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.
Question 2The student nurse is ambulating with a blind patient. Which technique(s) indicate(s) that the student nurse requires further instruction? (Select all that apply.)
a. Holding the patient's dominant arm
b. Instructing the patient to put both hands on his shoulders
c. Allowing the patient to hold the nurse's arm
d. Holding the patient's hand
e. Walking just behind the patient
Question 3When the nurse is caring for a patient who reports he has blood that begins when he initiates the urine stream and then abates. Based on underlying pathophysiology, the nurse concludes that the hematuria is occurring in which location?
a. In the kidney
b. Above the neck of the bladder
c. In the neck of the bladder
d. In the urethra
Question 4The nurse is caring for a patient diagnosed with an abdominal aortic aneurysm who complains of sudden, intense abdominal pain and light-headedness. What action should the nurse take next?
a. Monitor the patient's blood pressure every 15 minutes.
b. Contact the physician immediately.
c. Notify the patient's family of the change in condition.
d. Continue to assess the patient's pain.
Question 5The nurse is planning care for a patient and determines that Expanded Precautions are warranted when performing care for a patient with which infection?
a. Active tuberculosis (TB)
b. Bacterial pneumonia
c. A urinary tract infection (UTI) caused by E. coli
d. A fungal infection of the groin and axilla
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