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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Measure the circumference of both upper arms. B. Notify the provider who inserted the PICC line. C. Remove the PICC line. D. Apply a cold pack to the client's upper arm.

Correct Answer is A

Explanation

Choice A reason: Measuring arm circumference quantifies swelling, a sign of complications like thrombosis or infection. Comparing both arms establishes a baseline, aiding in assessing edema severity. This objective data guides interventions, prioritizing assessment before invasive actions, ensuring accurate diagnosis and management of PICC-related issues like venous thrombosis.

Choice B reason: Notifying the provider is important but not the first step. Measuring arm circumference provides objective data to report accurately. Swelling may indicate thrombosis or infection, but without measurements, premature notification lacks specificity, potentially delaying interventions based on clinical findings and diagnostic confirmation.

Choice C reason: Removing the PICC line is premature without confirming the cause of swelling. Thrombosis, infection, or mechanical issues could cause swelling, but removal risks complications like bleeding. Assessment, like measuring arm circumference, is needed first to determine if removal or other interventions are warranted.

Choice D reason: Applying a cold pack may reduce swelling but does not address underlying causes like thrombosis or infection. Without assessing the extent and cause of swelling, this intervention is inappropriate as a first step. Objective data collection, like measuring arm circumference, guides effective treatment and prevents complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the laboratory results of a client. Which result should the nurse identify as the priority finding?

Correct Answer is B

Explanation

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

The nurse is caring for a client with a chest tube. Which supplies should the nurse ensure are readily available at the client's bedside for emergencies?

A nurse is caring for a client who has a postoperative ileus and a nasogastric (NG) tube that has drained 2,500 mL in the past 6 hours. Which electrolyte imbalance should the nurse monitor the client for?

The patient has an order for Penicillin-G 1 gram intramuscularly. The instructions read: reconstitute the vial with 9.8 mL of normal saline to yield 2 grams in 10 mL. How many mL will the nurse administer per dose? Round the answer to the nearest whole number. Record numeric answer only.

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery. The nurse understands that the JP drain was placed for which purpose?

The nurse is caring for a client with a new tracheostomy. What will the nurse prioritize for care?

A nurse is caring for a client who has pneumonia. The nurse notes that the client has thick secretions and needs to thin them. What intervention will help thin the secretions?

A nurse is assessing four clients. Which client requires interventions for dehydration?

Which client with chronic obstructive pulmonary disease (COPD) will the nurse assess first?