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 ["50"]
Explanation
To calculate the infusion rate in gtts/min, the nurse should use the following formula: Infusion rate (gtts/min) = Volume (mL) x Drop factor (gtts/mL) / Time (min) Plugging in the given values, we get:
Infusion rate (gtts/min) = 400 mL x 60 gtt/mL / 480 min Simplifying, we get:
Infusion rate (gtts/min) = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtts/min.
Correct Answer is ["C","D","F","G"]
Explanation
A. The absence of pain does not necessarily indicate the absence of infection.
B. An oral temperature of 98.9 degrees F is within the normal range and does not indicate infection.
C. Decreased level of consciousness can be a sign of systemic infection, especially if accompanied by other symptoms.
D. An elevated white blood cell count (WBC) is indicative of an inflammatory response, which can occur in infection.
E. A scab forming on the incision line is a normal part of wound healing and does not necessarily indicate infection.
F. Crackles in bilateral lung bases may indicate a possible infection.
G. Redness and warmth at the incision site are signs of inflammation and can indicate infection.
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