A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?
Lie in a low Fowler’s or supine position
Increase oral fluids unless contraindicated
Increase activity
Call the nurse for oral suctioning as needed
The Correct Answer is D
A. Lie in a low Fowler’s or supine position:
Lying in a low Fowler's or supine position may worsen respiratory distress and compromise oxygenation. It can reduce lung expansion and increase the work of breathing, especially in patients with pneumonia. This is not a recommended position for individuals with respiratory issues.
B. Increase oral fluids unless contraindicated:
Increasing oral fluids is generally a good practice, especially in respiratory conditions like pneumonia. It helps thin respiratory secretions, making them easier to clear. However, this alone may not address copious tracheobronchial secretions. Suctioning may be needed to effectively remove excess secretions.
C. Increase activity:
Increasing activity may be beneficial for some patients, but it might exacerbate respiratory distress in others, especially if they are already experiencing increased work of breathing. The appropriateness of increasing activity depends on the specific condition and the patient's overall stability.
D. Call the nurse for oral suctioning as needed:
This is the most appropriate choice. If the client is experiencing increased work of breathing due to copious tracheobronchial secretions, calling the nurse for oral suctioning is an intervention aimed at maintaining a clear airway and alleviating respiratory distress. Regular suctioning may be necessary to assist the client in managing secretions effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “I will have canned chicken noodle soup with crackers and an apple for lunch.”
This option may not be the best choice for a low-sodium diet. Canned soups often contain high levels of sodium.
B. “I will have a tossed salad with cheese and croutons for lunch.”
This option is a better choice, as salads with fresh vegetables can be lower in sodium compared to other options.
C. “I will have a ham and cheese sandwich for lunch.”
Ham and cheese are generally high in sodium, so this would not be a suitable choice for a low-sodium diet.
D. “I will have a baked potato with broiled chicken for dinner.”
This option seems to be a good choice. Baked potato and broiled chicken can be part of a low-sodium meal.
Correct Answer is A
Explanation
A. "The test will provide a detailed profile of the heart’s electrical activity."
This statement is inappropriate because transesophageal echocardiography (TEE) primarily provides detailed images of the heart's structure, such as the valves and chambers, rather than focusing on the heart's electrical activity. The assessment of electrical activity is typically associated with electrocardiography (ECG or EKG) rather than echocardiography.
B. "I will need to start an IV in your arm before the test."
This statement is appropriate. It is common for medical procedures, including TEE, to require an intravenous (IV) line for administration of medications or fluids during or after the procedure.
C. "Your throat may be a little sore after the exam."
This statement is appropriate. TEE involves inserting a probe through the esophagus, and it is common for patients to experience a sore throat afterward due to the presence of the probe.
D. "You will need to refrain from eating and drinking 6-8 hours before this test."
This statement is appropriate. It is standard practice to ask patients to fast for a specific period before TEE to minimize the risk of complications, such as aspiration, during the procedure.
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