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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 B

Explanation

B. When purulent drainage is observed at a wound site, obtaining a culture of the drainage is essential for identifying the specific microorganisms causing the infection and determining their sensitivity to antibiotics.

A. Serum blood glucose level is not directly relevant to the assessment of purulent drainage at a wound site.

C. An elevated CRP level may indicate the presence of infection but obtaining a CRP level may not be as immediate or specific as obtaining a wound culture.

D. Blood pH level is not directly relevant to the assessment of purulent drainage at a wound site.

A. Difficulty with urination. B. Trouble sleeping. C. Unexplained weight loss. D. Recent oral intake.

Correct Answer is A

Explanation

A. Pyridostigmine is a cholinergic medication that can affect bladder function, and difficulty with urination could indicate a bladder obstruction, which is a contraindication for this medication.
B. Trouble sleeping or insomnia is not typically associated with pyridostigmine use.
C. Unexplained weight loss is not a common side effect of pyridostigmine.
D. Administering pyridostigmine with food or shortly after a meal may help minimize gastrointestinal side effects such as nausea and abdominal discomfort. This however, is not of immediate concern when administering pyridostigmine.

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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

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

Correct Answer is A

Explanation

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

The antitubercular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness of this medication, which outcome can the nurse expect this client to exhibit?

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow- up action by the nurse?

An adult client with multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

An adult client is admitted with AIDS and oral Candide albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?

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?

The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease. Which menu choice by the client indicates a need for further teaching?

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Patient Data

Exhibits

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