A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness.
Which action is most important for the nurse to instruct the client about self-care?

Increase the daily intake of oral fluids to liquefy secretions.

Call the clinic if undesirable side effects of medications occur.

Teach anxiety reduction methods for feelings of suffocation.

Avoid crowded enclosed areas to reduce pathogen exposure.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Liquefying secretions is the most crucial action to address the client's immediate respiratory concerns. Thickened mucus obstructs airflow, leading to shortness of breath, productive cough, and difficulty breathing upon exertion. Increasing fluid intake thins mucus, making it easier to expel and improving ventilation. This directly addresses the client's current symptoms and promotes airway clearance.

Hydration and Mucociliary Clearance: Adequate hydration is indispensable for optimal mucociliary clearance, the natural mechanism that removes mucus from the airways. Fluids moisten the respiratory tract, allowing cilia (tiny hair-like structures) to effectively move mucus upwards, where it can be coughed out or swallowed.

Thinning Mucus: Water acts as a natural expectorant, thinning mucus and reducing its viscosity. This makes it easier for the client to cough up the mucus, clearing the airways and reducing the sensation of breathlessness.

Decreasing Mucus Production: Dehydration can trigger the body to produce more mucus as a protective response. By staying hydrated, the client can help prevent excessive mucus production, further easing symptoms.

Supporting Overall Respiratory Health: Proper hydration maintains the health of the respiratory system's tissues and cells, promoting efficient gas exchange and reducing inflammation.

Preventing Dehydration-Related Complications: Dehydration can exacerbate respiratory problems and lead to other complications, such as fatigue, headaches, and impaired immune function. Maintaining adequate fluid intake helps prevent these issues.

Key points to emphasize to the client:

Drink fluids throughout the day, even if not feeling thirsty.

Water is the best choice, but clear broths, juices, and herbal teas can also contribute to fluid intake. Avoid caffeine and alcohol, as they can be dehydrating.

Monitor urine output to ensure adequate hydration (urine should be pale yellow or clear).

Increase fluid intake during periods of increased mucus production, such as during respiratory infections or exercise.

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Correct Answer is D

Explanation

Choice A rationale:
Anorexia is a common symptom of cirrhosis, but it is not the most immediate concern in a client with esophageal varices.
Anorexia can result from various factors, including impaired liver function, hormonal imbalances, early satiety due to ascites,
and nausea.
While it's important to address anorexia to maintain nutritional status, it doesn't directly indicate a life-threatening
complication like bleeding varices.
Choice B rationale:
Brown, foamy urine is a characteristic of kidney problems, specifically proteinuria.
It's not directly associated with esophageal varices or their complications.
While cirrhosis can affect kidney function due to fluid imbalances and impaired filtering, brown, foamy urine wouldn't be the
primary indicator of bleeding varices.
Choice C rationale:
Clay-colored stool is a sign of biliary obstruction, which can occur in cirrhosis due to impaired bile flow.
However, it's not a direct indicator of bleeding varices.
Clay-colored stool results from a lack of bile pigments in the stool, which give it its typical brown color.
Choice D rationale:
Hematemesis, or vomiting of blood, is the most critical symptom to monitor in a client with esophageal varices.
Here's why:
Esophageal varices are enlarged, swollen veins in the esophagus that develop due to increased pressure in the portal venous
system, a common consequence of cirrhosis.
These varices are fragile and prone to rupture, which can lead to massive, life-threatening bleeding.
Hematemesis is a clear sign that variceal bleeding has occurred and requires immediate intervention.

A. Leave the dressing off until consulting with the healthcare provider. B. Apply a hydrocolloidal gel dressing. C. Increase the frequency of the dressing changes. D. Replace the gauze with a transparent dressing.

Correct Answer is B

Explanation

Choice A rationale:

Leaving the dressing off would expose the wound to air and potential contamination, which could delay healing and increase the risk of infection.

While consulting with the healthcare provider is always an option, it's not necessary in this case as the nurse has the knowledge and skills to select an appropriate dressing.

Additionally, leaving the wound uncovered could cause pain and discomfort to the patient, as well as potentially disrupt the delicate granulation tissue that has already formed.

Choice C rationale:

Increasing the frequency of dressing changes could disrupt the healing process and irritate the wound bed.

It's generally recommended to change dressings only as often as necessary to keep the wound clean and moist. Excessive dressing changes can also be costly and time-consuming for both the patient and the healthcare provider. Choice D rationale:

Transparent dressings are not ideal for stage 3 pressure injuries with significant granulation tissue. These dressings are more suitable for wounds with minimal exudate and that are not actively healing. Transparent dressings can also adhere to the wound bed, causing pain and trauma upon removal.

Choice B rationale:

Hydrocolloidal gel dressings are a good choice for stage 3 pressure injuries with granulation tissue because they: Provide a moist wound environment, which promotes healing.

Absorb exudate, which helps to prevent maceration of the surrounding skin. Form a protective barrier over the wound, which helps to prevent infection.

Are comfortable for the patient and can be left in place for several days.

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Naxlex Comprehensive Predictor Exams

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

Correct Answer is D

Explanation

The nurse is performing a routine dressing change for a patient with a stage 3 pressure injury that is red with significant granulation.The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is B

Explanation

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed.Which prescription should the nurse teach the client to use for the skin condition?

A 51-year-old male client with pneumonia has undergone several days of antibiotic and respiratory treatment. Given the following assessment findings, mark whether they indicate that the treatment was effective or ineffective:

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

The nurse notes that a patient has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound.Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?

Which action should be included in the teaching plan for a patient with hypernatremia?