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 ["0.1"]

Explanation

(desired dose ÷ available concentration) = amount to administer.

For a desired dose of 5 mg and an available concentration of 50 mg/mL, the calculation would be 5 mg ÷ 50 mg/mL = 0.1 mL.

Therefore, the nurse should administer 0.1 mL per dose.

A. Allow the client to expel some fluid before continuing. B. Lower the height of the solution container. C. Encourage the client to bear down. D. Stop the enema and document that the client did not tolerate the procedure.

Correct Answer is B

Explanation

A. Expulsion of water does not address the underlying issue.
B. Lowering the height of the solution container can help reduce the force of the fluid entering the colon, which may lessen cramping. This method slows the flow rate of the solution, allowing the client's body to adjust without stopping the procedure entirely.
C. Bearing down (straining) may increase the discomfort and is not recommended during the administration of an enema. It could potentially lead to rectal trauma or increase intrarectal pressure, which is not beneficial during the procedure.

D. While stopping the procedure is an option if the client is unable to tolerate it due to severe discomfort or distress, in this scenario where cramping is the main issue, allowing the client to expel some fluid is more appropriate before deciding to stop the procedure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer haloperidol 5 mg IM to a client. Available is haloperidol 50 mg/mt. How many mt should the nurse administer per dose? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.1"]

Explanation

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is B

Explanation

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