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 D
Explanation
A. The client with a history of a myocardial infarction who has a p wave before every QRS complex.
This may indicate a heart block, which requires attention. However, it's not an immediate life-threatening situation.
B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.
Bilateral pitting pedal edema is a sign of fluid overload, which is concerning and requires attention.
C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue.
While bradycardia and fatigue are concerns, they might not be as urgent as the client with fluid overload.
D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.
New onset of severe indigestion in a client with coronary artery disease raises concern for a potential cardiac event, and this should be addressed promptly.
Correct Answer is ["125"]
Explanation
To calculate the amount of mL that the client should receive, we need to use the formula:
mL = (g * 5 mL) / mg
where g is the ordered dose of the medication, mg is the concentration of the medication, and mL is the volume of the solution.
Plugging in the given values, we get:
mL = (4 g * 5 mL) / 160 mg
Simplifying, we get:
mL = 0.125 g/mL
Multiplying by 1000 to convert grams to milligrams, we get:
mL = 125 mg/mL
Therefore, the client should receive 125 mL of the solution.
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