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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Collective bargaining activity at a nearby hospital may be of interest, but it is not directly related to the quality improvement of the unit.
Choice B rationale
Systems that make it difficult for the nurses to do their job directly impact the quality of care provided in the unit. Addressing these issues can lead to improvements in workflow, patient care, and nurse satisfaction.
Choice C rationale
While nurse pay is an important issue, it is typically addressed through human resources or union negotiations, not a unit-based quality improvement project.
Choice D rationale
The number of medication errors committed by another nurse is a serious concern, but it is a specific personnel issue. It should be addressed, but it may not reflect the overall quality of the unit.

A. Think critically. B. Evaluate outcomes at the start of the shift. C. Communicate the plan. D. Plan and report outcomes. E. Evaluate outcomes at the end of the shift.

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

Explanation

Choice A rationale
Thinking critically is a fundamental skill in nursing. It involves the ability to question, analyze, and evaluate care processes and outcomes. Critical thinking allows nurses to make informed decisions, prioritize tasks, and solve problems efficiently and effectively, which ultimately leads to safe, quality, patient-centered care.
Choice B rationale
Evaluating outcomes at the start of the shift is not typically recommended. Instead, continuous evaluation throughout the shift is more beneficial. This allows for timely interventions and adjustments to the care plan as needed.
Choice C rationale
Communication is a vital aspect of patient-centered care. Effective communication ensures that all members of the healthcare team, including the patient, are informed about the patient’s care plan. This promotes collaboration, improves patient outcomes, and enhances patient satisfaction.
Choice D rationale
Planning and reporting outcomes are crucial components of the nursing process. They enable the tracking of progress, facilitate communication among healthcare providers, and ensure that care is aligned with the patient’s goals.
Choice E rationale
Evaluating outcomes at the end of the shift is important as it provides an opportunity to assess the effectiveness of interventions, make necessary adjustments to the care plan, and ensure continuity of care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assigned to a quality improvement committee to decide on a quality improvement project for the unit. Which issues should the nurse discuss at the committee meeting?

Correct Answer is B

Explanation

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

Explanation

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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?