A nurse is caring for a client diagnosed with pneumonia who has labored breathing and copious tracheobronchial secretions.

What priority action should the nurse encourage with the client?

Limit oral fluids to minimize labored breathing.

Lie in a low Fowler’s position to promote lung expansion.

Perform hourly incentive spirometry to inflate lungs and mobilize secretions.

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

Answer and Explanation

The Correct Answer is C

Choice A rationale
Limiting oral fluids is not the best action for a client with pneumonia and copious tracheobronchial secretions. Adequate hydration can actually help thin and loosen pulmonary secretions, making them easier to expel.
Choice B rationale
While lying in a low Fowler’s position can aid in lung expansion, it is not the priority action in this case. The client has copious tracheobronchial secretions, and the most effective way to mobilize these secretions is through incentive spirometry.
Choice C rationale
Performing hourly incentive spirometry can help inflate the lungs and mobilize secretions, which is particularly beneficial for a client with pneumonia who has copious tracheobronchial secretions. This is the priority action as it directly addresses the client’s issue of labored breathing due to excessive secretions.
Choice D rationale
Pursed lip breathing is a technique used primarily to slow the pace of breathing and can help maintain open airways longer. However, it is not the most effective method for mobilizing tracheobronchial secretions.

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Correct Answer is C

Explanation

Choice A rationale
A non-productive cough is not a definitive sign of inadequate drug therapy for tuberculosis. It could be a symptom of many other respiratory conditions.
Choice B rationale
Decreased shortness of breath is generally a positive sign indicating improvement in the patient’s condition. It does not necessarily indicate inadequate drug therapy.
Choice C rationale
The presence of positive acid-fast bacilli in the sputum after 2 months of treatment indicates that the tuberculosis bacteria are still present in the patient’s body. This suggests that the triple antibiotic therapy is not effectively eliminating the bacteria, thus indicating inadequate drug therapy.
Choice D rationale
Poor appetite is a common symptom of tuberculosis, but it does not specifically indicate the effectiveness or inadequacy of drug therapy.

A. pH 7.55, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 24 mEq/L B. pH 7.40, PaCO2 40 mm Hg, PaO2 94 mm Hg, HCO3 22 mEq/L C. pH 7.30, PaCO2 60 mm Hg, PaO2 70 mm Hg, HCO3 30 mEq/L D. pH 7.38, PaCO2 45 mm Hg, PaO2 88 mm Hg, HCO3 26 mEq/L .

Correct Answer is C

Explanation

Choice A rationale
A pH of 7.55, PaCO2 of 30 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 24 mEq/L would indicate respiratory alkalosis, which is not typically associated with progressive COPD67.
Choice B rationale
A pH of 7.40, PaCO2 of 40 mm Hg, PaO2 of 94 mm Hg, and HCO3 of 22 mEq/L represent normal ABG values.
Choice C rationale
A pH of 7.30, PaCO2 of 60 mm Hg, PaO2 of 70 mm Hg, and HCO3 of 30 mEq/L are indicative of respiratory acidosis with metabolic compensation, which is commonly seen in patients with progressive COPD67.
Choice D rationale
A pH of 7.38, PaCO2 of 45 mm Hg, PaO2 of 88 mm Hg, and HCO3 of 26 mEq/L would indicate a slight respiratory acidosis, which is not typically associated with progressive COPD67.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client newly diagnosed with active tuberculosis (TB) and prescribed triple antibiotic therapy. The nurse should recognize that which clinical sign indicates inadequate drug therapy after 2 months of treatment?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse is caring for a client diagnosed with pneumonia who has labored breathing and copious tracheobronchial secretions.

What priority action should the nurse encourage with the client?