Raises levels of endorphins. 4. Promotes alertness, enthusiasm and physical energy.
The mother of a 6-month-old infant asks the nurse at a community health center what she should do about her baby, who always wants to put everything in his mouth. What would be an appropriate response by the nurse, based on Freud's theory?
A) "There must be something wrong…your baby should not be doing that." B) "I don't know if that is normal or not, but I will check on it." C) "Babies at this age explore and enjoy their world with their mouths." D) "This usually does not happen until babies are 2 years old."
Health teaching that the nurse should implement prior to discharging a client who was brought to the ED during a "bad trip" following LSD ingestion is:
1. How to ensure good trips in the future 2. How to treat needle tracks to avoid infection 3. What flashbacks are and what to do if they occur 4. Arranging for a sponsor who will guide recovery