A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?

Encourage the client to cough and deep breathe.

Obtain the client's temperature.

Encourage the client to increase oral fluids.

Provide chest percussion on the client.

Answer and Explanation

The Correct Answer is A

A.   This action helps the client to clear pulmonary secretions and improve ventilation. Coughing and deep breathing exercises are essential for maintaining airway patency and preventing complications such as atelectasis and respiratory distress.
B.   Monitoring the client's temperature is important to assess for fever, which can indicate infection severity or response to treatment. However, in a client actively coughing up secretions, immediate interventions to promote airway clearance take precedence over obtaining temperature.
C.   Adequate hydration can help liquefy pulmonary secretions, making them easier to expectorate. However, this action is secondary to promoting effective coughing and deep breathing to clear secretions already present in the airways.

D.   Chest percussion can help loosen and mobilize secretions in the lungs. However, this intervention requires assessment of the client's respiratory status and may not be appropriate as the first action without first assessing the client's tolerance and condition.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Stiffness in the lower extremities can occur due to lack of movement and muscle disuse. Prolonged immobility leads to muscle atrophy and contractures, causing stiffness and reduced range of motion. This is a common complication seen in clients who are bedridden or have limited mobility.
B. A reddened area over the sacrum indicates a potential pressure injury or pressure ulcer. Immobility increases the risk of pressure ulcers due to prolonged pressure on bony prominences, such as the sacrum. Regular repositioning and pressure relief strategies are essential to prevent skin breakdown in immobile clients.
C. Difficulty hearing certain types of sounds is not typically associated with immobility. It may be related to age-related changes in hearing or other auditory issues but is not a direct complication of immobility.
D. Difficulty moving the upper extremities can occur due to muscle weakness or disuse atrophy, which can result from immobility. However, it is less common compared to stiffness and difficulty in the lower extremities because upper extremities are often more frequently moved or exercised even in bedridden clients.

A. Clamp the chest tubes if it becomes disconnected B. Maintain the drainage container below the level of the client's chest. C. Empty the collection container every shift. D. Add tap water as needed to the suction control chamber.

Correct Answer is B

Explanation

A. Clamping the chest tubes is contraindicated because it can lead to tension pneumothorax, a life- threatening condition where air accumulates in the pleural space under pressure. If the chest tube becomes disconnected, the nurse should immediately place the end of the tube in sterile water to maintain the water seal and prevent air from entering the pleural space.
B. The drainage container must always be kept below the level of the client's chest. This position allows gravity to facilitate drainage from the pleural space into the collection chamber. If the container is positioned above the client's chest, drainage could potentially flow back into the pleural space, leading to complications.
C. It is essential to monitor and record the amount and characteristics of drainage regularly. Emptying the collection container at least once every shift ensures accurate measurement of drainage output and helps in assessing the client's response to treatment.
D. The water-seal chamber of the chest drainage system maintains the desired amount of suction (usually
-20 cm H2O) to facilitate lung re-expansion. This chamber should be filled with sterile water to the recommended level, usually marked on the device. Adding tap water can introduce contaminants and should be avoided.

View Question and Answer

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

A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

Correct Answer is B

Explanation

The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

A nurse is preparing to administer dextrose 5% in water (DSW) 100 mL to infuse over 1 hr. The drop factor of the manual IV tubing is 15 gtt/ml. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. She tells the nurse. "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse?

A nurse is preparing to administer morphine 15 mg subcutaneously. The amount available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is preparing to lift a box of supplies in the supply room. Which of the following body mechanics should the nurse plan to use?

A nurse is assisting with developing the plan of care for a client who requires airborne precautions. Which of the following actions should the nurse suggest?

A nurse is reinforcing teaching about a high-fiber diet with a client who has constipation. Which of the following statements indicates the client understands the best choice for a high-fiber diet?

A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?