A nurse is caring for a client diagnosed with pneumonia and assesses labored breathing and copious tracheobronchial secretions. What priority action should the nurse encourage with the client?

Limit oral fluids to minimize labored breathing.

Perform pursed-lip breathing to expel trapped carbon dioxide from the alveoli

Lie in a low Fowler's position to promote lung expansion

Perform hourly incentive spirometry to inflate lungs and mobilize secretions.

Answer and Explanation

The Correct Answer is D

A. Limit oral fluids to minimize labored breathing: This action is not appropriate, as adequate hydration is important for thinning mucus secretions, making it easier for the client to expectorate them. Limiting fluids could lead to thicker secretions, which may worsen the client’s respiratory distress and increase the difficulty of clearing secretions. Therefore, this approach is not suitable for a client with pneumonia and respiratory compromise.
B. Perform pursed-lip breathing to expel trapped carbon dioxide from the alveoli: While pursed-lip breathing can help with exhalation and improve oxygenation, it does not directly address the need to mobilize and clear copious secretions. This technique is beneficial in managing dyspnea and improving ventilation but is not the priority action when the client has significant secretions that need to be cleared.
C. Lie in a low Fowler's position to promote lung expansion: A low Fowler's position (30 degrees) is less effective for promoting lung expansion compared to higher Fowler's positions. Semi-Fowler's (30-45 degrees) or high Fowler's (greater than 45 degrees) positions are more beneficial for improving lung expansion and facilitating breathing in clients with respiratory distress. Therefore, this option does not provide the most effective intervention for the client's condition.
D. Perform hourly incentive spirometry to inflate lungs and mobilize secretions: This is the priority action for the nurse to encourage, as incentive spirometry is specifically designed to help inflate the lungs and improve lung function. It promotes deep breathing, which can enhance ventilation, prevent atelectasis, and facilitate the mobilization of secretions. Regular use of incentive spirometry is essential in managing pneumonia and can significantly improve respiratory outcomes for the client.

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Correct Answer is ["A","D","E"]

Explanation

A. The student's asthma is not well controlled: Being in the yellow zone indicates that the student's asthma is not well controlled and that their peak expiratory flow rate (PEFR) is lower than usual. This is a crucial point for the nurse to recognize, as it suggests that the student may need to adjust their management plan to prevent an exacerbation.
B. The nurse should obtain a second expiratory flow rate: While it can be helpful to reassess peak flow rates, it is not always necessary unless there is a concern about the accuracy of the initial measurement. The initial yellow zone result provides sufficient information for the nurse to take appropriate action regarding the student's asthma management.
C. The student needs to go to the hospital: Being in the yellow zone does not automatically require hospitalization. The yellow zone typically indicates that the student is experiencing some worsening of asthma symptoms but can often be managed at home with appropriate interventions. Hospitalization is usually reserved for the red zone, where severe symptoms or a significant decrease in peak flow occurs.
D. The student should use his quick-relief inhaler: This is an appropriate action for a student in the yellow zone. The yellow zone often indicates the need for the use of a quick-relief inhaler to alleviate symptoms and improve airflow. The nurse should advise the student to use their inhaler as per their asthma action plan.
E. The student's peak flow is 50% to 80% of his best peak flow: This statement accurately describes the yellow zone, where the peak flow is between 50% and 80% of the student's personal best. This information is essential for determining the appropriate response to the current asthma status and guides the nurse's actions.

A. Opening and utilizing supplies that are necessary for the task B. Working to reduce wait times in the emergency department C. Using an interpreter for patients who do not speak the health-care provider's language D. Utilizing the CAUTI bundle to prevent urinary tract infections when placing indwelling urinary catheters

Correct Answer is A

Explanation

A. Opening and utilizing supplies that are necessary for the task. The efficiency domain in healthcare quality focuses on minimizing waste, optimizing resource utilization, and reducing unnecessary costs. By ensuring that only necessary supplies are used, healthcare facilities can prevent waste, control expenses, and enhance operational efficiency, making this choice the best representation of the efficiency domain.
B. Working to reduce wait times in the emergency department. Reducing wait times falls under the timeliness domain rather than efficiency. Timeliness ensures that patients receive care without unnecessary delays, improving access to treatment and patient outcomes. While efficiency and timeliness are related, reducing wait times primarily aligns with improving prompt care delivery rather than minimizing waste.
C. Using an interpreter for patients who do not speak the health-care provider's language. This action falls under the equity domain, which ensures that all individuals receive fair and unbiased care regardless of language, socioeconomic status, or cultural background. Providing language services improves access to quality healthcare but does not specifically address efficiency.
D. Utilizing the CAUTI bundle to prevent urinary tract infections when placing indwelling urinary catheters. This initiative falls under the safety domain, which focuses on preventing harm to patients through evidence-based practices. Implementing infection prevention measures improves patient safety but is not directly related to efficiency, which focuses on cost-effectiveness and resource management.

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A nurse is caring for a client diagnosed with pneumonia and assesses labored breathing and copious tracheobronchial secretions. What priority action should the nurse encourage with the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A college health nurse interprets the peak expiratory flow rate for student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is learning about the Institute of Medicine (IOM) [now National Academy of Medicine (NAM) characteristics of Healthcare Quality. The nurse should recognize which of the following best describes the characteristics of the efficiency domain in Healthcare Quality initiatives.

Correct Answer is A

Explanation

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