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 B
Explanation
Choice A rationale
Irrigating the client's throat can introduce fluid into the airway before the gag reflex has returned, significantly increasing the risk of aspiration. This practice is contraindicated in the immediate post-bronchoscopy period due to residual topical anesthetic effects.
Choice B rationale
Topical anesthetics are used during bronchoscopy to suppress the gag reflex and discomfort. Until this reflex, which protects the airway from aspiration, has fully returned, withholding food and liquids is crucial to prevent aspiration of foreign material into the lungs.
Choice C rationale
While some oral secretions may be present, frequent oropharyngeal suctioning can cause mucosal trauma or stimulate gagging before the gag reflex is fully restored, potentially inducing vomiting and increasing aspiration risk. It should be performed only as needed, judiciously.
Choice D rationale
Refraining from talking for 24 hours is unnecessary after a flexible bronchoscopy. While some clients may experience mild hoarseness or sore throat, vocal rest is not a standard or required post-procedure intervention and does not pose a significant risk if the gag reflex is intact. .
Correct Answer is C
Explanation
Choice A rationale
Aspirin exhibits analgesic properties by inhibiting prostaglandin synthesis, primarily through irreversible acetylation of cyclooxygenase enzymes (COX-1 and COX-2). This reduces the perception of pain stimuli. However, for a client with a history of MI, its primary therapeutic benefit extends beyond pain relief.
Choice B rationale
Aspirin acts as an anti-inflammatory agent by inhibiting prostaglandin production, which are key mediators of inflammation. This reduces vasodilation, increased vascular permeability, and leukocyte infiltration at sites of inflammation. While aspirin has anti-inflammatory effects, it's not the primary reason for its prescription in MI prevention.
Choice C rationale
Aspirin's antiplatelet aggregate action is crucial in MI prevention. It irreversibly inhibits cyclooxygenase-1 (COX-1) in platelets, thereby preventing the synthesis of thromboxane A2 (TXA2). TXA2 is a potent vasoconstrictor and platelet aggregator, so its inhibition reduces the risk of clot formation in coronary arteries. This is the primary reason for its use in MI.
Choice D rationale
Aspirin possesses antipyretic effects by inhibiting prostaglandin E2 synthesis in the hypothalamus, which helps to reset the body's thermoregulatory set point during fever. While this is a known effect of aspirin, it is not the primary indication for its use in a client with a history of myocardial infarction.
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