A nurse is assessing a client who has a possible right pneumothorax.
Which of the following findings should the nurse expect?

The correct answer is choice c. Limit fluid intake with meals.

Choice A rationale:

Administering a bronchodilator after meals is not ideal because bronchodilators are typically given before meals to help open the airways and make breathing easier during eating.

Choice B rationale:

Ambulating the client before each meal might cause fatigue, making it harder for the client to eat and potentially decreasing their overall intake.

Choice C rationale:

Limiting fluid intake with meals can help prevent the client from feeling too full, which can make it easier for them to consume more solid food. This is particularly important for clients with COPD who may already have a reduced appetite and difficulty eating large amounts at once.

Choice D rationale:

Offering three large meals each day is not recommended for clients with COPD. Smaller, more frequent meals are generally better tolerated and can help prevent the feeling of fullness that can make breathing more difficult.

Question 1: The correct answer is Choice A - Stabilize the tube by taping it to the infant’s cheek.

Choice A Rationale: Stabilizing the nasogastric tube by taping it to the infant's cheek is crucial to prevent displacement, which could lead to complications such as misplacement into the respiratory tract or discomfort for the infant. Proper securing ensures the tube remains in the intended position, facilitating the safe and effective delivery of nutrients. This action aligns with standard nursing practices to promote patient safety and comfort during enteral feedings.

Choice B Rationale: Option B suggests positioning the infant in a supine position during feedings, which is incorrect. Placing the infant in a supine position increases the risk of aspiration due to the potential for reflux. Instead, the infant should be positioned upright or semi-upright with the head elevated to minimize the risk of regurgitation and aspiration.

Choice C Rationale: Aspiration of residual fluid from the infant's stomach and discarding it (Option C) is not recommended practice. Aspirated gastric contents should be measured and assessed for volume and color to evaluate gastrointestinal function and potential complications. Discarding the aspirate without evaluation could lead to the oversight of important clinical indicators or abnormalities in the infant's condition.

Choice D Rationale: Microwaving the infant's formula to a temperature of 41°C (105.8°F) (Option D) is an incorrect practice. Heating formula in a microwave can result in uneven temperature distribution, creating hot spots that may cause burns to the infant's delicate oral mucosa or esophagus. The preferred method for warming formula is to use a water bath or bottle warmer to achieve a consistent temperature close to body temperature (around 37°C or 98.6°F).