A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?
Encourage the client to cough and deep breathe.
Obtain the client's temperature.
Encourage the client to increase oral fluids.
Provide chest percussion on the client.
The Correct Answer is A
A. This action helps the client to clear pulmonary secretions and improve ventilation. Coughing and deep breathing exercises are essential for maintaining airway patency and preventing complications such as atelectasis and respiratory distress.
B. Monitoring the client's temperature is important to assess for fever, which can indicate infection severity or response to treatment. However, in a client actively coughing up secretions, immediate interventions to promote airway clearance take precedence over obtaining temperature.
C. Adequate hydration can help liquefy pulmonary secretions, making them easier to expectorate. However, this action is secondary to promoting effective coughing and deep breathing to clear secretions already present in the airways.
D. Chest percussion can help loosen and mobilize secretions in the lungs. However, this intervention requires assessment of the client's respiratory status and may not be appropriate as the first action without first assessing the client's tolerance and condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This instruction is more appropriate for female clients performing perineal hygiene before providing a clean-catch urine specimen. For straight catheterization, the nurse typically performs sterile technique, including cleansing the urethral meatus with an antiseptic solution as part of the procedure. The client's perineal area may be cleansed if necessary, but the primary focus is on maintaining sterile technique during catheter insertion.
B. When performing straight catheterization, the nurse inserts a sterile catheter into the client's bladder via the urethra to obtain urine directly. The urine is collected from the catheter itself as it drains into a sterile specimen container. It's essential to avoid touching the catheter's port or allowing it to come into contact with non-sterile surfaces to prevent contamination.
C. When inserting a Foley catheter (indwelling catheter), sterile water is used to inflate the balloon at the tip of the catheter after insertion into the bladder. For straight catheterization, a balloon is not typically inflated because the catheter is removed immediately after urine is obtained. Therefore, this step is not applicable in this context.
D. It is crucial to use a sterile specimen container to collect urine obtained via straight catheterization. This ensures that the specimen remains uncontaminated and suitable for culture and sensitivity testing, which requires accurate identification of any bacteria present in the urine.
Correct Answer is D
Explanation
A. Sour cream is a dairy product, providing protein. This option provides protein from the sour cream, which is suitable for a vegetarian who consumes dairy products.
B. Fruits and vegetables generally do not provide significant protein. While fruits and vegetables are nutritious, they do not provide sufficient protein for a meal, especially for someone who is vegetarian and needs adequate protein sources.
C. Cream cheese is a dairy product that provides protein. This option also provides protein from the cream cheese, which is suitable for a vegetarian who consumes dairy products.
D. Peanut butter is a plant-based protein source and enriched bread provides carbohydrates. Peanut butter is a good source of protein for vegetarians and is a suitable option for the adolescent client who does not like beans.
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