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 D
Explanation
A. Hypercalcemia can lead to muscle weakness and fatigue rather than hypotonicity. High calcium levels affect neuromuscular function, potentially causing muscle weakness and decreased muscle tone rather than increased flaccidity.
B. Chvostek's sign is a clinical sign of hypocalcemia, not hypercalcemia. It is characterized by facial muscle twitching in response to tapping the facial nerve just anterior to the ear. Therefore, a positive Chvostek's sign would not be expected in hypercalcemia.
C. Hypercalcemia can cause gastrointestinal disturbances such as constipation rather than diarrhea. High calcium levels can lead to decreased smooth muscle contractility in the intestines, resulting in constipation rather than increased motility leading to diarrhea.
D. Hypercalcemia can lead to a variety of cardiovascular effects, including arrhythmias. Tachycardia can occur as a result of increased sensitivity of the heart to catecholamines and altered electrical conductivity in hypercalcemia.
Correct Answer is C
Explanation
A. This description is more indicative of a stage 1 pressure ulcer, where the skin is intact but shows non- blanchable redness. Stage 1 ulcers do not involve skin loss.
B. This description might indicate a stage 2 pressure ulcer, where there is partial-thickness skin loss involving the epidermis and/or dermis. Stage 2 ulcers are characterized by shallow open ulcers with a red- pink wound bed, without slough.
C. This description accurately defines a stage 3 pressure ulcer. Stage 3 ulcers involve full-thickness skin loss where adipose (fat) tissue may be visible, but deeper structures such as muscle, tendon, and bone are not exposed.
D. Slough refers to yellow, tan, gray, green, or brown necrotic tissue in the wound bed that must be removed to facilitate wound healing. Slough can be present in both stage 3 and stage 4 pressure ulcers, where stage 4 involves full-thickness skin loss with exposure of muscle, bone, or supporting structures.
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