A nurse is caring for a client diagnosed with pneumonia who has labored breathing and copious tracheobronchial secretions.
What priority action should the nurse encourage with the client?
Limit oral fluids to minimize labored breathing.
Lie in a low Fowler’s position to promote lung expansion.
Perform hourly incentive spirometry to inflate lungs and mobilize secretions.
Perform pursed lip breathing to expel trapped carbon dioxide from the alveoli.
The Correct Answer is C
Choice A rationale
Limiting oral fluids is not the best action for a client with pneumonia and copious tracheobronchial secretions. Adequate hydration can actually help thin and loosen pulmonary secretions, making them easier to expel.
Choice B rationale
While lying in a low Fowler’s position can aid in lung expansion, it is not the priority action in this case. The client has copious tracheobronchial secretions, and the most effective way to mobilize these secretions is through incentive spirometry.
Choice C rationale
Performing hourly incentive spirometry can help inflate the lungs and mobilize secretions, which is particularly beneficial for a client with pneumonia who has copious tracheobronchial secretions. This is the priority action as it directly addresses the client’s issue of labored breathing due to excessive secretions.
Choice D rationale
Pursed lip breathing is a technique used primarily to slow the pace of breathing and can help maintain open airways longer. However, it is not the most effective method for mobilizing tracheobronchial secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Dyspnea, or difficulty breathing, is a common symptom of Obstructive Sleep Apnea (OSA). This occurs due to the repeated episodes of upper airway obstruction and resultant intermittent hypoxia.
Choice B rationale
Insomnia is not a typical symptom of OSA. While individuals with OSA may experience disrupted sleep, it is usually characterized by excessive daytime sleepiness rather than an inability to sleep.
Choice C rationale
Snoring is a hallmark symptom of OSA. It occurs due to the partial obstruction of the upper airway, which causes vibration of the tissues and results in the sound of snoring.
Choice D rationale
Daytime sleepiness is a common symptom of OSA. This is due to the repeated awakenings throughout the night to resume breathing, which disrupts the sleep cycle and leads to excessive sleepiness during the day.
Choice E rationale
Dyspnea on exertion is not a typical symptom of OSA. While it can occur in severe cases, it is more commonly associated with conditions that affect the heart or lungs, such as heart failure or chronic obstructive pulmonary disease.
Correct Answer is A
Explanation
Choice A rationale
Restlessness in a client with a tracheostomy could indicate respiratory distress or hypoxia. It’s important for the nurse to further assess the client’s vital signs, oxygen saturation, and overall appearance.
Choice B rationale
A SaO2 of 92% on 40% humidified oxygen via tracheostomy collar is within the acceptable range for a client with a tracheostomy. However, it’s important to consider the client’s baseline SaO2 and any changes in their condition.
Choice C rationale
Scattered rhonchi throughout the lung fields could indicate secretions in the airways. However, this finding alone does not necessarily indicate a problem with the tracheostomy.
Choice D rationale
Suctioning of thin clear secretions from a tracheostomy is a routine part of tracheostomy care. This finding does not necessarily indicate a problem with the tracheostomy.
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