A nurse is reinforcing teaching with a client who has pleurisy. Which of the following statements by the client indicates an understanding of the teaching?
“I should expect to develop a fever and a productive cough."
"This condition is chronic."
"I should lie on the affected side."
"I should take shallow breaths while I have pleurisy."
The Correct Answer is C
A. Pleurisy can be associated with fever due to inflammation, but a productive cough is not a defining characteristic of pleurisy. Pleurisy is often marked by sharp chest pain, especially during breathing or coughing, rather than a productive cough.
B. Pleurisy is typically an acute condition, often resulting from an infection or other inflammatory processes, such as pneumonia or autoimmune diseases. It is not classified as chronic unless there is a recurring underlying issue.
C. Lying on the affected side can help alleviate pain because it reduces movement of the pleura (the membranes surrounding the lungs) and may provide comfort. This demonstrates an understanding of the comfort measures that can be taken to manage pleuritic pain.
D. Patients with pleurisy should be encouraged to take deep breaths, as shallow breathing can lead to atelectasis (collapse of the lung) due to reduced lung expansion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Shortness of breath can indicate a serious respiratory issue, and this client may require immediate assessment and intervention. Respiratory distress can rapidly deteriorate a patient’s condition, making it essential to address this situation first.
B. While monitoring for pain relief and potential side effects is important, this client does not present an immediate threat to their health compared to the client experiencing shortness of breath. This client can be assessed after the more urgent cases.
C. Since the client is ambulatory and scheduled for an x-ray later, they can be seen after more critical needs have been addressed. Their situation is stable at this time.
D. While the discharge process is important, it can typically wait until more urgent situations are addressed. The nurse can prepare for the discharge but should focus on clients who have immediate health concerns first.
Correct Answer is D
Explanation
A. Chest physiotherapy can help mobilize secretions, but it primarily aids in clearing secretions rather than directly thinning them. While it may be beneficial as part of a comprehensive approach, it is not the most direct method for thinning secretions.
B. Prelubricating the suction catheter with saline does not effectively thin secretions. In fact, using saline in this way may introduce moisture that could inadvertently lead to complications, such as introducing infection or causing the client to cough.
C. While hyperventilation and providing oxygen are important for maintaining oxygen saturation during suctioning, this method does not help in thinning secretions. It may be used to ensure oxygenation during suctioning but is not effective for secretion management.
D. Providing humidified oxygen is an effective way to thin secretions. Humidity adds moisture to the airways, which can help to keep secretions less viscous and easier to clear. This is a standard practice in managing secretions in clients with tracheostomies.
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