A client with pneumonia is experiencing ineffective airway clearance related to pain, fatigue, and толстые secretions. Which evaluation best indicates to the nurse a therapeutic response to treatment?
Increased respiratory rate
Clear lung sounds
Brisk capillary refill
Decreased pleuritic pain
The Correct Answer is B
Choice A reason: Increased respiratory rate suggests persistent respiratory distress or ineffective airway clearance in pneumonia, as the body compensates for hypoxia or hypercapnia. This indicates ongoing secretions or inflammation, not a therapeutic response, making it an incorrect indicator compared to clear lung sounds.
Choice B reason: Clear lung sounds indicate effective airway clearance in pneumonia, as treatments like antibiotics and chest physiotherapy reduce secretions and inflammation, allowing normal air movement. This reflects resolved airway obstruction and improved gas exchange, making it the best indicator of a therapeutic response to treatment.
Choice C reason: Brisk capillary refill reflects adequate peripheral perfusion but is unrelated to airway clearance in pneumonia. It does not indicate resolution of secretions or improved lung function, making it an irrelevant marker for evaluating treatment response compared to clear lung sounds, which directly assess airway patency.
Choice D reason: Decreased pleuritic pain suggests reduced pleural inflammation but does not confirm airway clearance. Pain reduction may occur without clearing secretions, the primary issue in pneumonia. Clear lung sounds better indicate successful treatment by demonstrating unobstructed airways and improved respiratory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Sodium 138 mEq/L is normal (135–145 mEq/L), indicating no immediate concern. Abnormal sodium levels risk neurological or cardiac issues, but this value is normal, making it a lower priority compared to an abnormal potassium level, which poses immediate cardiac risks.
Choice B reason: Potassium 3.2 mEq/L indicates hypokalemia (normal 3.5–5.0 mEq/L), risking arrhythmias, muscle weakness, and respiratory compromise. Low potassium disrupts membrane potential, affecting cardiac and skeletal muscle function, making this the priority finding requiring immediate correction to prevent life-threatening complications.
Choice C reason: Glucose 110 mg/dL is within normal fasting range (70–110 mg/dL), indicating no urgent concern. Abnormal glucose levels risk metabolic issues, but this value is normal, making it a lower priority compared to hypokalemia, which poses immediate cardiac risks in this client.
Choice D reason: Hemoglobin 12 g/dL is borderline low (normal 13–17 g/dL males, 12–15 g/dL females) but not immediately life-threatening. Anemia may cause fatigue, but hypokalemia’s cardiac risks are more urgent, making hemoglobin a secondary priority in this laboratory review.
Correct Answer is C
Explanation
Choice A reason: Hypoactive bowel sounds in two quadrants suggest reduced peristalsis, indicating persistent postoperative ileus rather than resolution. Normal peristalsis produces active bowel sounds across all quadrants, making this an incorrect indicator of returned gastrointestinal motility in a postoperative client.
Choice B reason: Requesting food indicates appetite but not necessarily peristalsis. Appetite can return before gastrointestinal motility, driven by neurological and hormonal factors. Passage of flatus directly confirms intestinal motility, making appetite a less accurate indicator of peristalsis restoration in this context.
Choice C reason: Passage of flatus is the most accurate indicator of returned peristalsis, as it reflects gastrointestinal motility. Gas movement through the intestines, expelled as flatus, confirms resolution of postoperative ileus, indicating normal bowel function, making this the best sign of recovery.
Choice D reason: Abdominal distention suggests gas accumulation, indicating persistent ileus rather than returned peristalsis. Gas buildup occurs when motility is impaired, causing bloating. Passage of flatus confirms gas movement and restored motility, making distention an incorrect indicator of recovery.
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