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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Enteric-coated medications are designed to dissolve in the small intestine rather than the stomach. This is important for ileostomy patients because medications that dissolve in the stomach may be poorly absorbed or can cause irritation to the stoma or the small intestine.
B. It's recommended to empty the ostomy pouch when it's about one-third to half full to prevent leakage or discomfort.
C. How often the pouch system needs to be changed can vary depending on individual factors such as skin sensitivity, output consistency, and the type of pouch system used. Generally, changing the pouch system every 3-7 days is recommended.
D. High fiber foods can increase stool output and gas production, which can be challenging for individuals with an ileostomy. However, fiber is important for overall digestive health, so moderation rather than avoidance is typically recommended.
Correct Answer is ["B","D"]
Explanation
A. Butter is a dairy product, but it is not typically high in potassium. It is generally safe for clients following a low-potassium diet. Therefore, clients do not need to avoid butter specifically for its potassium content.
B. Yogurt, especially the varieties that are not low-fat or non-fat, can have a significant amount of potassium.
C Pears are generally considered low in potassium and are usually safe to include in a low-potassium diet.
D. Orange juice is a fruit juice and is naturally high in potassium. Clients should avoid or limit orange juice when following a low-potassium diet due to its potassium content.
E. Cabbage is a vegetable that is generally low in potassium. It is safe for clients following a low-potassium diet and does not need to be avoided for its potassium content.
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