The nurse is developing the plan of care for a client with pneumonia and includes the nursing problem of Ineffective airway clearance related to thick pulmonary secretions. Which intervention is most important for the nurse to include in the client's plan of care?
Increase fluid intake to 3,000 mL/daily.
Provide frequent rest periods.
Administer O2 at 5 L/minute per nasal cannula.
Maintain the client in a semi-Fowler's position.
The Correct Answer is A
A. Increasing fluid intake helps thin pulmonary secretions, making them easier to expectorate and is most directly related to clearing the airway.
B. Providing frequent rest periods is important but does not directly clear the airway.
C. Administering O2 addresses hypoxia but does not clear secretions.
D. Semi-Fowler's position helps with breathing but does not specifically address thick secretions.
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Related Questions
Correct Answer is D
Explanation
A. Discouraging visits from friends may contribute to social isolation, which can negatively impact the child's psychosocial well-being. Encouraging social interactions, when appropriate, is generally beneficial.
B. While play therapy may be useful in certain situations, it may not be the primary focus for a 10-year-old child. Encouraging age-appropriate activities and interactions, including school work, is important.
C. Varying the child's schedule each day might introduce unnecessary stress and disrupt the sense of routine and stability, which is essential for psychosocial well-being.
D. Encouraging the client to complete school work is aligned with Erikson's psychosocial stage of industry vs. inferiority. This stage emphasizes the importance of developing competence and skills, including academic achievements, during the school-age years. Supporting the child's educational needs is crucial for positive psychosocial development.
Correct Answer is A
Explanation
A. Increasing fluid intake helps thin pulmonary secretions, making them easier to expectorate and is most directly related to clearing the airway.
B. Providing frequent rest periods is important but does not directly clear the airway.
C. Administering O2 addresses hypoxia but does not clear secretions.
D. Semi-Fowler's position helps with breathing but does not specifically address thick secretions.
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