A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and the secretions are thick and sticky. Which intervention will the nurse use to promote respiratory hygiene in this situation?
Decrease fluid intake.
Take Tylenol for the secretions.
Range -of-motion exercises as tolerated
Increase fluid intake.
The Correct Answer is D
Explanation: In clients with COPD, the secretions tend to be thick and sticky, which makes it difficult to cough up and clear the airway. To promote respiratory hygiene in this situation, the nurse should recommend increasing fluid intake. Adequate hydration helps to thin the secretions, making them easier to expectorate. The client should aim to drink at least 8-10 glasses of water or other fluids per day unless there is a medical reason not to do so.
Decreasing fluid intake (option a) would make the secretions even thicker and more difficult to clear. Taking Tylenol for secretions (option b) is not a recommended intervention as Tylenol is not indicated for thinning of secretions. Range-of-motion exercises (option c) are important to prevent complications such as pneumonia, but they are not directly related to promoting respiratory hygiene in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This response provides the patient with accurate and reassuring information about the EKG procedure. It explains that the test is painless and describes what will happen during the test. The other responses do not provide as much information or reassurance to the patient.
Correct Answer is A
Explanation
Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.
Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.
While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.
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