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Patient Data

Exhibits

What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Avoid treating fever with antipyretics

Encourage the client to take breaks from the oxygen mask every few hours

Providing suctioning so the client does not have to cough

Assist the client in ambulating safely

Asking the client do quick, shallow breaths

Positioning the client with the head of the bed elevated

Teaching the client to cough at least once an hour

Answer and Explanation

Correct Answer : B,D,F

B. Encourage the client to take breaks from the oxygen mask every few hours: While supplemental oxygen may be necessary for clients with pneumonia who are hypoxemic, encouraging periodic breaks from the oxygen mask allows the client to mobilize and promote lung expansion, which can improve ventilation and oxygenation.

D. Ambulation helps prevent complications such as pneumonia-associated atelectasis by promoting lung expansion and mobilizing respiratory secretions. However, it's essential to ensure that ambulation is safe and appropriate based on the client's condition and mobility status.

F. Elevating the head of the bed promotes optimal lung expansion, reduces the work of breathing, and helps improve oxygenation in clients with pneumonia. This position also facilitates drainage of respiratory secretions and decreases the risk of aspiration.

A. Fever is often a sign of infection and can increase metabolic demand and oxygen consumption. Treating fever with antipyretics helps reduce metabolic demand, discomfort, and respiratory distress, thereby potentially improving ventilation and oxygenation.

C. Suctioning may be necessary to remove respiratory secretions in clients with pneumonia who are unable to clear their airways effectively. However, routine suctioning should be avoided unless clinically indicated, as it may cause discomfort and irritation to the airways.

E. Quick, shallow breaths (hyperventilation) can lead to respiratory alkalosis and impair oxygenation. Instead, clients with pneumonia should be encouraged to breathe slowly and deeply to promote effective gas exchange and lung expansion.

G. Teaching the client to cough at least once an hour: While coughing can help clear respiratory secretions and improve ventilation in clients with pneumonia, coughing excessively or unnecessarily may cause fatigue and discomfort. Clients should be encouraged to cough as needed to clear secretions but not excessively.

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Correct Answer is A

Explanation

A. Pulse oximetry measures the oxygen saturation of arterial blood, which is a crucial parameter to assess in clients with respiratory distress. Obtaining a pulse oximetry reading will provide information about the client's oxygenation status and help guide further interventions.

B. Huff coughing may be helpful for airway clearance but it may not be the most immediate intervention needed to address the client's respiratory distress.

C. Humidification may be beneficial for airway clearance in the long term but it may not be the most immediate intervention needed to address the client's acute respiratory distress.

D. Nebulizer breathing treatments, such as bronchodilators or corticosteroids, are commonly used to relieve bronchospasm and improve airflow in clients with COPD. However, in this scenario, the client's primary symptoms are dyspnea and tachypnea, indicating acute respiratory distress.

A. Presence of bowel sounds and degree of abdominal pain. B. Severity of nausea and vomiting and serum amylase results. C. Reports of chronic constipation and serum gastrin levels. D. Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts.

Correct Answer is B

Explanation

B. Pancreatitis is often associated with elevated serum amylase levels due to pancreatic inflammation. Therefore, this combination of clinical symptoms and laboratory findings is valuable in assessing the severity and confirming the diagnosis of pancreatitis.

A. While these are important clinical findings, they are not specific to pancreatitis and may not provide definitive information about the severity or cause of the condition.

C. Chronic constipation and serum gastrin levels are not typically associated with pancreatitis.

D. Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts are not directly related to pancreatitis. H. pylori infection is associated with peptic ulcers and gastritis but not typically with pancreatitis.

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Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea, tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

A client with emphysema reports difficulty breathing and exhibits audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants Immediate intervention by the nurse?

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

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To assess the quality of an adult client's pain, which approach should the nurse use?

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client's serum laboratory values is most important for the nurse to review?

A client receives a prescription for ophthalmic ketorolac, Prior to administering the medication, the nurse should review the medical record for which condition?

Patient Data

Exhibits

What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.