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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Dairy products such as milk, yogurt, and cheese are rich sources of calcium, which is essential for bone health and can help prevent osteoporosis, especially in older adults.
B: While fruits and vegetables are important for overall health, they do not provide significant amounts of calcium, which is the primary nutrient needed for preventing osteoporosis.
C: Iron-rich meals are important for preventing anemia but do not directly contribute to bone health and prevention of osteoporosis.
D: While hydration is important for overall health, water and herbal teas do not provide significant amounts of calcium needed for bone health.
Correct Answer is ["B","H"]
Explanation
A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.
B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.
E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.
H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.
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