A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client asks about this action, saying "I have been drinking tons of water.
How am I dehydrated?" What response by the nurse is best?
Breathing so quickly can be dehydrating.
Everyone with pneumonia is dehydrated.
This is really just to administer your antibiotics.
Why do you think you are so dehydrated?
The Correct Answer is A
Choice A rationale
Tachypnea, or rapid breathing, significantly increases insensible fluid loss through the respiratory tract. Each exhalation carries water vapor, and with increased respiratory rate and depth, the total volume of water lost through respiration can be substantial, leading to dehydration despite oral fluid intake. This explains the physiological mechanism of fluid imbalance related to respiratory effort.
Choice B rationale
While pneumonia can be associated with dehydration due to fever, decreased oral intake, and increased metabolic demands, stating that "everyone with pneumonia is dehydrated" is an overgeneralization and not scientifically accurate. The degree of dehydration varies among individuals based on their specific physiological response and hydration status.
Choice C rationale
While intravenous fluids are often used to administer antibiotics, the client specifically asked about dehydration despite drinking water. This response avoids directly addressing the client's concern and the physiological reason for their dehydration, missing an opportunity for client education regarding their condition.
Choice D rationale
This response is a therapeutic communication technique, but in this specific scenario, the client is directly asking for a scientific explanation of their dehydration. Responding with another question shifts the burden of explanation back to the client and does not provide the requested physiological information, which is critical for their understanding and adherence. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A 30-pack-year smoking history indicates significant cumulative exposure to respiratory irritants, predisposing the client to COPD development. However, this historical factor does not indicate acute respiratory distress requiring immediate intervention. While a strong risk factor, it doesn't present as an emergent physiological alteration demanding first assessment in this scenario. Current physiological stability takes precedence over historical risk.
Choice B rationale
A client in a tripod position utilizing accessory muscles to breathe indicates significant respiratory distress and increased work of breathing. This compensatory mechanism suggests impending respiratory failure or severe hypoxemia. This is an acute, life-threatening physiological manifestation demanding immediate nursing assessment and intervention to prevent respiratory arrest and optimize oxygenation.
Choice C rationale
Dependent edema and clubbed fingers are chronic manifestations of long-standing respiratory and/or cardiovascular compromise, often seen in advanced COPD or cor pulmonale. While indicative of significant disease progression, they do not represent an acute, life-threatening emergency demanding immediate assessment over active respiratory distress. These are chronic adaptations, not acute decompensation.
Choice D rationale
A chronic cough with thick, tenacious secretions is a common symptom in COPD, indicating impaired mucociliary clearance and chronic inflammation. While these symptoms can exacerbate acute respiratory issues, they do not inherently suggest the acute, life-threatening respiratory distress seen in a client using accessory muscles, thus not requiring the absolute first assessment.
Correct Answer is C
Explanation
Choice A rationale
Antitubercular medications are not typically taken for the rest of a client's life. The standard treatment duration for active pulmonary tuberculosis is a multi-drug regimen lasting typically 6 to 9 months. Prolonged unnecessary use can lead to increased side effects and antibiotic resistance without additional therapeutic benefit.
Choice B rationale
The Mantoux test, or tuberculin skin test, indicates exposure to Mycobacterium tuberculosis but does not confirm active disease or determine treatment effectiveness. A positive Mantoux test can persist for life even after successful treatment. Treatment efficacy is primarily monitored through symptom resolution and sputum smear/culture negativity.
Choice C rationale
A typical course of antitubercular treatment involves a multi-drug regimen administered consistently for 6 to 9 months. This prolonged duration is critical to eradicate the slow-growing Mycobacterium tuberculosis and prevent the development of drug resistance, ensuring complete cure and minimizing relapse. Inconsistent or premature cessation of therapy can lead to treatment failure and resistance.
Choice D rationale
Not all family members of a client with pulmonary tuberculosis will need to take medications. Prophylactic treatment (latent TB infection therapy) is typically recommended for close contacts, especially children and immunocompromised individuals, after they have been evaluated for latent TB infection (positive tuberculin skin test or interferon-gamma release assay) to prevent progression to active disease.
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