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 C
Explanation
A. Glucagon is administered to increase blood glucose levels in hypoglycemic states. However, the client's glucose level is within the normal range (72 mg/dL), so administering glucagon is not appropriate.
B. Chvostek's sign is assessed to detect hypocalcemia, not hypokalemia. It involves tapping the facial nerve anterior to the earlobe and observing for facial muscle contraction. This action is not relevant to the potassium level and is not indicated based on the laboratory findings provided.
C. The client's potassium level of 3.0 mEq/L is below the normal range, indicating hypokalemia. Potassium replacement is essential to prevent complications such as cardiac arrhythmias. The nurse should follow the facility's protocol for administering potassium replacement, which may include adjusting the TPN solution or administering intravenous potassium supplements.
D. Discontinuing the TPN infusion is not warranted based solely on the potassium level. The TPN infusion provides essential nutrition and should not be stopped without addressing the electrolyte imbalance separately.
Correct Answer is C
Explanation
A. Place the client in a high Fowler's position:High Fowler’s would increase intra-abdominal pressure and strain sutures. For peritonitis recovery, semi-Fowler’s is preferred-promotes drainage of peritoneal fluid into the pelvis, preventing spread to diaphragm and lungs.
B. Ambulate the client twice daily:Too early after peritonitis lavage. Initially, the client is very weak, at risk for sepsis/shock. Early ambulation is not a priority here.
C. Mark abdominal girth once daily:Abdominal girth measurement is important to monitor for distention, fluid accumulation, or bleeding. Marking ensures accuracy in repeated measurements. This is a key intervention in monitoring postop peritonitis.
D. Irrigate the nasogastric tube with tap water:Never irrigate with tap water (risk of electrolyte imbalance, infection). Only sterile normal saline or as prescribed is used.
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