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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Tiotropium is a long-acting bronchodilator, not a rescue inhaler for sudden shortness of breath.
It takes several hours to reach its full effect and is not designed to provide immediate relief during acute symptoms.
Using tiotropium for sudden shortness of breath could delay the use of a more appropriate rescue medication, potentially worsening the situation.
Choice B rationale:
While tiotropium can help reduce mucus production and make secretions easier to clear, this is not its primary mechanism of action.
The client's statement focuses on a potential side effect rather than demonstrating a clear understanding of the medication's intended purpose.
Choice C rationale:
The frequency of inhaler use depends on the specific medications prescribed. Some inhalers are used daily, while others are used only as needed for symptoms.
It's essential to follow the healthcare provider's instructions for each inhaler to ensure proper use and avoid potential drug interactions.
Choice D rationale:
This statement correctly reflects the appropriate use of tiotropium.
It's typically taken once daily via a handihaler device to maintain open airways and prevent COPD symptoms. Regular daily use is crucial for optimal effectiveness.
Correct Answer is C
Explanation
Choice A rationale:
Checking the patient's temperature again is not a priority at this time. The patient's temperature is within the normal range, and there is no indication that it is the cause of the patient's hypoxia.
Focusing on temperature measurement could delay more crucial interventions to address the patient's breathing difficulty.
Choice B rationale:
While monitoring the patient's heart rate is important, it is not the most immediate priority in this situation. The patient's heart rate is elevated, but it is not dangerously high.
The elevated heart rate is likely a compensatory response to the patient's low oxygen saturation. Addressing the underlying cause of the hypoxia, which is likely respiratory in nature, will also help to stabilize the heart rate.
Choice C rationale:
Observing the patient's breathing is the most important action the nurse can take at this time. The patient's respirations are rapid and shallow, indicating respiratory distress.
This is a serious condition that requires immediate intervention. By observing the patient's breathing, the nurse can assess the severity of the distress and determine the best course of action.
The nurse can observe for signs of increased work of breathing, such as use of accessory muscles, nasal flaring, and retractions. They can also auscultate the lungs to assess for any abnormal breath sounds, such as wheezing or crackles.
This information will help the nurse to determine the underlying cause of the respiratory distress and to initiate appropriate interventions, such as administering oxygen, positioning the patient, or calling for assistance from a respiratory therapist.
Choice D rationale:
Checking the patient's blood pressure is not a priority at this time. The patient's blood pressure is within the normal range. While it is important to monitor the patient's blood pressure, it is not the most immediate concern in this situation.
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