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 {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}
Explanation
A. Placing the client on Contact Precautions is appropriate to prevent the transmission of MRSA to other patients and healthcare workers.
B. Applying a cold compress may worsen tissue damage and compromise blood flow, which can exacerbate the wound infection and cellulitis.
C. Elevating the client's arm can help reduce swelling and improve circulation, aiding in the resolution of cellulitis.
D. Taking a wound culture every shift is not necessary or useful, as it can be painful for the client and does not provide timely information on the infection status. A wound culture is usually done once before starting antibiotic therapy and then repeated only if there is no improvement or signs of worsening.
E. Initiating IV access for fluid and antibiotic therapy is necessary for treating the systemic infection caused by MRSA and cellulitis.
F. Subcutaneous sodium heparin is an anticoagulant that prevents blood clots, but it is not indicated for this client unless they have a history or risk of thromboembolic events, such as deep vein thrombosis or pulmonary embolism.
Correct Answer is C
Explanation
A. While pain is a common symptom associated with inflammation, providing a feedback mechanism for pain identification is not the ultimate purpose of the inflammatory process.
B. The inflammatory process is not primarily aimed at increasing fatty deposits in affected tissue.
C. The ultimate purpose of the inflammatory process is to localize, destroy, and remove injurious agents such as pathogens and damaged cells, thereby preparing the wound for healing.
D. Releasing antigens into the general circulation is not the primary purpose of the inflammatory process.
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