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 C
Explanation
A. Partial non-rebreathing mask:
This mask delivers higher concentrations of oxygen than a nasal cannula. It has a reservoir bag that allows the client to rebreathe some exhaled air, increasing the oxygen concentration delivered. However, it may not be necessary for a client with mild shortness of breath and slightly reduced oxygen saturation.
B. Simple (Oxy Plus) mask:
The simple mask provides a higher concentration of oxygen than a nasal cannula but lacks the reservoir bag found in the non-rebreathing mask. It is generally used for moderate oxygen needs. However, it might be more than what is required for a client with mild shortness of breath and slightly reduced oxygen saturation.
C. Nasal cannula:
Nasal cannulas are commonly used for clients with mild respiratory distress. They deliver a lower to moderate concentration of oxygen and are well-tolerated by most clients. They are suitable for individuals with mild shortness of breath and can be adjusted based on the required flow rate.
D. Non-rebreathing mask:
The non-rebreathing mask provides the highest concentration of oxygen among the options listed. It includes a reservoir bag to deliver a higher oxygen concentration. It is typically reserved for clients with higher oxygen requirements. For a client with mild shortness of breath and slightly reduced oxygen saturation, this may be more than necessary.
Correct Answer is B
Explanation
A. International normalized ratio (INR):
INR is a test used to monitor the effectiveness of anticoagulant therapy, particularly drugs like warfarin. It measures the time it takes for blood to clot. It's not directly related to assessing heart failure but is more associated with monitoring anticoagulation status.
B. Brain natriuretic peptide (BNP):
BNP is a peptide released by the heart in response to increased pressure and volume in the heart, often seen in heart failure. Elevated BNP levels can indicate the presence of heart failure. It's a useful diagnostic marker for heart failure.
C. Troponin:
Troponin is a protein released into the blood when there is damage to the heart muscle, usually during a heart attack. It is not specific to heart failure but is commonly used to diagnose myocardial infarction (heart attack).
D. Creatinine:
Creatinine is a waste product that comes from the normal wear and tear on muscles. While elevated creatinine levels can be seen in conditions affecting kidney function, it's not a direct marker for assessing heart failure. However, kidney function is often evaluated in conjunction with heart failure assessments.
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