A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness.
Which action is most important for the nurse to instruct the client about self-care?

Increase the daily intake of oral fluids to liquefy secretions.

Call the clinic if undesirable side effects of medications occur.

Teach anxiety reduction methods for feelings of suffocation.

Avoid crowded enclosed areas to reduce pathogen exposure.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Liquefying secretions is the most crucial action to address the client's immediate respiratory concerns. Thickened mucus obstructs airflow, leading to shortness of breath, productive cough, and difficulty breathing upon exertion. Increasing fluid intake thins mucus, making it easier to expel and improving ventilation. This directly addresses the client's current symptoms and promotes airway clearance.

Hydration and Mucociliary Clearance: Adequate hydration is indispensable for optimal mucociliary clearance, the natural mechanism that removes mucus from the airways. Fluids moisten the respiratory tract, allowing cilia (tiny hair-like structures) to effectively move mucus upwards, where it can be coughed out or swallowed.

Thinning Mucus: Water acts as a natural expectorant, thinning mucus and reducing its viscosity. This makes it easier for the client to cough up the mucus, clearing the airways and reducing the sensation of breathlessness.

Decreasing Mucus Production: Dehydration can trigger the body to produce more mucus as a protective response. By staying hydrated, the client can help prevent excessive mucus production, further easing symptoms.

Supporting Overall Respiratory Health: Proper hydration maintains the health of the respiratory system's tissues and cells, promoting efficient gas exchange and reducing inflammation.

Preventing Dehydration-Related Complications: Dehydration can exacerbate respiratory problems and lead to other complications, such as fatigue, headaches, and impaired immune function. Maintaining adequate fluid intake helps prevent these issues.

Key points to emphasize to the client:

Drink fluids throughout the day, even if not feeling thirsty.

Water is the best choice, but clear broths, juices, and herbal teas can also contribute to fluid intake. Avoid caffeine and alcohol, as they can be dehydrating.

Monitor urine output to ensure adequate hydration (urine should be pale yellow or clear).

Increase fluid intake during periods of increased mucus production, such as during respiratory infections or exercise.

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Correct Answer is B

Explanation

Choice B rationale:

Isoniazid's Mechanism of Action:

It targets and inhibits the synthesis of mycolic acids, which are essential components of the cell wall of Mycobacterium tuberculosis, the bacteria that cause tuberculosis.

By disrupting cell wall formation, isoniazid prevents bacterial growth and multiplication, leading to the suppression and eventual eradication of the infection.

Clinical Manifestations of Active TB:

Persistent cough, often productive of sputum (phlegm), is a hallmark symptom of TB. The sputum may contain blood or have a rusty-colored appearance.

Other common symptoms include fever, night sweats, fatigue, weight loss, and chest pain. How Isoniazid Reduces Cough and Sputum:

As isoniazid effectively kills the TB bacteria, the inflammatory process within the lungs subsides.

This leads to a gradual decrease in the production of sputum, which is a direct result of the inflammatory response. Consequently, the frequency and severity of coughing episodes also diminish.

Monitoring Treatment Response:

Regular sputum smears and cultures are essential to assess the response to treatment.

A positive sputum smear indicates the presence of live TB bacteria, while a positive culture confirms their growth in the laboratory.

A gradual decrease in the number of bacteria seen on sputum smears, followed by negative cultures, signals a favorable response to treatment.

Timeframe for Improvement:

It's important to note that clinical improvement, including a reduction in cough and sputum, may not be immediately evident. It typically takes several weeks of consistent isoniazid therapy to achieve noticeable results.

Therefore, adherence to the prescribed treatment regimen is crucial for successful TB eradication. Addressing Other Choices:

Choice A: Decreased appetite and weight loss are often associated with active TB due to systemic inflammation and nutritional deficiencies. While isoniazid treatment may indirectly improve appetite and weight gain over time, these are not primary indicators of its effectiveness in suppressing the TB infection itself.

Choice C: Vertigo and tinnitus are potential side effects of isoniazid, but they do not reflect its efficacy in treating TB.

Choice D: A positive sputum smear and culture would indicate ongoing TB infection and a lack of response to treatment.

A. Observe for edema around the ankles. B. Count the apical and radial pulses simultaneously. C. Measure the patient’s capillary glucose level. D. Auscultate the patient’s bowel sounds.

Correct Answer is D

Explanation

Rationale for Choice A:

Observing for edema around the ankles is a relevant assessment, but it's not the most crucial one in this context. Edema can be a sign of fluid retention, which is a potential side effect of hydromorphone. However, it's not the most immediate or dangerous concern associated with prolonged hydromorphone use.

Rationale for Choice B:

Counting the apical and radial pulses simultaneously is a technique used to assess for pulse deficits, which can indicate heart rhythm irregularities. While hydromorphone can potentially cause cardiac effects, it's not the most common or primary concern with its use. Other assessments take priority.

Rationale for Choice C:

Measuring the patient's capillary glucose level is important for patients with diabetes or those at risk for hyperglycemia. However, there's no direct link between hydromorphone use and blood glucose levels. This assessment isn't the most relevant in this specific scenario.

Rationale for Choice D:

Auscultating the patient's bowel sounds is the most important assessment for a patient who has been receiving hydromorphone for four days. Here's why:

Hydromorphone is a potent opioid analgesic that can significantly slow down gastrointestinal motility. This can lead to constipation, which, if severe, can progress to ileus (a complete lack of bowel movement).

Ileus is a serious complication that can cause abdominal pain, bloating, nausea, vomiting, and even bowel obstruction or perforation if left untreated.

Auscultating bowel sounds helps assess the patient's bowel activity and detect early signs of constipation or ileus. Normal bowel sounds are typically heard every 5-15 seconds. Decreased or absent bowel sounds can indicate decreased bowel activity.

Early identification of constipation or ileus allows for prompt intervention, such as increasing fluid and fiber intake, administering laxatives or stool softeners, and potentially discontinuing or adjusting the hydromorphone dosage. This can prevent the development of more serious complications.

Therefore, auscultating the patient's bowel sounds is the most important assessment for the nurse to complete in this case, as it directly addresses the most significant potential complication associated with prolonged hydromorphone use.

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Naxlex Comprehensive Predictor Exams

The antitubercular drug isoniazid is prescribed for a client with active tuberculosis.To evaluate the effectiveness of this medication, which outcome can the nurse expect this client to exhibit?

Correct Answer is B

Explanation

The nurse notes that a patient has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Correct Answer is D

Explanation

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