On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?

Correct Answer: A

Rationale: The correct answer is A: Inspiratory crackles at the bases. This finding indicates the presence of crackles, which are discontinuous, non-musical sounds heard during inspiration. Crackles in the lower third of both lungs suggest the presence of fluid or mucus in the alveoli or small airways. The term "bases" refers to the lower portions of the lungs. Crackles are typically associated with conditions such as pneumonia, heart failure, or pulmonary edema. Explanation of other choices: B: Expiratory wheezes in both lungs - Wheezes are continuous, high-pitched musical sounds heard during expiration and are typically associated with asthma or bronchitis. This does not match the description provided in the question. C: Abnormal lung sounds in the apices of both lungs - The apices refer to the upper portions of the lungs. The description in the question does not match this location. D: Pleural friction rub in the right and left lower

Correct Answer: B

Rationale: The correct answer is B: Initiate oxygen therapy at 2 liters per minute via nasal cannula. Oxygen saturation of 88% indicates hypoxemia, requiring immediate intervention to improve oxygenation. Administering oxygen via nasal cannula at 2 liters per minute can help increase oxygen levels and alleviate symptoms. Choice A (Administer prescribed bronchodilators) is incorrect as bronchodilators are not the first-line treatment for hypoxemia in pneumonia. Choice C (Encourage the use of an incentive spirometer every hour) is incorrect as while important for respiratory hygiene, it does not address the immediate need for oxygen therapy in a hypoxemic patient. Choice D (Increase the patient's fluid intake to thin secretions) is incorrect as it addresses secretion management, which is not the priority in this scenario where oxygenation is compromised.

Correct Answer: C

Rationale: The correct answer is C: Lethargy and confusion. This is the most concerning assessment finding in a patient receiving oxygen therapy because it indicates potential oxygen deprivation to the brain, which can lead to serious complications. Lethargy and confusion are signs of hypoxia, which can be life-threatening if not addressed promptly. Respiratory rate of 24 breaths per minute (choice A) may indicate increased effort to breathe but is not as immediately concerning as hypoxia. Oxygen saturation of 92% (choice B) is below the normal range but not critically low. Mild nasal dryness (choice D) is a common side effect of oxygen therapy and does not indicate a serious issue with oxygen delivery.

Correct Answer: C

Rationale: Step-by-step rationale for why choice C is correct: 1. Pleural effusion can cause shortness of breath. 2. Promptly notifying the healthcare provider about worsening symptoms is crucial. 3. Demonstrates patient understanding of the condition. 4. Enables timely intervention to prevent complications. Summary of why other choices are incorrect: A: Limiting fluid intake may not directly impact pleural effusion. B: Lying flat may not be recommended post-procedure and could worsen symptoms. D: Monitoring every six months is insufficient for a condition that can cause acute symptoms.

Correct Answer: B

Rationale: The correct answer is B. The patient should continue wearing a mask until the treatment is completed to prevent the spread of tuberculosis. Stopping the mask before completing treatment can lead to transmission of the disease. Choices A, C, and D are correct statements that show understanding of tuberculosis treatment and monitoring.