A nurse is caring for a patient who has been prescribed nebulized Acetylcysteine for thick respiratory secretions. Which of the following actions should the nurse take to ensure effective secretion clearance after administration of the medication?
Instruct the patient to limit their fluid intake
Perform chest physiotherapy
Instruct the patient to avoid coughing to prevent airway irritation
Administer a bronchodilator
The Correct Answer is B
A. Instruct the patient to limit their fluid intake: Limiting fluids can worsen secretion thickness and impair mucociliary clearance. Hydration is essential for thinning secretions and supporting the action of mucolytics like Acetylcysteine.
B. Perform chest physiotherapy: Chest physiotherapy, including percussion and postural drainage, helps mobilize loosened secretions following Acetylcysteine administration. This facilitates airway clearance and improves ventilation and oxygenation.
C. Instruct the patient to avoid coughing to prevent airway irritation: Coughing is a natural and beneficial response that helps expel mucus after mucolytic therapy. Inhibiting the cough reflex can lead to secretion retention and airway obstruction.
D. Administer a bronchodilator: While bronchodilators may be helpful in patients with bronchospasm, they are not required after every dose of Acetylcysteine. Chest physiotherapy is more directly effective in clearing mucus after mucolytic administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Total volume to be infused = 750 mL
Total infusion time = 4 hours
Convert hours to minutes: 4 hours × 60 minutes/hour = 240 minutes
Drop factor = 10 gtt/mL
- Calculate the total number of drops needed:
Total drops (gtt) = Total volume (mL) × Drop factor (gtt/mL)
= 750 mL × 10 gtt/mL
= 7500 gtt
- Calculate the flow rate in drops per minute (gtt/min):
Flow rate (gtt/min) = Total drops (gtt) / Total infusion time (minutes)
= 7500 gtt / 240 minutes
= 31.25 gtt/min
- Round to the nearest whole number:
Rounding 31.25 to the nearest whole number gives 31.
= 31 gtt/min.
Correct Answer is D
Explanation
A. "Limit your fluid intake to meal times.": Fluid restriction is not a standard recommendation for patients taking Verapamil unless they have another condition like heart failure. Adequate hydration is important, especially to counter constipation, a known side effect of the drug.
B. "You can expect swelling of the ankles while taking this medication.": While peripheral edema is a known side effect of Verapamil, it is not something patients should expect or accept without reporting. Significant swelling may require dose adjustment or switching medications.
C. "This medication will not affect your heart rate": Verapamil is a calcium channel blocker that slows AV node conduction and reduces heart rate. It is used for conditions like hypertension, angina, and arrhythmias, and can cause bradycardia, especially in high doses.
D. "Increase your daily intake of dietary fiber.": Verapamil frequently causes constipation by decreasing gastrointestinal motility. Increasing dietary fiber, fluid intake, and physical activity are recommended to minimize this side effect and promote regular bowel movements.
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