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.
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.
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