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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. This technique, known as pursed lip breathing, can help improve gas exchange by slowing down the respiratory rate, promoting more efficient exhalation, and reducing air trapping in the lungs.

A. While raising the hands above the head can help expand the chest and improve lung expansion to some extent, it may not be as effective as pursed lip breathing in improving gas exchange or alleviating dyspnea.

B. Increasing the breathing rate for a full 30 seconds may not be beneficial and could potentially worsen dyspnea, especially in individuals with emphysema or other respiratory conditions.

D. While changing positions and focusing on diaphragmatic breathing can be helpful techniques in managing dyspnea, lying down on each side with knees bent may not be practical for a client who is ambulatory and experiencing mild dyspnea after ambulation.

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

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Tachypnea refers to abnormally rapid breathing, characterized by an increased respiratory rate. In adults, tachypnea is typically defined as a respiratory rate above 20 breaths per minute at rest.

Tachycardia is a medical condition characterized by a rapid heart rate, typically above 100 beats per minute in adults at rest.

Eupnea refers to normal, unlabored breathing at a normal rate and depth. It is characterized by regular inhalations and exhalations without any signs of respiratory distress or abnormalities.

Hypothermia is a medical condition characterized by an abnormally low body temperature, typically below 95°F (35°C).

Bradycardia is a medical condition characterized by an abnormally slow heart rate, typically below 60 beats per minute in adults.

Hyperthermia is a medical condition characterized by an abnormally high body temperature, typically above 100.4°F (38°C).

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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

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?

Correct Answer is C

Explanation

Patient Data Exhibits According to the client's vital signs, he is experiencing dropdown and dropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

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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.