A nurse is caring for a client diagnosed with pneumonia and assesses labored breathing and copious tracheobronchial secretions. What priority action should the nurse encourage with the client?
Limit oral fluids to minimize labored breathing.
Perform pursed-lip breathing to expel trapped carbon dioxide from the alveoli
Lie in a low Fowler's position to promote lung expansion
Perform hourly incentive spirometry to inflate lungs and mobilize secretions.
The Correct Answer is D
A. Limit oral fluids to minimize labored breathing: This action is not appropriate, as adequate hydration is important for thinning mucus secretions, making it easier for the client to expectorate them. Limiting fluids could lead to thicker secretions, which may worsen the client’s respiratory distress and increase the difficulty of clearing secretions. Therefore, this approach is not suitable for a client with pneumonia and respiratory compromise.
B. Perform pursed-lip breathing to expel trapped carbon dioxide from the alveoli: While pursed-lip breathing can help with exhalation and improve oxygenation, it does not directly address the need to mobilize and clear copious secretions. This technique is beneficial in managing dyspnea and improving ventilation but is not the priority action when the client has significant secretions that need to be cleared.
C. Lie in a low Fowler's position to promote lung expansion: A low Fowler's position (30 degrees) is less effective for promoting lung expansion compared to higher Fowler's positions. Semi-Fowler's (30-45 degrees) or high Fowler's (greater than 45 degrees) positions are more beneficial for improving lung expansion and facilitating breathing in clients with respiratory distress. Therefore, this option does not provide the most effective intervention for the client's condition.
D. Perform hourly incentive spirometry to inflate lungs and mobilize secretions: This is the priority action for the nurse to encourage, as incentive spirometry is specifically designed to help inflate the lungs and improve lung function. It promotes deep breathing, which can enhance ventilation, prevent atelectasis, and facilitate the mobilization of secretions. Regular use of incentive spirometry is essential in managing pneumonia and can significantly improve respiratory outcomes for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Poorly coordinated care and nosocomial infections are examples of errors: While poorly coordinated care can lead to adverse events, nosocomial infections are typically classified as healthcare-associated infections rather than errors. Errors generally refer to mistakes made in clinical practice that can lead to harm, whereas nosocomial infections are outcomes that arise from the healthcare environment.
B. As many as 90% of medication errors are preventable: This statement is true and highlights the significant opportunity for improvement in patient safety. Recognizing that a large percentage of medication errors can be prevented underscores the importance of implementing safety protocols, effective communication, and education to reduce the likelihood of errors occurring in clinical practice.
C. Errors of execution are usually intentional and occur because of time or resource constraints: This statement is misleading, as errors of execution typically refer to mistakes made during the performance of a task rather than intentional actions. These errors often occur due to lack of knowledge, skill, or attention rather than being intentional, and they are not solely attributed to time or resource constraints.
D. Medication errors are adverse events: While medication errors can lead to adverse events, not all medication errors result in harm. An adverse event is defined as an injury caused by medical management rather than the underlying condition of the patient, so this statement is not entirely accurate. Medication errors can be classified as near misses or adverse events, depending on whether they resulted in harm to the patient.
Correct Answer is D
Explanation
A. Use many "I's" in the message: Overusing the word "I" can make a message seem self-centered and less engaging. Instead, a balanced approach that highlights accomplishments and skills without excessive focus on oneself is more effective. Using "I" sparingly helps maintain professionalism and keeps the focus on how the nurse's qualifications meet the needs of potential employers.
B. Be sure to remove your address and phone number and replace it with your email because your resume will be on the internet: While protecting personal information is important, completely removing contact details is not advisable. Including a professional email along with appropriate contact information allows potential employers to reach out directly. Instead of removing all personal contact information, consider using a professional email address while maintaining other essential contact details as needed.
C. Save your resume in .docx format: While .docx is a commonly used format, it is not the best choice for online job applications, as some applicant tracking systems may not parse it correctly. Instead, saving the resume as a PDF is often recommended, as it preserves formatting and is widely accepted by employers. Therefore, this option may not be the most effective recommendation.
D. Focus on selling yourself: This is a good recommendation for a nurse searching for a job. Effectively presenting skills, experiences, and accomplishments demonstrates to potential employers how the nurse can add value to their organization. A well-crafted resume and cover letter should highlight the nurse's qualifications, passion for nursing, and ability to meet the specific needs of the position and the organization. This approach can significantly enhance the chances of securing an interview and ultimately a job.
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