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. Secretion removal is enhanced with adequate hydration, which thins and liquefies secretions.
You may also like to solve these questions
The nurse is aware that immunization of infants does not begin until 2 months of age because:
The nurse is aware that immunization of infants does not begin until 2 months of age because:
- A. The neonatal spleen is unable to produce efficient antibodies.
- B. Infants under 2 months are rarely exposed to infectious diseases.
- C. The immunization would attack the immature infant's body and produce the disease.
- D. Maternal antibodies interfere with the development of active antibodies by the infant.
Correct Answer: D
Rationale: Maternal antibodies present at birth interfere with vaccine-induced immunity until about 2 months.
The physician has ordered IV replacement of potassium for a patient with severe hypokalemia.
The nurse would administer the IV potassium
- A. by rapid bolus.
- B. diluted in 100 cc over 1 hour.
- C. diluted in 10 cc over 10 minutes.
- D. IV push.
Correct Answer: B
Rationale: Potassium is diluted and infused slowly to prevent cardiac arrhythmias.
A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101°F (38.3°C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion?
- A. Insulin
- B. Hydrocortisone
- C. Potassium
- D. Hypotonic saline
Correct Answer: B
Rationale: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given 100 mg of hydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal - not hypotonic - saline solution.
A patient with borderline personality disorder is exhibiting self-harming behaviors. Which of the following interventions is most appropriate?
- A. Ignore the self-harming behaviors
- B. Provide immediate medical care for injuries
- C. Punish the patient for self-harming
- D. Encourage the patient to discuss their feelings
Correct Answer: B
Rationale: Providing immediate medical care for injuries ensures safety and addresses physical harm, the priority in self-harming behaviors. Ignoring, punishing, or only discussing feelings delays critical intervention.
A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse?
- A. Avoid Alka-Seltzer because it contains aspirin
- B. Take Alka-Seltzer at a different time of day than the warfarin
- C. Select an antacid that does not interact with warfarin
- D. Use one-half the recommended dose of Alka-Seltzer
Correct Answer: A
Rationale: Avoid Alka-Seltzer because it contains aspirin. Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet drug, will potentiate the anticoagulant effect of warfarin, which may result in excess bleeding.