A nurse is caring for a client who has pneumonia on a medical-surgical unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale
The nurse should administer a bronchodilator and prepare the client for intubation because the client is likely experiencing respiratory acidosis and respiratory distress. The nurse should then monitor for the correct placement of the ETT following intubation as well as the client's arterial blood gases to normalize.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While assessing sputum is important to determine its color, consistency, and amount, it is not the priority before performing percussion, vibration, and postural drainage. The nurse should first assess the patient's overall respiratory status.
B. Assessing pulse and respirations is the first step in ensuring the patient's baseline respiratory status is stable before performing respiratory therapies. This allows the nurse to detect any signs of distress or abnormal respiratory patterns, which could indicate the need for further intervention before the procedure.
C. Auscultating lung fields is important for evaluating the effectiveness of the percussion and drainage procedure, but the initial assessment should include vital signs, such as pulse and respirations, to ensure the patient is stable.
D. Instructing the patient to slowly exhale with pursed lips is a helpful technique for managing respiratory distress, but it is not the first priority before conducting percussion or postural drainage. The nurse should first assess vital signs.
Correct Answer is C
Explanation
A. It is appropriate to notify the physician if bright red blood is found in the NG tube, as this could indicate bleeding, which requires prompt medical attention.
B. It is standard practice to keep the NG tube taped and secured to the patient’s nares to prevent dislodgement and ensure proper function.
C. A temperature under 100.5°F is generally not a cause for concern postoperatively, unless it is persistent or accompanied by other signs of infection. Typically, a low-grade fever is expected after surgery, but further investigation is only warranted for higher fevers or other concerning symptoms.
D. Irrigating the NG tube every 6 hours with 30 mL of normal saline is standard practice to ensure patency of the tube and prevent clogging.
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