A nurse is caring for a client diagnosed with left lower lobe pneumonia who experiences pain when coughing. Which intervention should the nurse include in the plan of care?
Limit ambulation to avoid fatigue associated with coughing.
Administer pain medication every two hours.
Encourage holding the chest with a pillow or hands.
Teach pursed-lip breathing technique and deep breathing.
The Correct Answer is C
Choice A reason:
Limiting ambulation is not typically recommended as part of the management for pneumonia. While rest is important, some movement is beneficial for preventing complications such as deep vein thrombosis. Ambulation should be encouraged as tolerated to promote circulation and prevent stasis of secretions.
Choice B reason:
Administering pain medication every two hours may not be necessary and could lead to overmedication. Pain management should be based on the client's reported pain levels and response to medication, with adjustments made as needed for effective relief.
Choice C reason:
Encouraging the client to hold their chest with a pillow or hands, known as splinting, can help reduce the pain experienced during coughing by providing support and stabilizing the chest wall. This technique is a non-pharmacological intervention that can effectively manage pain associated with coughing in pneumonia patients.
Choice D reason:
Teaching pursed-lip breathing and deep breathing techniques is beneficial for clients with respiratory conditions, including pneumonia. These techniques can help improve ventilation and oxygenation, but they are not specifically aimed at managing pain during coughing. However, they can be included as part of the overall respiratory care plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a reason:
Diuretic use is not typically associated with an increased risk of developing fibromyalgia. Diuretics are commonly used to treat conditions like hypertension and edema by helping the body eliminate excess fluid, but they do not contribute to the onset of fibromyalgia¹.
Choice b reason:
Emotional or physical trauma has been identified as a risk factor for fibromyalgia. Individuals who experience significant stress or traumatic events may develop the disorder due to changes in how their central nervous system processes pain. Stress can lead to long-lasting effects on the body and may trigger fibromyalgia or worsen its symptoms²³⁴.
Choice c reason:
Being overweight is not a direct risk factor for fibromyalgia, but it can exacerbate symptoms in those who have the condition. Excess weight can increase the strain on the body and may contribute to the chronic pain and fatigue associated with fibromyalgia. However, it is not considered a causative factor¹.
Choice d reason:
Being an adolescent male is not a recognized risk factor for fibromyalgia. The disorder is more commonly diagnosed in women, and while it can occur at any age, it is most often diagnosed during middle age. Gender and age alone are not sufficient to determine the risk of developing fibromyalgia.
Correct Answer is B
Explanation
Choice A Reason
A blood pressure of 120/80 mmHg is considered within the normal range and is an ideal target for most individuals being treated for hypertension. This finding would not typically alert the nurse to a side effect of lisinopril.
Choice B Reason
Serum potassium of 5.5 mEq/L is higher than the normal range, which is typically between 3.5 and 5.0 mEq/L. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. This is a known side effect of lisinopril, especially in clients with renal impairment, as it inhibits the renin-angiotensin-aldosterone system and reduces potassium excretion.
Choice C Reason
A heart rate of 80 beats per minute is within the normal range for adults, which is typically 60-100 beats per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.
Choice D Reason
A respiration rate of 16 breaths per minute is within the normal range for adults, which is typically 12-20 breaths per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.
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