Auscultation of a client’s lungs reveals crackles in the left posterior base. The nursing intervention is to:
A. Repeat auscultation after asking the client to deep breathe and cough.
B. Instruct the client to limit fluid intake to less than 2000 ml/day.
C. Inspect the client’s ankles and sacrum for the presence of edema.
D. Place the client on bedrest in a semi-Fowler's position.
Correct Answer: A. Repeat auscultation after asking the client to deep breathe and cough.
Although crackles often indicate fluid in the alveoli, they may also be related to hypoventilation and will clear after a deep breath or a cough. Assess cough effectiveness and productivity. Coughing is the most effective way to remove secretions. Pneumonia may cause thick and tenacious secretions to patients.
Option B: It is premature to impose fluid or activity restrictions. Assess the rate, rhythm, and depth of respiration, chest movement, and use of accessory muscles. Tachypnea, shallow respirations and asymmetric chest movement are frequently present because of the discomfort of moving chest wall and/or fluid in the lung due to a compensatory response to airway obstruction. Altered breathing patterns may occur together with use of accessory muscles to increase chest excursion to facilitate effective breathing.
Option C: Inspection for edema would be appropriate after re-auscultation. Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes. Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction.
Option D: Elevate the head of bed, change position frequently. Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization, and expectoration of secretions.
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