The client has right lower lobe pneumonia with a non-productive cough. Which intervention is the nurse’s priority?

Suction the client at least every two hours.

Encourage fluids up to 3000 mL/day unless contraindicated.

Encourage a right side-lying position.

Administer codeine elixir PRN following prescription.

Answer and Explanation

The Correct Answer is B

Choice A reason: Suctioning the client at least every two hours is not typically necessary for a non-productive cough. Suctioning is more appropriate for patients with excessive secretions that they cannot clear on their own. Overuse of suctioning can cause irritation and discomfort.

Choice B reason: Encouraging fluids up to 3000 mL/day unless contraindicated is crucial for a client with pneumonia. Adequate hydration helps to thin mucus, making it easier to expectorate and clear from the lungs. This can improve the client’s ability to cough effectively and reduce the risk of complications such as atelectasis. Hydration also supports overall bodily functions and helps in maintaining electrolyte balance.

Choice C reason: Encouraging a right side-lying position is not the best intervention for a client with right lower lobe pneumonia. This position may not promote optimal lung expansion and drainage. Instead, positioning the client to maximize lung expansion and facilitate drainage, such as sitting up or lying on the unaffected side, is more beneficial.

Choice D reason: Administering codeine elixir PRN following prescription is not the priority intervention. While codeine can help suppress a cough, it is generally not recommended for a non-productive cough in pneumonia because it can suppress the cough reflex needed to clear secretions. Additionally, codeine can cause respiratory depression and other side effects.

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Correct Answer is A

Explanation

Choice A reason: Fine crackles are often associated with bronchitis, particularly chronic bronchitis. These sounds are caused by the presence of mucus in the airways, which creates a crackling noise when air passes through. Chronic bronchitis involves inflammation and increased mucus production in the bronchi, leading to these characteristic lung sounds.

Choice B reason: A pneumothorax, or collapsed lung, typically presents with absent or diminished breath sounds on the affected side rather than fine crackles. The absence of breath sounds is due to the lack of air movement in the collapsed portion of the lung. Fine crackles are not a common finding in pneumothorax.

Choice C reason: Asthma is characterized by wheezing, which is a high-pitched whistling sound caused by narrowed airways. While crackles can occasionally be heard in asthma, they are not the primary lung sound associated with this condition. Wheezing is more indicative of asthma due to bronchoconstriction and inflammation.

Choice D reason: Emphysema, a form of chronic obstructive pulmonary disease (COPD), typically presents with decreased breath sounds and prolonged expiration rather than fine crackles. The destruction of alveolar walls in emphysema leads to reduced lung sounds overall. Fine crackles are not a hallmark of emphysema.

A. Place on cardiac monitoring. B. Monitor breath sounds every 4 hours. C. Restrict fluids to 500 mL per day. D. Implement safety precautions.

Correct Answer is C

Explanation

Choice A reason: Placing the client on cardiac monitoring is important, especially if there are signs of cardiac involvement or if the client is at risk for arrhythmias. However, it is not the primary intervention for hypernatremia. Hypernatremia primarily affects fluid balance and neurological status.

Choice B reason: Monitoring breath sounds every 4 hours is a good practice, particularly if there is a risk of fluid overload or respiratory complications. However, it does not directly address the issue of hypernatremia. The primary concern with hypernatremia is managing fluid balance and preventing further increases in serum sodium levels.

Choice C reason: Restricting fluids to 500 mL per day is a critical intervention for managing hypernatremia. Hypernatremia often results from a deficit in free water, leading to an elevated serum sodium level. Fluid restriction helps to prevent further increases in sodium concentration and assists in gradually correcting the imbalance. This intervention directly addresses the underlying issue of hypernatremia and helps to stabilize the client’s condition.

Choice D reason: Implementing safety precautions is important, especially if the client is experiencing neurological symptoms such as confusion or agitation. While safety precautions are necessary, they are not the primary intervention for correcting hypernatremia. The focus should be on managing fluid balance and serum sodium levels.

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The client has right lower lobe pneumonia with a non-productive cough. Which intervention is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the client and notes fine crackles throughout the lungs bilaterally. This assessment finding is often associated with:

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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