Exhibits
Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.
Positioning the client with the head of the bed elevated
Avoid treating fever with antipyretics
Encourage the client to take breaks from the oxygen mask every few hours
Providing suctioning so the client does not have to cough
Assist the client in ambulating safely
Asking the client to do quick, shallow breaths
Teaching the client to cough at least once an hour
Correct Answer : A,E,G
A. Positioning the client with the head of the bed elevated helps improve lung expansion and facilitates better ventilation and oxygenation, reducing the work of breathing.
B. Avoid treating fever with antipyretics is not appropriate, as managing fever can help reduce metabolic demand and improve overall comfort, which aids in ventilation.
C. Encouraging the client to take breaks from the oxygen mask is not advisable, as consistent oxygen delivery is critical for maintaining adequate oxygen saturation, especially in cases of pneumonia.
D. Providing suctioning so the client does not have to cough may not be necessary; coughing is a natural mechanism to clear secretions and improve airway patency.
E. Assisting the client in ambulating safely promotes lung expansion, enhances circulation, and aids in the mobilization of secretions, contributing positively to ventilation and oxygenation.
F. Asking the client to do quick, shallow breaths is counterproductive, as it can lead to inadequate ventilation and decreased oxygenation; deep breathing is preferred.
G. Teaching the client to cough at least once an hour is essential for clearing secretions and improving lung function, thereby enhancing ventilation and oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increasing intestinal peristalsis is not a primary goal related to managing a hiatal hernia. While peristalsis is important for digestion, the focus should be on the esophagus and stomach.
B. Preventing esophageal reflux is the main goal for clients with a hiatal hernia, especially sliding type, as the hernia can cause the stomach to push into the esophagus, leading to reflux symptoms. Strategies to prevent reflux may include dietary modifications and positioning.
C. Promoting effective swallowing may be important in some contexts, but it is not a primary goal associated with managing a hiatal hernia.
D. Maintaining intact oral mucosa is generally a broader nursing goal and not specific to the management of a hiatal hernia. The focus should be on preventing reflux rather than oral mucosa integrity in this case.
Correct Answer is B
Explanation
A. Step-by-step verbal directions may be confusing for clients with Huntington's disease due to cognitive and motor difficulties.
B. Escorting the client to the cafeteria ensures safety and provides direct assistance, which is crucial given the potential for impaired judgment and coordination in Huntington's disease.
C. While using a map might help some clients, it may overwhelm or confuse others, particularly those with cognitive impairments associated with Huntington's disease.
D. Orienting the client to a color-coding system could also be confusing andmay not be an effective method of navigation for someone with cognitive challenges.
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