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 ["2"]
No explanation
Correct Answer is B
Explanation
A. Urinary frequency refers to the need to urinate more often than usual. It does not typically cause changes in the color, clarity, or odor of urine. It may be associated with conditions like urinary tract infections (UTIs) or other urinary issues but does not directly cause dark amber, cloudy, or foul-smelling urine.
B. A UTI is a common cause of changes in urine characteristics. Dark amber color can indicate concentrated urine due to dehydration or the presence of blood. Cloudiness suggests the presence of pus or bacteria, while an unpleasant odor can be due to bacterial growth. UTIs often cause these symptoms due to inflammation and infection of the urinary tract.
C. Urinary incontinence refers to involuntary loss of urine. It does not typically cause changes in the appearance or odor of urine unless it leads to urine pooling and subsequent bacterial growth, which could potentially cause odor. However, incontinence itself is not a direct cause of dark amber, cloudy urine with an unpleasant odor.
D. Urinary retention occurs when the bladder does not empty completely or at all. It can lead to concentrated urine (dark amber color) due to prolonged storage in the bladder. Cloudiness and an unpleasant odor can occur if there is bacterial growth in stagnant urine. Therefore, urinary retention can contribute to the observed urine characteristics.
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