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 B
Explanation
A. Standing with feet close together reduces the base of support, making the nurse less stable and increasing the risk of losing balance or straining muscles. It is not recommended for lifting because it compromises stability and balance.
B. Keeping the box close to the body reduces the leverage and strain on the back muscles. This technique utilizes the strength of the legs and core muscles more effectively and helps to maintain balance and stability while lifting.
C. Bending at the waist puts excessive strain on the lower back muscles and can lead to back injury, especially when lifting heavy objects. The correct technique is to bend at the knees and hips while keeping the back straight to maintain proper alignment and reduce strain on the spine.
D. Twisting while lifting or carrying heavy objects can strain the muscles and ligaments of the spine, leading to injury, particularly to the intervertebral discs. The nurse should avoid twisting and instead pivot the entire body with the feet to change direction.
Correct Answer is ["2"]
Explanation
To administer a dose of 10 mg of olanzapine using 5 mg tablets, the nurse would need to give two (2) tablets
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