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ANCC Medical-Surgical Nursing Exam Prep

Category - Medical-Surgical Nursing Practice Test

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Auscultation of a client’s lungs reveals rales (crackles) in the left posterior base. The nursing intervention is to:
  1. Repeat auscultation after asking the client to take deep breaths and cough.
  2. Instruct the client to limit fluid intake to less than 2000 mL/day.
  3. Inspect the client’s ankles and sacrum for the presence of edema.
  4. Place the client on bed rest in a semi-Fowler’s position.
Explanation
Answer - A - Although crackles often indicate fluid in the alveoli, they may be related to hypoventilation and will clear after a deep breath or a cough. It is, therefore, premature to impose fluid (Choice B) or activity (Choice D) restrictions. Inspection for edema (Choice C) would be appropriate after re-auscultation.
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