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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Correct Answer is B
Explanation
Choice A rationale
While immunosuppressive drug therapy can facilitate organ rejection, it is not directly related to the development of chronic rhinosinusitis in patients who have undergone organ transplants.
Choice B rationale
Immunosuppressive drug therapy can indeed contribute to chronic rhinosinusitis. Patients who have undergone organ transplants are often on long-term immunosuppressive therapy to prevent organ rejection. This can make them more susceptible to infections, including chronic rhinosinusitis.
Choice C rationale
Chronic rhinosinusitis does not typically damage the transplanted organ. It primarily affects the sinuses and nasal passages.
Choice D rationale
All of the above is not the correct answer because Choices A and C are not accurate in the context of chronic rhinosinusitis in patients who have undergone organ transplants.
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