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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale
Intermittent oxygen use is common in clients with COPD, especially during activities that increase oxygen demand or during acute exacerbations.
Choice B rationale
Clubbing of fingers is a sign of chronic hypoxia, which can occur in advanced COPD78.
Choice C rationale
Pursed-lip breathing is a technique often used by clients with COPD to improve exhalation and reduce breathlessness.
Choice D rationale
Prolonged exhalation is a common finding in COPD due to airway obstruction and air trapping.
Choice E rationale
Dyspnea on exertion is a common symptom in COPD due to decreased lung function and increased work of breathing.
Correct Answer is A
Explanation
Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
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