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 C
Explanation
Choice A Reason:
A client who is 3 days postoperative and has a nursing assistant helping him out of bed is at some risk for falls due to recent surgery and potential weakness. However, the presence of a nursing assistant reduces this risk significantly. Postoperative clients are often monitored closely and assisted with mobility to prevent falls.
Choice B Reason:
An adolescent client who has a leg fracture and has been using crutches for the past 2 weeks is at risk for falls due to the use of crutches and limited mobility. However, adolescents generally have better balance and coordination compared to older adults, and they adapt quickly to using mobility aids.
Choice C Reason:
An older adult client who is confused and has urinary frequency is at the greatest risk for falls. Confusion can lead to disorientation and poor judgment, increasing the likelihood of falls. Urinary frequency can cause the client to rush to the bathroom, further increasing fall risk. Older adults also tend to have decreased strength and balance, compounding the risk.
Choice D Reason:
A client with diabetes mellitus who has a leg ulcer is at risk for falls due to potential neuropathy and impaired mobility. However, this risk is generally lower compared to a confused older adult with urinary frequency. The leg ulcer may cause some mobility issues, but it does not typically lead to the same level of disorientation and urgency as urinary frequency.
Correct Answer is D
Explanation
The correct answer is d) Tighten the abdominal muscles while exhaling.
Choice A Reason:
“Raise both shoulders while breathing deeply” is incorrect. Diaphragmatic breathing focuses on using the diaphragm rather than the shoulders. Raising the shoulders can lead to shallow chest breathing, which is less effective for oxygen exchange.
Choice B Reason:
“Inhale through the mouth” is incorrect. For diaphragmatic breathing, it is recommended to inhale through the nose. This helps filter, warm, and humidify the air before it reaches the lungs.
Choice C Reason:
“Exhale through the nose” is incorrect. While exhaling through the nose is beneficial in some breathing exercises, diaphragmatic breathing typically involves exhaling through pursed lips. This technique helps slow down the exhalation and keeps the airways open longer.
Choice D Reason:
“Tighten the abdominal muscles while exhaling” is correct. Tightening the abdominal muscles helps push the diaphragm up, forcing air out of the lungs more efficiently. This action is a key component of effective diaphragmatic breathing.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today