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.

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Correct Answer is C

Explanation

A. Apples are a good source of fiber, with about 4.4 grams of fiber in a medium-sized apple with the skin. Apples contain soluble and insoluble fiber, which can aid in digestion and help prevent constipation. This is a suitable choice for a high-fiber snack.
B. Almonds are nutritious and provide fiber, but they are not as high in fiber compared to other options like fruits, vegetables, and whole grains. One ounce of almonds contains about 3.5 grams of fiber. While almonds are beneficial, they are not typically the primary choice for increasing fiber intake to alleviate constipation.
C. Bran cereals are often recommended for their high fiber content. Half a cup of bran cereal can provide around 10 grams of fiber or more, depending on the brand and type. Bran cereals are particularly rich in insoluble fiber, which adds bulk to stool and helps promote regular bowel movements. This is an excellent choice for increasing fiber intake to manage constipation.
D. Sweet potatoes are nutritious and contain dietary fiber, with about 3.8 grams of fiber in half a cup of cooked sweet potatoes. While they contribute to fiber intake, they generally do not provide as much fiber compared to options like whole grains or bran cereals.

A. Protein B. Tea C. Sodium D. Water

Correct Answer is D

Explanation

A. Protein intake, especially animal protein (such as meat and dairy), can increase the excretion of calcium and other minerals into the urine, potentially leading to the formation of certain types of kidney stones (like calcium stones). Therefore, clients with a history of kidney stones are generally advised to moderate their intake of animal protein.
B. Some types of tea, particularly black tea, contain oxalates, which are substances that can contribute to the formation of calcium oxalate kidney stones in susceptible individuals. Therefore, clients with kidney

stones may be advised to limit their intake of tea, especially if they have a history of calcium oxalate stones.
C. High dietary sodium intake can increase calcium excretion in the urine, which may lead to the formation of calcium-containing kidney stones. Therefore, clients with kidney stones are often advised to reduce their sodium intake to help prevent stone formation.
D. Adequate fluid intake, primarily in the form of water, is crucial for preventing kidney stones. Increased water intake helps dilute urine and reduces the concentration of stone-forming substances, making it less likely for crystals to form and grow into stones. The goal is typically to produce at least 2 to 2.5 liters (about 8 to 10 cups) of urine per day.

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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

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Correct Answer is C

Explanation

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Correct Answer is D

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