The nurse is providing care to a client admitted with a diagnosis of bacterial pneumonia. On assessment, the client has dry mucous membranes and coarse rhonchi. What nursing interventions would the nurse include in the plan of care?

Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest

Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing

Decrease activity, increase bronchodilator use, and encourage pursed lip breathing

Place in prone position, begin steroid therapy, and monitor glucose levels

Answer and Explanation

The Correct Answer is B

A) Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest:
This approach is inappropriate for a client with bacterial pneumonia. While oxygen therapy may be necessary for some clients, administering a cough suppressant in this scenario is counterproductive. Pneumonia often leads to the accumulation of secretions, and suppressing the cough would prevent the client from clearing mucus from their airways, potentially worsening the condition. Bedrest is generally indicated, but it should not be the sole intervention.

B) Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing:
This is the most appropriate plan of care. Increasing fluid intake helps to thin the mucus, making it easier to clear from the airways, which is crucial in pneumonia. Antibiotics are necessary to treat the bacterial infection causing pneumonia. Facilitating adequate coughing helps the client expel secretions, reducing the risk of airway obstruction and improving oxygenation. Coarse rhonchi indicate the presence of mucus or secretions, which should be cleared with effective coughing.

C) Decrease activity, increase bronchodilator use, and encourage pursed lip breathing:
Decreasing activity is generally appropriate for a client with pneumonia to reduce fatigue, but increasing bronchodilator use is not typically indicated unless there is underlying bronchospasm, such as in asthma or COPD. Pursed lip breathing can help improve ventilation, but it is more beneficial for clients with obstructive airway diseases, not primarily for those with bacterial pneumonia. Therefore, this option does not address the immediate needs of the client.

D) Place in prone position, begin steroid therapy, and monitor glucose levels:
While prone positioning is helpful in some conditions like acute respiratory distress syndrome (ARDS), it is not routinely used for bacterial pneumonia unless the client has severe hypoxemia and requires advanced respiratory support. Steroid therapy is generally not indicated for bacterial pneumonia unless there is a specific inflammatory component (such as a superimposed condition like asthma or COPD). Monitoring glucose levels may be important in clients on steroid therapy, but this is not a primary concern in the treatment of bacterial pneumonia.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. There is continuous bubbling in the water-seal chamber: Continuous bubbling in the water-seal chamber suggests a potential air leak in the system, which needs to be investigated. The water-seal chamber is designed to prevent backflow of air into the pleural space, and persistent bubbling typically indicates that air is escaping from the pleural cavity or there is a problem with the tubing or chest tube placement. This is the first sign that the system may not be sealed properly and should be checked for leaks.

B. The water levels in the water-seal chamber and suction chambers are decreased: Decreased water levels in both the water-seal and suction chambers may be indicative of fluid loss or evaporation, but it does not necessarily point to a leak. In the case of a chest tube, water levels may also drop due to suction pressure or gradual evaporation, which would need to be adjusted or monitored. While this should be addressed, it is not an immediate cause for suspicion of an air leak in the system.

C. Fluid in the water-seal chamber fluctuates with the client's breathing: The fluctuation (also known as "tidaling") in the water-seal chamber is a normal finding that occurs when the client breathes in and out. It reflects the pressure changes in the pleural cavity during respiration. The absence of tidaling might indicate that the lung has re-expanded or that there is a blockage in the tubing. While tidaling is a normal occurrence, the absence or abnormality of this fluctuation would require further assessment but not for an air leak.

D. There is constant bubbling in the suction-control chamber: Constant bubbling in the suction-control chamber generally indicates that suction is appropriately applied to the system. However, if there is continuous bubbling in this chamber, it is typically related to the level of suction being applied, not an air leak. This is a normal occurrence and does not require checking for leaks in the system unless suction pressure is too high or low for optimal functioning.

A. allowing undamaged areas in the lower part of the lungs to be ventilated." B. relieving pressure on the diaphragm and allowing expansion." C. decreasing pressure to the back of the rib cage." D. snifting fluid into the back area of the lungs.'

Correct Answer is A

Explanation

A. Allowing undamaged areas in the lower part of the lungs to be ventilated: The prone position is commonly used in patients with acute respiratory distress syndrome (ARDS) to improve oxygenation and ventilation. In ARDS, the lung tissue is often damaged, particularly in the dorsal (back) regions of the lungs, due to gravity and ventilation-perfusion mismatch. By placing the patient in the prone position, gravity helps redistribute the blood flow and improve ventilation to the posterior (lower) parts of the lungs, which are typically under-ventilated in the supine position. This positioning allows healthier or less-damaged areas of the lungs to receive better airflow, improving overall oxygenation.

B. Relieving pressure on the diaphragm and allowing expansion: While the prone position does shift pressure away from certain areas, its primary benefit is not related to relieving pressure on the diaphragm. The diaphragm, while somewhat affected by body position, is not the key structure being targeted for ventilation improvement. The main goal of prone positioning is to improve lung aeration in areas affected by ARDS, not directly to relieve diaphragm pressure.

C. Decreasing pressure to the back of the rib cage: The prone position does not specifically target reducing pressure to the back of the rib cage. Although it changes how pressure is distributed across the body, the main goal is to facilitate better ventilation and perfusion to the posterior lung regions, not necessarily to reduce pressure on the rib cage itself.

D. Sniffing fluid into the back area of the lungs: This option is unclear and not accurate. The prone position does not "sniff" fluid into the lungs; rather, it helps to redistribute fluid and improve the ventilation of the lung areas that are less affected by edema or inflammation in ARDS. The goal is to improve the ventilation/perfusion ratio and prevent further collapse of lung tissue.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is providing care to a client admitted with a diagnosis of bacterial pneumonia. On assessment, the client has dry mucous membranes and coarse rhonchi. What nursing interventions would the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse would check for leaks in the chest tube and water seal system when:

Correct Answer is A

Explanation

A client with a medical diagnosis of acute respiratory distress syndrome (ARDS) is being placed in the prone position. The nurse explains to family members that, "This will help improve ventilation by:

Correct Answer is A

Explanation

The nurse is teaching the client and family about Huntington's Disease (HD). What information should the nurse include?

The nurse is caring for a client in acute respiratory distress syndrome (ARDS). The chest x-ray displays evidence of pulmonary edema. The nurse assesses the client for which clinical manifestation?

What is the first action the nurse should take with the accidental dislodgement of a chest tube?

A patient is prescribed 500 ml of Normal Saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (Round to the nearest whole number)

A client with an acute stroke must receive Alteplase 0.9 mg/kg (maximum dose 90 mg) over 60 minutes. The client weighs 220 pounds. How many mg should the client receive? (Round to the nearest tenth, do not use trailing zeros)

Which method would the nurse utilize to best facilitate communication when caring for a client with end stage amyotrophic lateral sclerosis (ALS)?

A client is admitted to the Emergency Department (ED) with a suspected ST elevation myocardial infarction (STEMI) involving the inferior wall. The nurse anticipates that this client will be immediately scheduled for the cardiac catheterization laboratory. The goal of treatment is to:

The nurse is caring for a client with respiratory failure. The client is lethargic and slow to follow commands. Current vital signs are: BP 88/52, pulse 132, respirations 8, and SPO2 84% on 35% Venturi mask. The nurse would anticipate which medical prescription?