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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Excessive pulmonary secretions can be a sign of airway irritation or infection rather than a direct adverse effect of oxygen therapy. It may warrant further assessment and intervention, but it is not typically attributed to oxygen therapy itself.
B. Dryness and cracking of oral mucous membranes can occur as a result of oxygen therapy. Oxygen delivered at higher concentrations or for prolonged periods can dry out mucous membranes, leading to discomfort and potential cracking.
C. Tachycardia (an elevated heart rate) can occur as a compensatory response to hypoxia or increased metabolic demands rather than as a direct adverse effect of oxygen therapy. However, if oxygen therapy leads to an overcorrection of hypoxemia, it could potentially contribute to changes in heart rate.
D. Poor skin turgor is typically a sign of dehydration or fluid imbalance, not directly related to oxygen therapy. It may be important to assess fluid status in clients receiving oxygen therapy, but poor skin turgor itself is not an adverse effect of oxygen administration.

A. "Wear a mask when entering the client's room." B. "Gloves are not necessary if you wash your hands well." C. "Place a mask on the client when you check her vital signs." D. "Wear a gown whenever you come in close contact with the client."

Correct Answer is A

Explanation

A. Wearing a mask helps prevent the spread of respiratory droplets that may contain infectious pathogens, such as those causing pneumonia. It protects both the client from potential pathogens carried by the AP and the AP from potential exposure to the client's respiratory secretions.

B. Gloves should be worn when there is a risk of contact with the client's body fluids, including respiratory secretions, to prevent transmission of infectious agents. Hand hygiene (washing hands well) is important but does not replace the need for gloves in situations where there is a risk of exposure to bodily fluids.
C. Placing a mask on the client would not typically be required unless the client is coughing excessively and the mask is intended to contain respiratory droplets. However, the focus of precautions should primarily be on protecting the AP.
D. Wearing a gown may be necessary if there is a risk of contamination with respiratory secretions or if the AP anticipates contact with the client's body fluids. However, it is not specifically required for routine vital sign measurement unless there is visible contamination or extensive contact with the client's secretions.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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