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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":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

A. Rhonchi are abnormal breath sounds that indicate the presence of mucus or fluid in the airways. Finding rhonchi in the right lung suggests the presence of respiratory congestion or obstruction, which may indicate ineffective treatment or ongoing respiratory issues.

B. Symmetric chest expansion indicates equal and adequate movement of both sides of the chest during inhalation. This finding suggests that there are no restrictions or abnormalities in the chest wall or lung tissue, which is indicative of effective treatment.

C. Oxygen saturation greater than 94% indicates adequate oxygenation of the blood, which is a positive indicator of effective treatment, particularly in clients with respiratory issues such as pneumonia or COPD.

D. A PaCO2 level of 55 mm Hg indicates hypercapnia, which is an elevated level of carbon dioxide in the blood. This finding suggests inadequate ventilation or respiratory failure, indicating ineffective treatment.

E. The ability to ambulate without experiencing shortness of breath suggests improved respiratory function and effective treatment, as it indicates adequate oxygenation and ventilation.

F. Diminished breath sounds suggest reduced airflow or lung volume in the affected area. This finding may indicate ongoing respiratory issues or incomplete resolution of the condition, suggesting ineffective treatment.

A. Palpate the lymph nodes. B. Observe the client's fingers. C. Palpate large joints for nodules. D. Observe the skin for lesions.

Correct Answer is B

Explanation

B Early signs of rheumatoid arthritis often manifest in the small joints of the hands and fingers. Common findings may include swelling, redness, warmth, and stiffness in these joints. Therefore, observing the client's fingers for any signs of inflammation or deformity can provide valuable clues for early detection of rheumatoid arthritis.

A Swollen lymph node may occur in certain types of arthritis, such as reactive arthritis but they are not typically a hallmark sign of rheumatoid arthritis.

C Rheumatoid nodules can develop in later stages of rheumatoid arthritis, but they are not typically present in the early stages of the disease.

D Rheumatoid arthritis is an autoimmune disease that can affect multiple organ systems, including the skin but characteristic skin lesions are not typically associated with the early stages of the condition.

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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

Patient Data Exhibits Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Patient Data Exhibits Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?

Correct Answer is B

Explanation

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

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The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Patient Data Exhibits Which physician orders would the nurse anticipate being prescribed after reporting findings? (Select all that apply).

Patient Data

Exhibits

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