A nurse is planning care for a client who is having an exacerbation of chronic bronchitis. Which of the following interventions should the nurse plan to include?
Keep the head of the client's bed at a 15° angle.
Place the client on bedrest for 24 hr.
Instruct the client to increase fluid intake to 2.5 L per day.
Encourage the client to perform deep-breathing exercises every 6 hr.
The Correct Answer is C
A. Keep the head of the client's bed at a 15° angle: Elevating the head of the bed only slightly is insufficient for optimal lung expansion. A higher elevation, usually 30–45°, is recommended to improve ventilation and ease breathing during an exacerbation.
B. Place the client on bedrest for 24 hr: Prolonged bedrest can decrease lung expansion and increase the risk of mucus retention. Encouraging activity as tolerated helps maintain respiratory function and prevents complications.
C. Instruct the client to increase fluid intake to 2.5 L per day: Increased fluid intake helps thin secretions, making them easier to expectorate. This is a key intervention in managing an acute exacerbation of chronic bronchitis to improve airway clearance.
D. Encourage the client to perform deep-breathing exercises every 6 hr: Deep-breathing exercises are beneficial, but they should be performed more frequently than every 6 hours, often hourly or as tolerated, to effectively prevent atelectasis and improve oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["45"]
Explanation
Identify the ordered dose and the available concentration
Ordered Dose: 30 g
Available Concentration: 10 g per 15 mL
Calculate the volume to administer per dose using the Dose/Have method
Amount to administer = (Ordered Dose ÷ Dose on Hand) × Quantity
Quantity corresponding to the Dose on Hand = 15 mL
Volume = (30 ÷ 10) × 15
= 3 × 15
= 45 mL
Correct Answer is D
Explanation
A. A client who has a burn requiring a sterile dressing change: While burn care is important to prevent infection and promote healing, a dressing change is not immediately life-threatening. This task can be safely addressed after assessing clients with higher-priority acute risks.
B. A client who had an appendectomy 6 hr ago and has diminished bowel sounds: Diminished bowel sounds are common in the immediate postoperative period and do not usually indicate an emergent problem. This client requires ongoing monitoring, but there is no acute threat to life at this time.
C. A client who received a chemotherapy treatment and reports nausea: Nausea following chemotherapy is uncomfortable and should be managed promptly, but it is not immediately life-threatening. Interventions such as antiemetics can be provided after more urgent needs are addressed.
D. A client who has hypothyroidism and is stuporous: Stupor in a client with hypothyroidism may indicate myxedema or severe hypothyroid crisis, which can be life-threatening due to risk of respiratory depression, cardiovascular compromise, or altered mental status. This client requires immediate assessment and intervention, making them the highest priority.
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