A nurse auscultates a client’s lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take
A.
Place the client on bed rest in a semi-Fowler’s position.
B.
Instruct the client to limit fluid intake to less than 2.000 mL/day.
C.
Prepare to administer antibiotics.
D.
Repeat auscultation after asking the client to breathe deeply and cough
The Correct Answer and Explanation is:
The correct answer is D. Repeat auscultation after asking the client to breathe deeply and cough.
Explanation:
Crackles, also known as rales, are abnormal lung sounds typically indicative of fluid in the airways or alveoli, often associated with conditions like pneumonia, heart failure, or pulmonary edema. When a nurse identifies crackles upon auscultation, it’s essential to understand the underlying cause and assess the client further.
Option A: Place the client on bed rest in a semi-Fowler’s position. While placing the client in a semi-Fowler’s position may help with respiratory comfort, it does not directly address the presence of crackles. This position can facilitate lung expansion and improve oxygenation, but it is not a definitive intervention.
Option B: Instruct the client to limit fluid intake to less than 2,000 mL/day. This intervention could be applicable if the crackles were due to fluid overload, as seen in heart failure. However, without further assessment to determine the cause of the crackles, restricting fluid intake may not be warranted or appropriate at this stage.
Option C: Prepare to administer antibiotics. Antibiotic therapy is typically indicated for bacterial infections such as pneumonia, which can cause crackles. However, it requires a definitive diagnosis. The nurse should not jump to this intervention without further assessment, including a thorough history, physical examination, and possibly diagnostic tests.
Option D: Repeat auscultation after asking the client to breathe deeply and cough. This option is the most appropriate initial intervention. Asking the client to take deep breaths and cough can help clear secretions and may temporarily alleviate crackles if they are due to retained mucus. By auscultating again, the nurse can determine if the crackles persist, which can inform further clinical decisions, such as whether to investigate for infection or consider other interventions.
In conclusion, repeating the auscultation after deep breathing and coughing is critical for effective assessment and further management of the client’s respiratory status.