A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?
Explanation & Rationale
A. Crackles are heard in bases. – The nurse encourages the client to cough forcefully: Crackles are caused by fluid in the alveoli and are often not cleared with coughing. Encouraging coughing may help with mucus, but for fluid-related crackles (e.g., in heart failure), diuretics or other interventions are more appropriate. B. Wheezes are heard in central areas. – The nurse administers an inhaled bronchodilator: Wheezes result from narrowed airways, commonly seen in asthma or bronchospasm. Bronchodilators relax airway smooth muscle, improving airflow and reducing wheezing. C. Vesicular sounds are heard over the periphery. – The nurse has the client breathe: Vesicular breath sounds are normal over the peripheral lung fields. No action is needed when these sounds are heard, so prompting the client to breathe differently is unnecessary. D. Hollow sounds are heard over the trachea. – The nurse increases the oxygen flow rate: Hollow, tubular sounds (bronchial) are expected over the trachea. These are normal findings and not an indication of hypoxia. Increasing oxygen unnecessarily could be harmful.