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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Administering inhaler medications and increasing oxygen may be necessary if the client is experiencing respiratory distress. However, since the client is not currently reporting increased dyspnea, this intervention is not immediately required. The focus should be on addressing the client’s anxiety.
Choice B reason:
Notifying the physician and administering lorazepam may be appropriate if the client’s anxiety is severe and not manageable through non-pharmacological means. However, it is generally best to try comfort measures and non-pharmacological interventions first.
Choice C reason:
Dimming the lights and encouraging the client to take a nap can help reduce anxiety, but it may not be the most effective initial intervention. Providing direct comfort and reassurance is often more beneficial in addressing immediate anxiety.
Choice D reason:
Sitting with the client and providing comfort measures is the most appropriate intervention. This approach helps to alleviate anxiety through direct support and reassurance. Techniques such as deep breathing exercises, talking calmly, and providing a comforting presence can significantly reduce anxiety.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason:
Avoiding crowds during the cold and flu season is crucial for a client recovering from pneumonia. Pneumonia weakens the lungs and the immune system, making the client more susceptible to infections. Crowded places increase the risk of exposure to respiratory infections, which can complicate recovery. According to UpToDate, patients with pneumonia should avoid exposure to infectious agents to prevent further complications.
Choice B reason:
Increasing activities to the previous level as soon as you get home is not advisable. Clients recovering from pneumonia need to gradually return to their normal activities. Overexertion can lead to fatigue and delay recovery. The Mount Sinai Health Library advises patients to rest and gradually increase activity levels as they regain strength.
Choice C reason:
Reporting temperature elevations to the healthcare provider is essential. Fever can be a sign of an ongoing infection or a complication. Normal body temperature ranges from 97°F to 99°F (36.1°C to 37.2°C). Any elevation above this range should be reported to ensure timely intervention.
Choice D reason:
Finishing taking oral antibiotics as prescribed is critical to ensure the infection is fully treated and to prevent antibiotic resistance. Incomplete antibiotic courses can lead to a resurgence of the infection and contribute to the development of resistant bacteria.
Choice E reason:
Electronic cigarettes are not a recommended alternative to tobacco while trying to quit. The safety and efficacy of e-cigarettes as a smoking cessation tool are still under investigation. The American Lung Association advises against using e-cigarettes due to potential health risks.
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