At 1930 the nurse notes that the client has rapid, more labored respirations with frequent coughing that is producing thick tenacious secretions. The client is alert and oriented and able to speak, between coughing episodes. She states that the last time she had this much coughing, the respiratory therapist (RT) gave her a nebulizer treatment, which "helped a lot."
What nursing actions would the nurse implement at this time in coordination with the registered nurse (RN)? Select all that apply.
Remind the client to drink additional fluids to thin secretions.
Obtain the client's vital signs and note change from previous readings.
Administer the antitussive medication as prescribed PRN.
Ensure that the client is positioned in a high-Fowler position.
Increase the supplemental oxygen flow.
Call the respiratory therapist to administer a nebulizer treatment.
Increase the rate of the client's IV fluids.
Document findings and actions.
Contact the Rapid Response Team
Listen to the client's breath sounds
Correct Answer : B,D,E,F,H,J
A. While encouraging fluid intake is generally beneficial, this action alone may not adequately address the client's respiratory distress.
B. Obtaining the client's vital signs and noting changes from previous readings is essential for assessing the client's condition and response to interventions.
C. Administering antitussive medication may not be appropriate as the client is able to expectorate secretions, and suppressing the cough may hinder clearance of secretions.
D. Positioning the client in a high-Fowler position helps improve lung expansion, aiding in respiratory effort.
E. Increasing the supplemental oxygen flow can help alleviate respiratory distress by improving oxygenation.
F. Calling the respiratory therapist for a nebulizer treatment is appropriate, especially since the client reported previous relief with this intervention.
G. Increasing IV fluids may not directly address the client's respiratory distress and should be based on fluid status and other clinical indications.
H. Documenting findings and actions taken ensures proper communication and continuity of care.
I. Contacting the Rapid Response Team may not be necessary as the client is alert and oriented and not in immediate distress.
J. Listening to the client's breath sounds allows the nurse to compare with previous findings and evaluate respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Naturally acquired active immunity refers to immunity acquired through natural exposure to a pathogen or antigen, leading to the production of antibodies by the individual's immune system.
B. Artificially acquired passive immunity refers to the transfer of antibodies produced by another individual or animal, such as through administration of immune globulin.
C. Naturally acquired passive immunity occurs when antibodies are transferred from mother to baby through the placenta or breast milk, providing temporary protection to the baby.
D. Artificially acquired active immunity refers to immunity acquired through vaccination, where the individual's immune system is stimulated to produce antibodies in response to an antigen.
Correct Answer is D
Explanation
A. Normal joint wear and tear typically do not result in bony enlargements, deviation of fingers, or hard, painless joints.
B. Osteomyelitis is a bone infection and would present with symptoms such as fever, localized pain, swelling, and redness over the affected bone, rather than bony enlargements of the joints.
C. Uric acid deposits are associated with conditions like gout and would typically manifest as acute attacks of severe pain, redness, and swelling in the affected joint, rather than the chronic, painless joint deformities seen in the scenario described.
D. Rheumatoid Arthritis (RA) is a chronic autoimmune disorder characterized by inflammation of the synovium, leading to joint deformities, bony enlargements, and deviation of fingers. Joints affected by RA are typically hard, painless, and may exhibit ulnar deviation.
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