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Exhibits

Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

A.

Positioning the client with the head of the bed elevated

B.

Avoid treating fever with antipyretics

C.

Encourage the client to take breaks from the oxygen mask every few hours

D.

Providing suctioning so the client does not have to cough

E.

Assist the client in ambulating safely

F.

Asking the client to do quick, shallow breaths

G.

Teaching the client to cough at least once an hour

Answer and Explanation

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.
 


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Related Questions

Correct Answer is []

Explanation

  • Small intestinal obstruction is indicated by the client’s abdominal distension, absence of bowel sounds, refusal to eat, and episodes of vomiting. The laboratory results show metabolic acidosis (HCO3 of 16 mEq), which can be associated with a bowel obstruction.
  • Placing a nasogastric tube helps decompress the stomach and relieve pressure caused by the obstruction, while giving IV fluids helps to prevent dehydration and electrolyte imbalances that can occur with vomiting and obstruction.
  • Monitoring signs and symptoms of dehydration is crucial as the client has been vomiting and may not be able to maintain adequate fluid intake. Monitoring temperature is also essential to detect any signs of infection or complications related to the obstruction.

Correct Answer is C

Explanation

A. Observing body language and movement can provide clues about the client's pain but does not directly assess the quality of the pain experienced.
B. Identifying effective pain relief measures is important for managing pain but does not assess the quality of pain itself.
C. Asking the client to describe the pain directly assesses its quality, allowing the nurse to understand its characteristics, such as intensity, duration, and type (e.g., sharp, dull, throbbing).
D. Providing a numeric pain scale is useful for quantifying pain intensity but does not capture the qualitative aspects of the pain experience.

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