The nurse is developing the plan of care for a client with pneumonia and includes the nursing problem of Ineffective airway clearance related to thick pulmonary secretions. Which intervention is most important for the nurse to include in the client's plan of care?

Increase fluid intake to 3,000 mL/daily.

Provide frequent rest periods.

Administer O2 at 5 L/minute per nasal cannula.

Maintain the client in a semi-Fowler's position.

Answer and Explanation

The Correct Answer is A

A. Increasing fluid intake helps thin pulmonary secretions, making them easier to expectorate and is most directly related to clearing the airway.
B. Providing frequent rest periods is important but does not directly clear the airway.

C. Administering O2 addresses hypoxia but does not clear secretions.

D. Semi-Fowler's position helps with breathing but does not specifically address thick secretions.

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Correct Answer is B

Explanation

A. Monitoring incision drainage is important for infection and wound healing but not directly related to the effectiveness of compression devices.
B. Observing both lower extremities for redness and swelling directly assesses the effectiveness of the pneumatic compression devices in preventing deep vein thrombosis (DVT).
C. Evaluating the use of an incentive spirometer is important for respiratory function but unrelated to the compression devices.
D. Palpating peripheral pulse points is useful for circulation assessment but does not specifically evaluate the prevention of DVT, which is the primary purpose of the compression devices.

A. Complete comprehensive assessments. B. Remove discontinued peripheral intravenous catheters. C. Evaluate and update plans of care for clients. D. Begin initial sterile wound care for surgical clients.

Correct Answer is B

Explanation

A. This task typically requires a more advanced level of clinical judgment and assessment skills, which are usually beyond the scope of practice for a PN and should be conducted by a Registered Nurse (RN).
B. Removing discontinued peripheral IV catheters is a task that falls within the scope of practice for a Practical Nurse (PN). It does not require the advanced assessment skills or judgment that some other tasks might require.
C. This involves critical thinking and clinical decision-making that are responsibilities typically reserved for an RN, as it requires integrating new information and adjusting care plans based on ongoing assessments.
D. While PNs can perform certain types of wound care, initiating sterile wound care for surgical clients often requires the advanced knowledge and assessment skills of an RN, particularly if the wound care involves evaluating surgical site integrity and potential complications.

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The nurse is developing the plan of care for a client with pneumonia and includes the nursing problem of Ineffective airway clearance related to thick pulmonary secretions. Which intervention is most important for the nurse to include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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