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.

Answer and Explanation

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.

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Correct Answer is ["A","B","D"]

Explanation

Choice A reason:
Being free of chest pain and dyspnea is a significant indicator of successful nursing intervention in a sickle cell crisis. Chest pain and dyspnea can occur due to acute chest syndrome, a life-threatening complication of sickle cell disease characterized by vaso-occlusion in the pulmonary microcirculation. Effective pain management and oxygen therapy can alleviate these symptoms, reflecting improved respiratory function and gas exchange.

Choice B reason:
Educating the client on the importance of increasing fluid intake is crucial in managing sickle cell crisis. Adequate hydration helps to reduce blood viscosity and prevent sickling of red blood cells, which can lead to vaso-occlusive episodes. When a client verbalizes understanding and the importance of hydration, it demonstrates the effectiveness of patient education and the client's engagement in self-care.

Choice C reason:
While increasing aerobic exercises may promote endurance, it is not typically a short-term outcome measure for a sickle cell crisis. Exercise must be approached with caution in these clients, as it can increase the risk of a vaso-occlusive crisis due to dehydration and increased oxygen demand during a sickle cell crisis.

Choice D reason:
Control of acute pain to a level of 3 on a standard pain scale indicates successful pain management, a primary goal in the treatment of sickle cell crisis. Pain in sickle cell crisis is due to ischemia from obstructed blood flow by sickled cells. Effective analgesic administration and pain management strategies are essential to achieve this outcome.

Choice E reason:
A leukocyte count of 18,000/mm³ is above the normal range (4,500 to 11,000/mm³) and may indicate an infection or inflammation, which are common complications of sickle cell disease. However, this is not a direct outcome of nursing interventions aimed at managing a sickle cell crisis and thus is not a correct choice.

A. Glucose level at least 600 mg/dL B. Fruity, acetone smell to the breath C. Absence of ketones in the urine D. Polyuria and polydipsia E. Rapid, deep breathing.

Correct Answer is ["B","D","E"]

Explanation

Choice A Reason:
A glucose level of at least 600 mg/dL is more indicative of hyperglycemic hyperosmolar state (HHS) rather than diabetic ketoacidosis (DKA). While both conditions involve high blood sugar levels, DKA is typically characterized by blood glucose levels that are high but not as extreme as those seen in HHS1.

Choice B Reason:
A fruity, acetone smell to the breath is a classic sign of DKA. This odor is due to the presence of ketones, particularly acetone, which is exhaled. It’s one of the key clinical manifestations that can help in the diagnosis of DKA.

Choice C Reason:
The absence of ketones in the urine would not be consistent with a diagnosis of DKA. One of the hallmarks of DKA is the presence of ketones in the urine, resulting from the breakdown of fats due to a lack of insulin.

Choice D Reason:
Polyuria (excessive urination) and polydipsia (excessive thirst) are symptoms of DKA. They occur as the body tries to eliminate excess glucose through the urine, which can lead to dehydration and the need to drink more fluids.

Choice E Reason:
Rapid, deep breathing, also known as Kussmaul respiration, is a compensatory mechanism for the acidosis seen in DKA. The body attempts to correct the acidic pH by exhaling more carbon dioxide.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

How can the nurse determine that the outcomes of nursing interventions have been successful for the client diagnosed with a sickle cell crisis? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

The nurse would assess for which clinical manifestations in a client suspected of having diabetic ketoacidosis? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

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