A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?
Lie in a low Fowler’s or supine position
Increase oral fluids unless contraindicated
Increase activity
Call the nurse for oral suctioning as needed
The Correct Answer is D
A. Lie in a low Fowler’s or supine position:
Lying in a low Fowler's or supine position may worsen respiratory distress and compromise oxygenation. It can reduce lung expansion and increase the work of breathing, especially in patients with pneumonia. This is not a recommended position for individuals with respiratory issues.
B. Increase oral fluids unless contraindicated:
Increasing oral fluids is generally a good practice, especially in respiratory conditions like pneumonia. It helps thin respiratory secretions, making them easier to clear. However, this alone may not address copious tracheobronchial secretions. Suctioning may be needed to effectively remove excess secretions.
C. Increase activity:
Increasing activity may be beneficial for some patients, but it might exacerbate respiratory distress in others, especially if they are already experiencing increased work of breathing. The appropriateness of increasing activity depends on the specific condition and the patient's overall stability.
D. Call the nurse for oral suctioning as needed:
This is the most appropriate choice. If the client is experiencing increased work of breathing due to copious tracheobronchial secretions, calling the nurse for oral suctioning is an intervention aimed at maintaining a clear airway and alleviating respiratory distress. Regular suctioning may be necessary to assist the client in managing secretions effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Frequent change of position:
Frequent changes in position help prevent pooling of secretions and promote lung expansion. This simple and cost-effective measure is important in preventing complications related to immobility, such as pneumonia and atelectasis. It aids in maintaining optimal respiratory function.
B. Antibiotics: Antibiotics are used to treat bacterial infections and would not directly address the risks associated with decreased mobility.
C. Oxygen humidification: While oxygen therapy may be necessary in some cases, humidification is typically used to prevent drying of mucous membranes and is not a primary intervention for preventing complications of decreased mobility.
D. Chest physiotherapy: Chest physiotherapy involves techniques to mobilize respiratory secretions and may be indicated in specific situations. However, it is not as simple and cost-effective as frequent changes in position.
Correct Answer is ["0.75"]
Explanation
The nurse needs to calculate the correct dose of atropine for a client who has a prescription for 0.3 mg IV stat. The nurse knows that atropine is a medication that blocks the effects of the parasympathetic nervous system and is used to treat bradycardia, heart block, and some types of poisoning.
To find out how many milliliters of atropine the nurse will administer, the nurse can use the formula:
Dose ordered / Dose available = Volume to administer
Plugging in the values, the nurse gets:
0.3 mg / 0.4 mg per mL = 0.75 mL
Therefore, the nurse will administer 0.75 mL of atropine to the client IV stat.
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