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","B","C","D"]
Explanation
Choice A rationale
Applying warm compresses can help relieve the pain and pressure associated with acute rhinosinusitis by reducing inflammation and promoting sinus drainage.
Choice B rationale
Completing prescribed antibiotics is crucial in treating acute bacterial rhinosinusitis. Antibiotics help eliminate the bacterial infection causing the inflammation and symptoms.
Choice C rationale
Smoking can irritate the nasal passages and exacerbate the symptoms of rhinosinusitis. Avoiding smoking can help reduce inflammation and promote healing.
Choice D rationale
Swimming, especially in chlorinated pools, can irritate the nasal passages and sinuses, potentially worsening the symptoms of rhinosinusitis. It’s recommended to avoid swimming until the condition has resolved.
Choice E rationale
Periorbital edema is not a normal finding and could indicate a complication of rhinosinusitis, such as a spread of the infection. If a client notices this symptom, they should seek medical attention.
Correct Answer is A
Explanation
Choice A rationale
In a client diagnosed with chronic obstructive pulmonary disease (COPD), an arterial blood gas (ABG) test would typically show an increased level of carbon dioxide (PaCO2)56. This is because COPD affects the ability of the lungs to expel carbon dioxide, leading to its buildup in the blood.
Choice B rationale
An increased pH is not typically seen in COPD. In fact, due to the increased carbon dioxide (which is acidic), the pH may be lower, indicating respiratory acidosis.
Choice C rationale
Decreased alveolar function is a characteristic of COPD, but it is not something that would be directly measured in an ABG test.
Choice D rationale
An increased arterial oxygen (PaO2) is not typically seen in COPD. In fact, due to the impaired gas exchange, PaO2 may be lower.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
