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 ["1.3"]

Explanation

To calculate the dosage of amoxicillin for the infant, first convert the weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds. The infant weighs 22 pounds, which is equivalent to 10 kilograms (22 lb / 2.2 lb/kg). The prescription is for 20 mg/kg/day, so the total daily dosage is 200 mg (10 kg * 20 mg/kg). This total daily dosage is divided into three doses, as it is to be administered every 8 hours, resulting in

66.7 mg per dose (200 mg / 3). The medication is supplied as 250 mg per 5 mL, so to find out how many mL per dose, set up a proportion: 250 mg is to 5 mL as 66.7 mg is to X mL. Solving for X gives us 1.334 mL (66.7 mg * 5 mL / 250 mg), which rounds to 1.3 mL when rounded to the nearest tenth.

A. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. D. The client with an obstruction of the large intestine who is experiencing abdominal distention.

Correct Answer is A

Explanation

A. Abdominal rigidity in a client with a bowel obstruction due to a volvulus indicates possible peritonitis, which is a medical emergency.
B. Paralytic ileus with absent bowel sounds is concerning but not immediately life- threatening.
C. A nasogastric tube draining greenish fluid is expected in small bowel obstruction.

D. Abdominal distention in large intestine obstruction is concerning but less urgent than potential peritonitis.

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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

Correct Answer is ["1.3"]

Explanation

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

Correct Answer is A

Explanation

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