A nurse is caring for a client diagnosed with left lower lobe pneumonia who experiences pain when coughing. Which intervention should the nurse include in the plan of care?

Limit ambulation to avoid fatigue associated with coughing.

Administer pain medication every two hours.

Encourage holding the chest with a pillow or hands.

Teach pursed-lip breathing technique and deep breathing.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Limiting ambulation is not typically recommended as part of the management for pneumonia. While rest is important, some movement is beneficial for preventing complications such as deep vein thrombosis. Ambulation should be encouraged as tolerated to promote circulation and prevent stasis of secretions.

Choice B reason:
Administering pain medication every two hours may not be necessary and could lead to overmedication. Pain management should be based on the client's reported pain levels and response to medication, with adjustments made as needed for effective relief.

Choice C reason:
Encouraging the client to hold their chest with a pillow or hands, known as splinting, can help reduce the pain experienced during coughing by providing support and stabilizing the chest wall. This technique is a non-pharmacological intervention that can effectively manage pain associated with coughing in pneumonia patients.

Choice D reason:
Teaching pursed-lip breathing and deep breathing techniques is beneficial for clients with respiratory conditions, including pneumonia. These techniques can help improve ventilation and oxygenation, but they are not specifically aimed at managing pain during coughing. However, they can be included as part of the overall respiratory care plan.

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Correct Answer is B

Explanation

Choice A reason:
Reviewing the diet and exercise guidelines with the client is an important step, but it may not address the immediate issue of the weight loss plateau. It's essential to first understand if the client has adhered to the guidelines before reviewing them.

Choice B reason:
Asking the client about any changes in diet or exercise patterns is the first step in identifying potential causes for the weight loss plateau. Changes in lifestyle, stress levels, eating habits, or physical activity can all contribute to a halt in weight loss. Understanding these factors can help the nurse tailor further advice and support.

Choice C reason:
Recommending a further reduction in calorie intake might not be the best initial approach. It's important to ensure that the client is not already consuming too few calories, which can slow metabolism and hinder weight loss. Moreover, drastic calorie reduction can be unsustainable and lead to nutritional deficiencies.

Choice D reason:
Instructing the client to record weights weekly is a useful tool for monitoring progress, but it does not address the current issue of the weight loss plateau. It's a supportive action that should follow after understanding and addressing the reasons behind the plateau.

A. Use an antiemetic one hour following administration. B. Drink 2-3 liters of water per day. C. Rinse mouth twice per day with an alcohol-based mouthwash. D. Take the medication with an NSAID.

Correct Answer is D

Explanation

Choice A Reason
Using an antiemetic one hour after administration of methotrexate is not a standard recommendation. Antiemetics are typically used to prevent nausea and vomiting associated with chemotherapy and are taken before or at the time of methotrexate administration, not afterward.

Choice B Reason
Drinking 2-3 liters of water per day is important for patients taking methotrexate to prevent kidney damage by ensuring adequate hydration and facilitating the excretion of the drug¹. Methotrexate can be nephrotoxic, and proper hydration helps to mitigate this risk.

Choice C Reason
Rinsing the mouth with an alcohol-based mouthwash is not recommended for patients taking methotrexate. Alcohol can cause drying and irritation, which might exacerbate any mouth sores caused by methotrexate. Instead, patients should use a gentle, non-alcoholic mouthwash to maintain oral hygiene.

Choice D Reason
Taking methotrexate with an NSAID is not advised without specific medical guidance. NSAIDs can increase the toxicity of methotrexate by displacing it from protein-binding sites and reducing its renal clearance, potentially leading to increased side effects.

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A nurse is caring for a client diagnosed with left lower lobe pneumonia who experiences pain when coughing. Which intervention should the nurse include in the plan of care?

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