A nurse is caring for a client who is complaining of thick respiratory secretions that are difficult to clear. What should the nurse encourage the client to do to help clear those secretions?
Encourage the patient to drink more fluids.
Get a prescription for an antitussive agent.
Teach effective deep breathing.
Change the patient’s position every 2 hours.
The Correct Answer is A
Choice A reason: Encouraging the patient to drink more fluids is a primary intervention for managing thick respiratory secretions. Adequate hydration helps to thin the mucus, making it easier to expectorate. Fluids such as water, herbal teas, and clear broths are particularly effective. The normal daily fluid intake for an adult is about 2-3 liters, depending on individual needs and health conditions.
Choice B reason: Getting a prescription for an antitussive agent is not the best initial approach for managing thick respiratory secretions. Antitussive agents are used to suppress coughing, which can be counterproductive when trying to clear mucus from the respiratory tract. Instead, expectorants or mucolytics are more appropriate as they help to thin and loosen the mucus.
Choice C reason: Teaching effective deep breathing is beneficial for overall lung health and can help in mobilizing secretions. However, it is not as immediately effective as increasing fluid intake for thinning thick secretions. Deep breathing exercises can be part of a comprehensive respiratory care plan but should be combined with other interventions like hydration.
Choice D reason: Changing the patient’s position every 2 hours is a good practice for preventing complications such as pressure ulcers and promoting lung expansion. However, it is not specifically targeted at thinning thick respiratory secretions. Positional changes can aid in the drainage of secretions but are secondary to ensuring adequate hydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
Date of birth is an acceptable client identifier. The Joint Commission specifies that using the date of birth helps ensure accurate identification of the client. This identifier is unique to each individual and is less likely to be duplicated.
Choice B Reason:
Photograph identification is not typically listed as an acceptable identifier by the Joint Commission. While it can be useful in some settings, it is not one of the primary identifiers recommended for ensuring patient safety.
Choice C Reason:
Facility room number is not an acceptable client identifier. The Joint Commission explicitly states that room numbers should not be used as identifiers because they can change and are not unique to the individual.
Choice D Reason:
Client’s full name is an acceptable client identifier. Using the full name helps to accurately identify the client and match them with their medical records and treatment plans.
Correct Answer is A
Explanation
Choice A Reason:
A 24-hour urinary output of 380 mL indicates oliguria. Oliguria is defined as a urine output of less than 400-500 mL per day in adults. This condition can be caused by various factors, including dehydration, kidney dysfunction, or postoperative complications. Monitoring urine output is crucial for assessing kidney function and overall fluid balance, especially after major surgeries like a colon resection.
Choice B Reason:
A 24-hour urinary output of 550 mL is slightly above the threshold for oliguria. While it is still relatively low, it does not meet the strict criteria for oliguria, which is typically defined as less than 400-500 mL per day. This output suggests that the client is producing an adequate amount of urine, though it may still warrant close monitoring to ensure it does not decrease further.
Choice C Reason:
A 24-hour urinary output of 600 mL is within the normal range and does not indicate oliguria. Normal urine output for adults is generally considered to be around 800-2000 mL per day, depending on fluid intake and other factors. This output suggests that the client’s kidneys are functioning properly and that there is no immediate concern for oliguria.
Choice D Reason:
A 24-hour urinary output of 720 mL is also within the normal range and does not indicate oliguria. This output is closer to the lower end of the normal range but still suggests adequate kidney function. It is important to continue monitoring the client’s urine output to ensure it remains within a healthy range, especially after surgery.
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