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Patient Data

Exhibits

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

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 do quick, shallow breaths

Positioning the client with the head of the bed elevated

Teaching the client to cough at least once an hour

Answer and Explanation

Correct Answer : B,D,F

B. Encourage the client to take breaks from the oxygen mask every few hours: While supplemental oxygen may be necessary for clients with pneumonia who are hypoxemic, encouraging periodic breaks from the oxygen mask allows the client to mobilize and promote lung expansion, which can improve ventilation and oxygenation.

D. Ambulation helps prevent complications such as pneumonia-associated atelectasis by promoting lung expansion and mobilizing respiratory secretions. However, it's essential to ensure that ambulation is safe and appropriate based on the client's condition and mobility status.

F. Elevating the head of the bed promotes optimal lung expansion, reduces the work of breathing, and helps improve oxygenation in clients with pneumonia. This position also facilitates drainage of respiratory secretions and decreases the risk of aspiration.

A. Fever is often a sign of infection and can increase metabolic demand and oxygen consumption. Treating fever with antipyretics helps reduce metabolic demand, discomfort, and respiratory distress, thereby potentially improving ventilation and oxygenation.

C. Suctioning may be necessary to remove respiratory secretions in clients with pneumonia who are unable to clear their airways effectively. However, routine suctioning should be avoided unless clinically indicated, as it may cause discomfort and irritation to the airways.

E. Quick, shallow breaths (hyperventilation) can lead to respiratory alkalosis and impair oxygenation. Instead, clients with pneumonia should be encouraged to breathe slowly and deeply to promote effective gas exchange and lung expansion.

G. Teaching the client to cough at least once an hour: While coughing can help clear respiratory secretions and improve ventilation in clients with pneumonia, coughing excessively or unnecessarily may cause fatigue and discomfort. Clients should be encouraged to cough as needed to clear secretions but not excessively.

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Correct Answer is C

Explanation

C. Asking the client to describe their pain allows the nurse to gather subjective information directly from the client, which can provide valuable insight into the quality, intensity, location, and duration of the pain.

A. This option focuses on pain management rather than pain assessment. While identifying effective pain relief measures is important, it does not directly address the need to assess the quality of the client's pain.

B. While numeric pain scales can be useful for quantifying pain intensity, they do not capture the quality or characteristics of the pain.

D. Observing body language and movement can provide valuable information about the client's pain experience, such as grimacing, guarding, or difficulty moving. However, this approach primarily assesses pain behaviors rather than the quality of the pain itself.

A. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient. B. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. D. Report the COVID-19 result to the local health department according to Center for Disease Control (CDC) guidelines.

Correct Answer is B

Explanation

B. Isolating the client is crucial to minimize exposure to individuals who are not wearing proper PPE and to reduce the risk of spreading the virus within the healthcare setting and among family members.

A. is important for informing family members about potential exposure and monitoring for symptoms, but it is not as immediate as isolating the client to prevent further transmission.

C. is also important for educating the client on preventive measures to reduce the spread of the virus, but isolating the client takes precedence in the immediate management of potential COVID-19 cases.

D. is important for public health surveillance and contact tracing efforts, but it is not as immediate as isolating the client and educating them about preventive measures.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess the quality of an adult client's pain, which approach should the nurse use?

Correct Answer is C

Explanation

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

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The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 mL of DW to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many glt/minute? (Enler numeric value only. If rounding is required, round to the nearest whole number.)

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Patient Data Exhibits Which physician orders would the nurse anticipate being prescribed after reporting findings? (Select all that apply).

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Patient Data

Exhibits

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