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 ["4"]

Explanation

Formula:

Volume to administer (mL) = (Desired dose (mg) / Available concentration (mg/mL))

Desired dose = 1.6 mg

Available concentration = 2 mg / 5 mL

Calculate the concentration per mL:

2 mg / 5 mL = 0.4 mg/mL

Volume to administer = 1.6 mg / 0.4 mg/mL

= 4 mL

The nurse should administer 4 mL per dose.

A. Reports routinely list the identification number of any equipment involved. B. Reports routinely include the client's hospital number. C. Reports routinely are completed within 24 hr after the incident. D. Reports routinely omit the names of witnesses to the occurrence.

Correct Answer is D

Explanation

A. Reports routinely list the identification number of any equipment involved: This practice is appropriate and helps in tracking any equipment-related issues. Including identification numbers can assist in identifying problems with specific devices or tools and does not represent a problem that needs to be reported.
B. Reports routinely include the client's hospital number: Including the client's hospital number in reports is standard practice for maintaining accurate records and ensuring proper tracking of incidents related to specific patients. This does not indicate a problem and is essential for accountability in healthcare reporting.
C. Reports routinely are completed within 24 hr after the incident: Timeliness in completing incident reports is important, and completing them within 24 hours is a best practice. This indicates a proactive approach to addressing incidents and does not represent a problem that needs to be reported to the risk manager.
D. Reports routinely omit the names of witnesses to the occurrence: This is a significant issue that should be reported to the risk manager. Witnesses can provide valuable information about the circumstances surrounding an incident, and their names should be documented for follow-up and investigation. Omitting this information could hinder the thoroughness of the incident review and the organization’s ability to address and prevent future occurrences effectively.

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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 preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["4"]

Explanation

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Correct Answer is D

Explanation

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