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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Consulting the family priest may provide spiritual support and guidance to the family, but it is not the most appropriate action for resolving a medical and ethical dilemma. The family priest may not have the necessary medical or ethical expertise to address the complexities of the situation

Choice B reason: The ethics committee is the appropriate body to consult in this situation. Ethics committees are composed of healthcare professionals, ethicists, and legal advisors who can provide guidance on complex ethical issues. They can help navigate the conflict between the parents’ religious beliefs and the medical necessity of the blood transfusion for the newborn. The committee can also ensure that the hospital’s actions align with legal and ethical standards.

Choice C reason: The Joint Commission is an accrediting body for healthcare organizations and does not provide direct assistance in individual patient care situations. While the Joint Commission sets standards for ethical practices, it is not involved in resolving specific ethical dilemmas at the patient level.

Choice D reason: The blood bank is responsible for the collection, testing, and distribution of blood products. While they can provide information about blood transfusions, they are not equipped to handle ethical conflicts related to the refusal of blood transfusions on religious grounds. The ethics committee is better suited for this role.

A. Encourage coughing and deep breathing. B. Elevate the client to a high Fowler’s position. C. Administer prescribed analgesic medication. D. Administer oxygen at 2 L/min.

Correct Answer is D

Explanation

Choice A reason: Encouraging coughing and deep breathing is important for postoperative care to prevent complications such as atelectasis and pneumonia. However, with an oxygen saturation of 85%, the immediate priority is to address the client’s hypoxemia. Once oxygen levels are stabilized, coughing and deep breathing exercises can be encouraged.

Choice B reason: Elevating the client to a high Fowler’s position can help improve lung expansion and ease breathing. While this is a beneficial intervention, it is not the first priority when the client’s oxygen saturation is critically low. Administering oxygen should be the initial step to quickly improve oxygenation.

Choice C reason: Administering prescribed analgesic medication is essential for managing the client’s pain, which can also help improve breathing patterns. However, pain management should follow the immediate correction of hypoxemia. Ensuring adequate oxygenation takes precedence over pain relief in this scenario.

Choice D reason: Administering oxygen at 2 L/min is the first action the nurse should take. With an oxygen saturation of 85%, the client is experiencing significant hypoxemia, which needs to be corrected promptly to prevent further complications. Oxygen therapy will help increase the oxygen levels in the blood and improve the client’s overall condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a newborn requiring a life-saving blood transfusion. The parents are practicing Jehovah’s Witnesses and refuse the transfusion. Who would the nurse consult for assistance in this situation?

Correct Answer is B

Explanation

A nurse is caring for a client who has returned to the unit following a surgical procedure of the abdomen. The client is complaining of pain 6/10. On assessment, the client’s oxygen saturation is 85%. Which action should the nurse take first?

Correct Answer is D

Explanation

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