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.

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Initiate a weight-based continuous heparin infusion: Continuous heparin infusion is typically used for managing or preventing thromboembolic events, such as deep vein thrombosis or pulmonary embolism. In this scenario, the primary concern is a pneumothorax, and there is no indication that the client requires anticoagulation therapy at this time.

Prepare client for a chest tube insertion: Given the diagnosis of a right upper lobe pneumothorax, preparing the client for chest tube insertion is essential. A chest tube is necessary to evacuate air from the pleural space, restore negative pressure, and allow for lung re-expansion, which is critical in managing a pneumothorax.

Administer an analgesic: Administering an analgesic is essential to help manage the client's pain, which is likely due to the pneumothorax. Effective pain management can help reduce anxiety and improve the client's ability to breathe comfortably.

Insert an indwelling urinary catheter: Inserting an indwelling urinary catheter is not essential in this situation. The client has voided a sufficient amount of clear yellow urine, and there is no indication of urinary retention or other complications that would require catheterization.

Initiate supplemental oxygen: Initiating supplemental oxygen is essential for the client, who is exhibiting hypoxia with a pulse oximetry reading of 85% on room air. Providing supplemental oxygen will help improve oxygenation and alleviate respiratory distress.

A. Clubbing of the fingers B. Bradycardia C. Barrel chest D. Dyspnea E. Deep respirations

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

Explanation

A. Clubbing of the fingers: This finding is often associated with chronic respiratory conditions, including emphysema, due to prolonged hypoxia. The chronic low oxygen levels can lead to changes in the nail beds, resulting in clubbing as the body attempts to compensate for the decreased oxygenation. Therefore, clubbing is a common assessment finding in clients with emphysema.
B. Bradycardia: Emphysema typically does not cause bradycardia; instead, clients may experience tachycardia due to increased respiratory effort and oxygen demand. While individual variations can occur, bradycardia is not a standard finding in clients with emphysema, making this option less likely to be present.
C. Barrel chest: This is a common physical assessment finding in clients with emphysema. The chronic overinflation of the lungs leads to a characteristic increase in the anteroposterior diameter of the chest, resulting in a barrel-shaped appearance. This occurs as the diaphragm becomes flattened and the rib cage is expanded from prolonged air trapping.
D. Dyspnea: Shortness of breath, or dyspnea, is a hallmark symptom of emphysema. As the disease progresses, clients may experience increased difficulty in breathing, especially during exertion, due to the destruction of alveoli and reduced lung elasticity. This finding is expected and significant in the assessment of a client with emphysema.
E. Deep respirations: In emphysema, clients often exhibit shallow, rapid breathing patterns rather than deep respirations. The loss of elasticity in the lungs leads to difficulty in full lung expansion, which can result in a more shallow and increased respiratory rate. Therefore, deep respirations are not a typical finding in clients with emphysema.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits For each potential nursing action, click to specify if the action is essential, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

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

Explanation

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