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
Atrial fibrillation is characterized by an irregularly irregular rhythm, absence of discernible P waves (often replaced by fibrillatory waves), and an unmeasurable PR interval due to disorganized atrial activity. The QRS duration is typically normal if ventricular conduction is intact. The given ECG findings of irregular rhythm, absent P waves, and unmeasurable PR interval are classic for atrial fibrillation.
Choice B rationale
Sinus bradycardia is characterized by a regular rhythm with a heart rate below 60 beats per minute, distinct P waves preceding each QRS complex, a measurable and normal PR interval (0.12-0.20 seconds), and a normal QRS duration (0.06-0.12 seconds). The given heart rate of 92/min and irregular rhythm contradict this interpretation.
Choice C rationale
Supraventricular tachycardia (SVT) typically presents with a regular, rapid heart rate (often 150-250 beats per minute), often with P waves buried within or immediately after the QRS complex, making them difficult to identify or measure. The QRS duration is usually normal. While P waves might be indiscernible, the irregular rhythm and a heart rate of 92/min are not typical for SVT.
Choice D rationale
First-degree heart block is characterized by a regular rhythm, a P wave preceding every QRS complex, and a prolonged but consistent PR interval (greater than 0.20 seconds), with a normal QRS duration. The key diagnostic feature is the prolonged PR interval, which is unmeasurable in the given scenario due to absent P waves.
Correct Answer is C
Explanation
Choice A rationale
Discomfort at the puncture site is a common and expected finding following a thoracentesis due to the needle insertion through the intercostal muscles and parietal pleura. Sensory nerve endings in these tissues are stimulated, causing localized pain. This typically resolves with mild analgesia and does not indicate a significant complication such as pneumothorax or hemorrhage.
Choice B rationale
Serosanguineous drainage from the puncture site, while requiring monitoring, is often a normal finding in small amounts after a thoracentesis. It represents a mixture of serous fluid and blood, indicating minor capillary oozing from the needle tract. Excessive or persistent bleeding would be concerning for hemorrhage, but minimal serosanguineous discharge is not immediately indicative of a major complication.
Choice C rationale
An increased heart rate, or tachycardia, after a thoracentesis can signify significant complications like hypovolemia due to hemorrhage or tension pneumothorax. A tension pneumothorax shifts mediastinal structures, impairing venous return and leading to compensatory tachycardia. Hypovolemia from internal bleeding also triggers a sympathetic response, increasing heart rate to maintain cardiac output.
Choice D rationale
A decreased temperature, or hypothermia, is not typically a direct or immediate complication of a thoracentesis. While systemic reactions can occur in rare instances, a sudden drop in temperature is not a characteristic sign of the most common acute post-procedure complications such as pneumothorax, hemorrhage, or infection, which usually manifest with fever or normal temperature.
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