A nurse formulates the problem of ineffective airway clearance for a client who has pneumonia. Which assessment data best supports this problem?

Respiratory rate of 24/min.

Weak, nonproductive cough.

Pulse oximetry (SpO2) of 90%.

Shortness of breath with activity.

Answer and Explanation

The Correct Answer is B

Choice A reason:
A respiratory rate of 24/min is slightly elevated, which can be expected in a client with pneumonia due to the body's attempt to increase oxygen intake and carbon dioxide elimination. However, this rate does not directly indicate ineffective airway clearance.

Choice B reason:
A weak, nonproductive cough is a key indicator of ineffective airway clearance. In pneumonia, the presence of secretions in the airways is common, and an effective cough is necessary to clear these secretions. A weak cough that does not produce sputum suggests that the client is unable to clear their airways effectively, which can lead to impaired gas exchange and worsening of symptoms.

Choice C reason:
Pulse oximetry (SpO2) of 90% indicates that the client's oxygen saturation is below the normal range, which is typically between 95-100% for healthy individuals. While this finding is concerning and warrants intervention, it is a result of ineffective airway clearance rather than a direct indicator of it.

Choice D reason:
Shortness of breath with activity is common in clients with pneumonia and can result from various factors, including impaired gas exchange, decreased lung compliance, and increased work of breathing. While it may be associated with ineffective airway clearance, it is not as specific as a weak, nonproductive cough for indicating this particular problem.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice a reason:
Risperidone is an antipsychotic medication that can help manage both positive symptoms (such as delusions and hallucinations) and negative symptoms (such as apathy and social isolation) of schizophrenia. Monitoring both types of symptoms is essential to evaluate the overall effectiveness of the treatment. Positive symptoms are often more responsive to medication, while negative symptoms can be more challenging to treat and may require a comprehensive approach including psychosocial interventions.

Choice b reason:
Disorganized symptoms, which include disorganized speech and behavior, are another aspect of schizophrenia that can be impacted by risperidone. While these symptoms are not mentioned in the client's current presentation, they are still important to monitor as part of a comprehensive assessment of the client's condition.

Choice c reason:
Negative symptoms like apathy and social isolation can significantly impact a client's quality of life and functional abilities. Risperidone can help improve these symptoms, but they often require longer treatment duration and additional supportive therapies for significant improvement.

Choice d reason:
Positive symptoms such as delusions and hallucinations are critical targets for risperidone treatment. These symptoms can be distressing and disruptive, and their improvement is a key indicator of the medication's effectiveness. Monitoring the reduction or resolution of these symptoms is crucial for assessing the client's response to risperidone.

A. Abdominal distention B. Hypoactive bowel sounds C. Diarrhea D. Fever

Correct Answer is A

Explanation

Choice A Reason:
Abdominal distention is a common finding in large bowel obstruction due to the accumulation of intestinal contents, gas, and fluid proximal to the obstruction site. This can lead to a visibly swollen abdomen and is often accompanied by discomfort or pain.

Choice B Reason:
Hypoactive bowel sounds are expected in large bowel obstruction as the peristaltic activity decreases below the point of obstruction. Initially, bowel sounds may be high-pitched or tinkling due to the intestine's attempt to move contents past the obstruction, but as the condition progresses, the sounds become less frequent or even absent.

Choice C Reason:
Diarrhea is not typically associated with large bowel obstruction. In fact, constipation or cessation of stool is a more common symptom. If diarrhea occurs, it may be due to a partial obstruction or the presence of liquid stool that can pass around the blockage.

Choice D Reason:
Fever may indicate a complication of large bowel obstruction, such as ischemia or perforation, leading to infection and inflammation. However, fever is not a primary symptom of uncomplicated large bowel obstruction and should prompt immediate further investigation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse formulates the problem of ineffective airway clearance for a client who has pneumonia. Which assessment data best supports this problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician prescribes risperidone for a client with schizophrenia who displays delusions, hallucinations, apathy, and social isolation. Which symptoms should be monitored to evaluate improvement?

Correct Answer is A

Explanation

A client is diagnosed with a large bowel obstruction. Which assessment findings by the nurse would be expected?

Correct Answer is A

Explanation

Two months after beginning drug therapy with alprazolam, a client states, "I feel much better, but I can't believe how dizzy and light-headed I get, and sometimes my mouth feels dry." Which would be the priority response by the nurse?

What environmental changes should the nurse make for a client who is experiencing perceptual alterations?

A nurse is assessing a client who has been taking simvastatin to treat hyperlipidemia. Which statement made by the client describes an adverse effect of the medication that should be reported to the provider immediately?

The nurse is teaching a client about preventing osteoporosis. Which statement made by the client indicates a need for further teaching? "I will:

When addressing a local community group on the topic of obesity, the nurse should include the following points:

The nurse is providing discharge teaching to a client with angina pectoris who is prescribed metoprolol 50 mg PO daily. Which information should the nurse include in the teaching?

The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:

After successfully losing one pound weekly for several months, an obese client at the clinic has not lost any weight for the last month. What should the nurse do first?