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 D

Explanation

Choice A reason: Asking if the client would like to see a member of the clergy to receive a blessing can be supportive, but it may not directly address the client’s immediate emotional needs. While spiritual support is important, the nurse should first focus on the client’s expressed concerns about their wife.

Choice B reason: Inquiring if the client has children who can help their wife is practical, but it may not address the client’s emotional distress. The nurse should prioritize providing emotional support and facilitating communication between the client and their family.

Choice C reason: Asking if the client has a living will is important for end-of-life planning, but it does not directly address the client’s emotional concerns. This question is more appropriate for a discussion about advance directives rather than an immediate response to the client’s expressed worries

Choice D reason: Encouraging the client to discuss their feelings with their wife is the most appropriate response. It addresses the client’s emotional needs and promotes open communication between the client and their spouse. This can help alleviate some of the client’s anxiety and ensure that their wife is aware of their feelings and concerns.

Correct Answer is ["25"]

Explanation

The nurse should regulate the IV flow at 25 gtts/min.

Calculation and Answer

Step 1: Determine the total volume to be infused.

Volume = 100 mL

Step 2: Determine the time over which the infusion will occur.

Time = 1 hour = 60 minutes

Step 3: Determine the drip factor.

Drip factor = 15 gtts/mL

Step 4: Calculate the IV flow rate using the formula:

Flow rate (gtts/min) = (Volume (mL) × Drop factor (gtts/mL)) ÷ Time (min)

Step 5: Substitute the values into the formula.

Flow rate (gtts/min) = (100 mL × 15 gtts/mL) ÷ 60 min

Step 6: Perform the multiplication.

100 mL × 15 gtts/mL = 1500 gtts

Step 7: Perform the division.

1500 gtts ÷ 60 min = 25 gtts/min

The nurse should regulate the IV flow at 25 gtts/min.

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

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Naxlex Comprehensive Predictor Exams

A client who is in the end stage of chronic bronchitis tells the nurse, “I don’t know how my wife will manage without me.” The most appropriate response by the nurse at this time is:

Correct Answer is D

Explanation

The nurse receives an order to administer drug R 300 mg IVPB over one hour. Drug R is available as 300 mg in 100 mL NSS. The drip factor of the piggyback tubing is 15 gtts/mL. At what rate should the nurse regulate the IV flow?

Correct Answer is ["25"]

Explanation

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