The nurse is listening to the client's breath sounds and hears a creaking, grating sound on inspiration and expiration over the posterior right lower lobe. How would the nurse correctly document this on the client's record?

Correct Answer: D

Rationale: The correct answer is D: Pleural friction rub. This sound is caused by inflamed pleural surfaces rubbing together during inspiration and expiration. The creaking, grating quality is characteristic of a pleural friction rub. Wheezes (A) are high-pitched musical sounds, crackles (B) are fine, crackling sounds, and rhonchi (C) are low-pitched, snoring sounds. These do not match the description given in the question.

Correct Answer: C

Rationale: The correct answer is C: Provide sedation. This is the priority intervention for a patient with severe burns to manage pain and anxiety, prevent shock, and facilitate wound care. Sedation helps to reduce the patient's distress and allows for better assessment and treatment. Administering IV fluids (B) is important but not the top priority. Providing pain relief (A) is crucial, but sedation may be more effective for severe burns. Administering an antiemetic (D) is not the priority unless the patient is actively vomiting.

Correct Answer: B

Rationale: The priority intervention in this scenario is to administer a nebulized bronchodilator (Choice B). This is because the patient is showing signs of respiratory distress, indicating a need for immediate bronchodilation to improve airway patency and ventilation. Checking the ventilator settings (Choice A) is important but not the priority when the patient is in distress. Administering bronchodilator therapy (Choice C) is similar to Choice B but is less specific and may not be as immediate. Administering insulin (Choice D) is not relevant in this situation since the patient's respiratory distress is the primary concern.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. Hypotension following surgery can indicate hypovolemia, so the priority is to increase fluid volume to improve perfusion to vital organs. Administering IV fluids will help increase blood pressure and improve circulation. Administering a vasopressor (B) should only be considered if fluid resuscitation is unsuccessful. Elevating the patient's legs (C) may help in some cases, but IV fluids are more critical. Monitoring vital signs (D) is important, but addressing the underlying cause of hypotension is the priority.

Correct Answer: B

Rationale: The correct answer is B: Administer morphine. Chest pain in a patient with a history of hypertension may indicate a myocardial infarction. Morphine is essential to alleviate pain and reduce myocardial oxygen demand. Nitroglycerin may lower blood pressure, which can be dangerous in a hypertensive patient. Aspirin is important for antiplatelet effects but not the immediate priority. Administering an antihypertensive is not necessary as the priority is managing chest pain.