Nokea
What do crackles heard on lung auscultation indicate?
- A. Cyanosis.
- B. Bronchospasm.
- C. Airway narrowing.
- D. Fluid-filled alveoli.
Correct Answer: D
Rationale: Crackles heard on lung auscultation are caused by the popping open of small airways that are filled with fluid. This is commonly associated with conditions such as pulmonary edema, pneumonia, or heart failure. Cyanosis (Choice A) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, not directly related to crackles. Bronchospasm (Choice B) refers to the constriction of the airway smooth muscle, causing difficulty in breathing but does not typically produce crackles. Airway narrowing (Choice C) can lead to wheezing but is not directly linked to crackles heard on auscultation.
You may also like to solve these questions
The client with chronic renal failure is being taught about the importance of fluid restrictions. Which of the following statements by the client indicates that the teaching has been effective?
- A. I can drink as much fluid as I want, as long as I take my medication.
- B. I will need to limit my fluid intake to prevent fluid overload.
- C. I can drink as much water as I want, as long as I limit other fluids.
- D. I will need to drink only when I am thirsty.
Correct Answer: B
Rationale: The correct answer is B: 'I will need to limit my fluid intake to prevent fluid overload.' In chronic renal failure, fluid restrictions are crucial to prevent fluid overload and further damage to the kidneys. Option A is incorrect as unrestricted fluid intake can worsen the condition. Option C is also incorrect as total fluid intake needs to be restricted, not just other fluids. Option D is not ideal because thirst may not accurately reflect the body's fluid needs in chronic renal failure.
A client with chronic kidney disease missed dialysis yesterday to attend a funeral. The client's wife calls the home health nurse and reports that her husband is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?
- A. Apply the client's home oxygen.
- B. Check for a thrill and bruit at the client's dialysis access site.
- C. Ensure the client avoids salt intake for the rest of the day.
- D. Take the client to the emergency department (ED).
Correct Answer: D
Rationale: In this scenario, the most crucial instruction for the nurse to provide is to take the client to the emergency department (ED). Missing dialysis can lead to severe complications in clients with chronic kidney disease, such as electrolyte imbalances and fluid overload. Lethargy and difficulty in arousing the client suggest a critical situation that requires immediate medical attention. Applying home oxygen, checking the dialysis access site, and ensuring salt intake avoidance, although important, are not as urgent as seeking emergency care to address the potential severe complications from missed dialysis.
Which electrolyte imbalance is most likely to be seen in a patient with chronic kidney disease?
- A. Hypernatremia.
- B. Hyperkalemia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: B
Rationale: In chronic kidney disease, hyperkalemia is the most common electrolyte imbalance due to the kidneys' reduced ability to excrete potassium. This impaired kidney function leads to potassium retention in the body, resulting in elevated serum potassium levels. Hypernatremia (increased sodium levels) is less likely in chronic kidney disease as the kidneys typically still function to regulate sodium levels. Hypocalcemia (low calcium levels) is not a prominent electrolyte imbalance in chronic kidney disease unless there are additional factors involved. Hypokalemia (low potassium levels) is less common in chronic kidney disease, as the primary issue is usually potassium retention rather than deficiency.
Laboratory findings indicate that a client's serum potassium level is 2.5 mEq/L. What action should the nurse take?
- A. Inform the healthcare provider of the need for potassium replacement.
- B. Prepare to administer a glucose-insulin-potassium replacement.
- C. Change the plan of care to include hourly urinary output measurement.
- D. Instruct the client to increase daily intake of potassium-rich foods.
Correct Answer: A
Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. The immediate action the nurse should take is to inform the healthcare provider of the need for potassium replacement. Option B, preparing to administer glucose-insulin-potassium replacement, is not the first-line intervention; it may be considered in specific situations but requires a healthcare provider's prescription. Option C, changing the plan of care to include hourly urinary output measurement, is not the priority when managing critically low potassium levels. Option D, instructing the client to increase daily intake of potassium-rich foods, is not appropriate in this acute situation where immediate intervention is needed to address the dangerously low potassium level.
For a client with peripheral vascular disease (PVD) of the lower extremities who is trying to manage their condition well, which routine should the nurse evaluate as appropriate?
- A. Resting with the legs elevated above the level of the heart.
- B. Walking slowly but steadily for 30 minutes twice a day.
- C. Minimizing activity.
- D. Wearing antiembolism stockings at all times when out of bed.
Correct Answer: B
Rationale: The correct answer is B. Walking slowly but steadily for 30 minutes twice a day is appropriate for clients with PVD as it helps stimulate collateral circulation and improve blood flow. Choice A is incorrect because while elevating the legs can help with symptoms temporarily, it is not as effective as walking for improving circulation. Choice C, minimizing activity, is not recommended as it can lead to further deconditioning and worsen symptoms. Choice D, wearing antiembolism stockings, is not specifically indicated for PVD and may not address the underlying circulation issues.