A patient's data shows consolidation in the right middle and lower lobe, consistent with pneumonia.
What actions can the nurse take to assist the patient in improving their ventilation and oxygenation? Select all that apply.
Provide suctioning so the patient does not have to cough.
Position the patient with the head of the bed elevated.
Encourage the patient to take breaks from the oxygen mask every few hours.
Ask the patient to do quick, shallow breaths.
Teach the patient to cough at least once an hour.
Avoid treating fever with antipyretics.
Assist the patient in ambulating safely.
Correct Answer : B,E,G
B. Position the patient with the head of the bed elevated. Rationale:
Promotes lung expansion: Elevating the head of the bed by at least 30 degrees utilizes gravity to assist in diaphragmatic descent and lung expansion. This allows for greater intake of air, optimizing oxygen intake and facilitating better gas exchange.
Reduces work of breathing: When upright, the abdominal muscles can more effectively aid in breathing, reducing the workload on the diaphragm and accessory muscles. This conserves energy and decreases the patient's respiratory effort.
Enhances secretion drainage: Gravity also aids in the movement of secretions from the lower lobes of the lungs towards the upper airways, where they can be more easily coughed up or suctioned. This helps to clear the airways and improve ventilation.
E. Teach the patient to cough at least once an hour. Rationale:
Clears secretions: Coughing is a natural mechanism to clear secretions from the lungs and airways. It helps to prevent mucus buildup and potential obstruction, which can lead to atelectasis (collapse of lung tissue) and further compromise ventilation.
Improves gas exchange: By removing secretions, coughing allows for better airflow and gas exchange within the lungs. This enhances oxygenation and helps to prevent respiratory complications.
G. Assist the patient in ambulating safely. Rationale:
Mobilizes secretions: Ambulation encourages movement of secretions from the lower lobes of the lungs, promoting their clearance and preventing mucus buildup.
Prevents atelectasis: Walking and movement help to expand the lungs, reducing the risk of atelectasis and improving overall ventilation.
Enhances circulation: Ambulation also improves circulation, which can help to deliver oxygen to the tissues more effectively and aid in healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While some individuals with Crohn's disease may find that avoiding gluten improves their symptoms, this is not a universal recommendation.
Gluten restriction is more often indicated for those with celiac disease or gluten sensitivity.
It's important to individualize dietary recommendations based on personal triggers and sensitivities.
Choice B rationale:
An elimination diet is a systematic approach to identifying foods that may trigger or worsen Crohn's disease symptoms.
It involves removing certain foods from the diet for a period of time, typically 2-4 weeks, and then gradually reintroducing them one at a time to observe any reactions.
This process can help individuals pinpoint specific foods that contribute to their symptoms and make informed dietary choices to manage their condition.
Choice C rationale:
There is no evidence to support a general restriction of calcium and iron in individuals with Crohn's disease.
In fact, these nutrients are essential for overall health and should be consumed in adequate amounts unless a specific deficiency or intolerance is identified.
Restriction of these nutrients could lead to nutritional deficiencies.
Choice D rationale:
Fluid restriction is not a primary dietary limitation for individuals with Crohn's disease.
Maintaining adequate hydration is crucial for overall health, especially during flares when fluid loss through diarrhea may be increased.
Restricting fluids could potentially lead to dehydration and electrolyte imbalances.
Correct Answer is C
Explanation
Choice A rationale:
It is true that antibiotics are not effective against viruses like influenza. They only work against bacteria.
However, while providing this information to the client is accurate, it does not directly address the client's inquiry about taking oseltamivir, which is an antiviral medication.
It's essential for the nurse to guide the client toward the appropriate healthcare provider who can assess the client's condition and make an informed decision about whether oseltamivir is a suitable treatment option.
Choice B rationale:
While it is true that influenza vaccination is most effective when given before exposure to the virus, it is still a relevant consideration even after symptoms have begun.
Studies have shown that antiviral medications like oseltamivir can potentially reduce the severity and duration of influenza symptoms, even when started within 48 hours of symptom onset.
Therefore, simply advising the client that it's too late for vaccination without exploring other potential treatment options would be incomplete and potentially disadvantageous to the client's care.
Choice C rationale:
This is the most appropriate response because it ensures that the client receives a comprehensive assessment and individualized treatment plan from a qualified healthcare provider.
The provider can evaluate the client's symptoms, medical history, and potential risk factors to determine if oseltamivir is a suitable medication.
Additionally, the provider can discuss other potential treatment options, such as over-the-counter medications for symptom relief, and provide guidance on self-care measures to promote recovery.
Choice D rationale:
While over-the-counter medications can help manage some symptoms of influenza, such as fever, aches, and cough, they do not directly target the virus itself.
Antiviral medications like oseltamivir can potentially shorten the duration of the illness and reduce the risk of complications, especially in individuals at higher risk.
Therefore, relying solely on over-the-counter medications without considering antiviral therapy could potentially delay recovery and increase the likelihood of adverse outcomes.
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