A patient's data shows consolidation in the right middle and lower lobe, consistent with pneumonia.
What actions can the nurse take to assist the patient in improving their ventilation and oxygenation? Select all that apply.
Provide suctioning so the patient does not have to cough.
Position the patient with the head of the bed elevated.
Encourage the patient to take breaks from the oxygen mask every few hours.
Ask the patient to do quick, shallow breaths.
Teach the patient to cough at least once an hour.
Avoid treating fever with antipyretics.
Assist the patient in ambulating safely.
Correct Answer : B,E,G
B. Position the patient with the head of the bed elevated. Rationale:
Promotes lung expansion: Elevating the head of the bed by at least 30 degrees utilizes gravity to assist in diaphragmatic descent and lung expansion. This allows for greater intake of air, optimizing oxygen intake and facilitating better gas exchange.
Reduces work of breathing: When upright, the abdominal muscles can more effectively aid in breathing, reducing the workload on the diaphragm and accessory muscles. This conserves energy and decreases the patient's respiratory effort.
Enhances secretion drainage: Gravity also aids in the movement of secretions from the lower lobes of the lungs towards the upper airways, where they can be more easily coughed up or suctioned. This helps to clear the airways and improve ventilation.
E. Teach the patient to cough at least once an hour. Rationale:
Clears secretions: Coughing is a natural mechanism to clear secretions from the lungs and airways. It helps to prevent mucus buildup and potential obstruction, which can lead to atelectasis (collapse of lung tissue) and further compromise ventilation.
Improves gas exchange: By removing secretions, coughing allows for better airflow and gas exchange within the lungs. This enhances oxygenation and helps to prevent respiratory complications.
G. Assist the patient in ambulating safely. Rationale:
Mobilizes secretions: Ambulation encourages movement of secretions from the lower lobes of the lungs, promoting their clearance and preventing mucus buildup.
Prevents atelectasis: Walking and movement help to expand the lungs, reducing the risk of atelectasis and improving overall ventilation.
Enhances circulation: Ambulation also improves circulation, which can help to deliver oxygen to the tissues more effectively and aid in healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Drinking plenty of water whenever thirsty is not the most appropriate action for a patient with hypernatremia. While it's important to stay hydrated, excessive water intake can potentially worsen hypernatremia by diluting blood sodium levels further. This is because the body tries to balance sodium levels by either retaining water or excreting it through urine. In hypernatremia, the body is already short on water relative to sodium, so consuming too much water can exacerbate the imbalance.
Choice B rationale:
Reviewing food labels for sodium content is crucial for managing hypernatremia. It empowers patients to make informed choices and limit their sodium intake.
Sodium is a major contributor to hypernatremia, and reducing dietary sodium intake is a key strategy to lower blood sodium levels.
By carefully reading food labels and selecting low-sodium options, patients can effectively manage their sodium intake and promote a gradual return to normal sodium levels.
This approach addresses the root cause of hypernatremia and promotes long-term control of blood sodium levels.
Choice C rationale:
Monitoring daily urine output volume can be helpful in tracking fluid status, but it's not the primary action for managing hypernatremia.
While urine output can provide insights into fluid balance, it doesn't directly address the underlying issue of excessive sodium. Focusing on dietary sodium intake is a more direct and effective approach to correcting hypernatremia.
Choice D rationale:
Using salt tablets after strenuous exercise is not recommended for patients with hypernatremia.
Salt tablets are intended to replenish electrolytes lost through sweating, but they can worsen hypernatremia by further increasing sodium levels.
Patients with hypernatremia should focus on reducing sodium intake, not increasing it.
Correct Answer is D
Explanation
Choice D rationale:
Highlights daily use: Tiotropium is a long-acting bronchodilator, meaning it works to relax and open the airways over an extended period. It's crucial for managing COPD symptoms and preventing exacerbations. Daily use is essential to maintain its effectiveness.
Emphasizes the Handihaler: The Handihaler is the specific inhalation device designed for tiotropium delivery. It ensures proper medication administration and optimal lung deposition.
Demonstrates understanding of instructions: Choosing this option indicates the client has correctly grasped the intended frequency and method of use.
Choice A rationale:
Misunderstanding of purpose: Tiotropium is not a rescue inhaler for sudden shortness of breath. It's a maintenance medication that works gradually to improve lung function. For acute symptoms, a short-acting bronchodilator, like albuterol, is required.
Potential delay in appropriate treatment: Reliance on tiotropium for acute episodes could lead to delayed use of the correct rescue medication, potentially worsening symptoms and increasing risks.
Choice B rationale:
Potential side effect, not primary goal: While tiotropium may reduce sputum thickness in some individuals, it's not the primary aim of therapy. Focusing on this aspect could overlook its broader benefits in managing COPD.
Variable response: The extent of sputum thinning varies among individuals and shouldn't be the sole indicator of effectiveness.
Choice C rationale:
Potential for overmedication: Using multiple inhalers without clear guidance from a healthcare provider could increase the risk of excessive medication and adverse effects.
Importance of individualized regimens: Inhaler use depends on the specific medications prescribed and the severity of COPD. Healthcare professionals tailor regimens to individual needs.
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