Nokea
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
- A. Administration of cough suppressants
- B. Increasing oral fluid intake to 3000 cc per day
- C. Maintaining bed rest with bathroom privileges
- D. Performing chest physiotherapy twice a day
Correct Answer: B
Rationale: Increasing oral fluid intake to 3000 cc per day is the most effective in removing respiratory secretions in a client with pneumococcal pneumonia. Adequate hydration helps thin secretions, making them easier to expectorate. Administration of cough suppressants (Choice A) may hinder the removal of secretions by suppressing the cough reflex. Maintaining bed rest with bathroom privileges (Choice C) is important but does not directly address the removal of respiratory secretions. Performing chest physiotherapy (Choice D) is beneficial for mobilizing secretions but may not be as effective as increasing fluid intake in thinning and facilitating the removal of secretions.
You may also like to solve these questions
The major target of the Philippine Family Program are women belonging to the high-risk group which includes:
- A. Women under 20 or over 35 years old
- B. Women suffering from certain medical conditions that contradict pregnancy
- C. All these groups
- D. Women who have had at least 4 deliveries
Correct Answer: C
Rationale: The correct answer is C, 'All these groups.' The Philippine Family Program targets women under 20 years old, over 35 years old, those with certain medical conditions that contradict pregnancy, and women who have had at least 4 deliveries. Therefore, choice C is the correct answer because it encompasses all the high-risk groups identified by the program. Choices A, B, and D are incorrect because they do not cover all the specified high-risk groups targeted by the program.
The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?
- A. Weight reduction
- B. Stress management
- C. Physical exercise
- D. Smoking cessation
Correct Answer: D
Rationale: The correct answer is D, smoking cessation. Smoking is a major and modifiable risk factor for cardiovascular disease. It is often the highest priority in cardiac risk reduction because stopping smoking has immediate and long-term benefits for heart health. Choices A, B, and C are also important in reducing cardiac risk factors, but smoking cessation takes precedence due to its significant impact on cardiovascular health.
Which topic should be included in planning a secondary prevention project for the local retirement community?
- A. Safety measures in the home.
- B. Adult immunization program.
- C. Rehabilitation after surgery.
- D. Vision and hearing screening.
Correct Answer: D
Rationale: In planning a secondary prevention project for the local retirement community, vision and hearing screening should be included. This is crucial as sensory impairments are common among older adults and early detection through screening can help in preventing further complications. Safety measures in the home, adult immunization programs, and rehabilitation after surgery are important but fall more under primary or tertiary prevention strategies rather than secondary prevention, which focuses on early detection and intervention to prevent the progression of health conditions.
A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?
- A. Arrange for a change in client care assignments
- B. Explain that this behavior is expected
- C. Discuss the appropriate use of 'time-out'
- D. Explain that the child is in need of extra attention
Correct Answer: B
Rationale: The correct answer is to explain that this behavior is expected. At 16 months of age, children commonly experience separation anxiety, especially in unfamiliar environments like hospitals. It is important for the nurse to reassure the child and the parent that such behavior is normal. Option A is incorrect as there is no need to change client care assignments based on the child's behavior. Option C is not appropriate as discussing the use of 'time-out' is more relevant in behavior management for older children. Option D is incorrect as it does not address the underlying cause of the child's behavior related to separation anxiety.
The RN is planning care at a team meeting for a 2-month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?
- A. Infant will experience minimal pain
- B. Muscle spasms will be relieved
- C. Mobility will be managed as tolerated
- D. Tissue perfusion will be maintained
Correct Answer: D
Rationale: Following cast application for congenital clubfoot in a 2-month-old child, the priority nursing goal should be to maintain tissue perfusion. This is crucial to prevent complications like compartment syndrome and ensure proper healing. While managing pain, relieving muscle spasms, and promoting mobility are important aspects of care, they are secondary to ensuring adequate tissue perfusion in this scenario.