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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?

A.

Encourage coughing and deep breathing

B.

Encourage regular use of the incentive spirometer

C.

Encourage the client to increase fluid intake

D.

Encourage the client to ambulate frequently

Answer and Explanation

The Correct Answer is C

Increasing fluid intake helps to hydrate the mucous membranes and thin the respiratory secretions, which facilitates expectoration and improves gas exchange.

  1. Encourage coughing and deep breathing. This is beneficial for clearing the airways and preventing atelectasis, but it does not directly affect the viscosity of the secretions.
  2. Encourage regular use of the incentive spirometer. This is helpful for expanding the lungs and preventing complications such as pneumonia or pleural effusion, but it does not influence the consistency of the secretions.
  3. Encourage the client to ambulate frequently. This is important for promoting circulation and mobility, but it does not have a significant effect on the thinning of the secretions.


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Related Questions

Correct Answer is A

Explanation

Radiation therapy can cause immunosuppression, which increases the risk of infection. The nurse should monitor the client for signs of infection such as fever, chills, malaise, or purulent drainage.

  1. Examine the skin for generalized urticaria. This is not a common side effect of radiation therapy, as urticaria is an allergic reaction that causes hives or welts on the skin. Radiation therapy can cause localized skin irritation, erythema, or dryness, but not generalized urticaria.
  2. Review laboratory test results for low hemoglobin. This is not a direct effect of radiation therapy, as hemoglobin is a component of red blood cells that carries oxygen in the blood. Radiation therapy can cause anemia, which is a low number of red blood cells, but not necessarily low hemoglobin.
  3. Monitor the mouth for signs of xerostomia. This is not relevant for a client who receives radiation therapy to treat lung cancer, as xerostomia is dry mouth caused by reduced salivary gland function. This can occur in clients who receive radiation therapy to treat head and neck cancer, but not lung cancer.

Correct Answer is ["A","C","E"]

Explanation

These are important safety and comfort measures for a client who uses home oxygen therapy via a nasal cannula.

The other options are not correct because:

b. Verify the oxygen flow rate every other day. This is not frequent enough, as the flow rate should be checked at least daily and whenever the client feels short of breath or has changes in vital signs.

d. Apply petroleum ointment to nares if they become dry and irritated. This is not recommended, as petroleum products can ignite in the presence of oxygen and cause burns or fire. A water-based lubricant should be used instead.

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