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 A

Explanation

A. Reminding the UAP to continue rubbing the hands together until they are dry ensures proper use of the hand rub, which is effective when fully dry.
B. Handwashing with soap and water is necessary after certain activities (e.g., after using the restroom, or when hands are visibly soiled), but using an alcohol-based hand rub is appropriate for routine hand hygiene.
C. Supervising in the next client's room is less direct and immediate than ensuring proper technique now.
D. Wearing gloves for all clients is not necessary and does not replace proper hand hygiene.

A. Heart rate 121 beats/minute B. Capillary refill 2 seconds C. Respirations 28 breaths/minute with shallow breathing D. Radial and pedal pulses 2+ E. Severe abdominal pain in right lower quadrant F. Feels anxious G. Temperature 100.8° F (38.2° C) H. Vomiting small amounts of green bile I. Blood pressure 115/76 mm Hg

Correct Answer is ["A","C","E","G","H"]

Explanation

A. Tachycardia indicates the body is responding to pain, infection, or potential sepsis. It's a critical vital sign indicating the body's stress response.
B. Tachypnea can be a response to pain or anxiety but also indicates the need for careful monitoring of respiratory status, especially postoperatively.

C. A capillary refill of 2 seconds is within the normal range and indicates adequate peripheral perfusion.
D. Radial and pedal pulses 2+ are within the normal range and indicates adequate peripheral perfusion.
E. Severe abdominal pain in the right lower quadrant is a primary symptom of appendicitis, which is confirmed by the CT scan showing a dilated appendix and fat stranding. Immediate attention is needed to address potential complications such as rupture.
F. Feeling anxious needs to be managed to promote patient comfort. However, it doesn’t need to be managed immediately since it is not life-threatening.
G. Fever is a sign of infection or inflammation, common in appendicitis. Monitoring and managing fever is crucial in preventing further complications.
H. Bilious vomitus is a common finding in appendicitis and may indicate that the inflammation has progressed to a point where it is causing a blockage in the intestines. This obstruction can lead to increased pressure within the abdominal cavity and compromise blood flow, potentially resulting in a life-threatening situation.
I. A blood pressure of 115/76 mm Hg is within normal limits and indicates stable hemodynamics at this point.

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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

The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

Correct Answer is A

Explanation

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

Correct Answer is ["A","C","E","G","H"]

Explanation

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