A nurse is caring for a client who has pneumonia.
Which of the following actions should the nurse take to promote thinning of respiratory secretions?
Encourage the client to ambulate frequently.
Encourage the client to increase fluid intake.
Encourage regular use of the incentive spirometer.
Encourage coughing and deep breathing.
The Correct Answer is B
Choice A rationale
Ambulation promotes lung expansion and improves ventilation-perfusion matching, which can help clear secretions by facilitating their movement. However, its primary mechanism is not direct thinning of secretions but rather mechanical mobilization and enhanced gas exchange.
Choice B rationale
Increased fluid intake enhances systemic hydration, which directly contributes to the thinning of respiratory secretions by altering their viscosity. Adequate hydration ensures that the mucus glands produce less viscous mucus, making it easier for the cilia to move and for the client to expectorate.
Choice C rationale
Regular use of an incentive spirometer promotes deep inspiration and lung expansion, which helps prevent atelectasis and improves alveolar ventilation. While beneficial for lung health, it does not directly influence the biochemical properties of mucus to reduce its thickness.
Choice D rationale
Coughing and deep breathing are essential for mobilizing and expelling secretions from the respiratory tract. These actions mechanically dislodge and move mucus. However, they do not directly alter the viscosity or thin the secretions themselves; rather, they exploit the physical properties of already thinned mucus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Continuous bubbling in the water-seal chamber after initial chest tube insertion indicates an air leak within the chest tube system. This is a critical finding because it compromises the negative intrathoracic pressure necessary for lung re-expansion and can lead to pneumothorax recurrence or inadequate drainage. Normal observation is intermittent bubbling with respirations, reflecting air expulsion from the pleural space, not a persistent leak.
Choice B rationale
Bloody drainage in the collection chamber is expected in the immediate postoperative period following chest surgery due to residual bleeding from the surgical site. The color and amount should progressively decrease over time. Large amounts of bright red blood, however, would warrant further investigation for active hemorrhage. This observation alone does not necessitate intervention unless excessive.
Choice C rationale
Fluid-level fluctuations, also known as tidaling, in the water-seal chamber are a normal and expected finding. These fluctuations reflect the changes in intrathoracic pressure during respiration, indicating that the chest tube system is patent and connected to the pleural space. Inspiratory effort causes the fluid to rise, and expiration causes it to fall.
Choice D rationale
Constant bubbling in the suction-control chamber is a normal and expected finding when a wet suction system is in operation. This bubbling indicates that the prescribed amount of suction is being applied to the chest drainage system, facilitating the removal of air and fluid from the pleural space. It confirms the functionality of the suction mechanism.
Correct Answer is A
Explanation
Choice A rationale
Slow, steady bubbling in the suction control chamber of a closed chest drainage system is an expected finding, indicating that the prescribed suction level is being appropriately applied to facilitate lung re-expansion and fluid removal. Continuing to monitor the client's respiratory status is the appropriate action to ensure optimal function and patient well-being.
Choice B rationale
Checking the tubing connections for leaks is indicated when there is continuous or excessive bubbling in the water-seal chamber, which suggests an air leak in the system. Slow, steady bubbling in the suction control chamber is normal and does not necessitate a leak check.
Choice C rationale
Checking the suction control outlet on the wall is necessary if there is no bubbling in the suction control chamber when suction is prescribed, indicating a lack of suction. Since bubbling is noted, the wall suction is likely functioning correctly.
Choice D rationale
Clamping the chest tube without a specific physician's order or immediate indication, such as accidental disconnection or tube change, is generally contraindicated. Clamping can lead to a tension pneumothorax by trapping air or fluid in the pleural space, which is a life-threatening complication.
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