Nokea
Which intervention should the nurse prioritize to promote effective airway clearance in a client with impaired oxygenation?
- A. Providing incentive spirometry exercises
- B. Administering bronchodilator medications
- C. Encouraging deep breathing and coughing
- D. Positioning the client in high Fowler's position
Correct Answer: C
Rationale: Deep breathing and coughing help to mobilize and clear respiratory secretions, promoting effective airway clearance and improved oxygenation.
You may also like to solve these questions
A nurse is teaching a patient with COPD about energy conservation. Which strategy is best?
- A. Exercise vigorously
- B. Take frequent rest breaks
- C. Avoid deep breathing
- D. Increase fluid restriction
Correct Answer: B
Rationale: Frequent rest breaks conserve energy in COPD, reducing oxygen demand, unlike vigorous exercise, avoiding breathing exercises, or fluid restriction.
Which time would be ideal for the LPN/LVN to collect a sputum specimen?
- A. At bedtime
- B. In the morning
- C. After meals
- D. After start of antibiotics
Correct Answer: B
Rationale: Morning is considered the ideal time for collecting a sputum specimen. Overnight, mucus accumulates in the respiratory tract because the patient is less active and not clearing their throat or coughing as much. This means that the mucus is more concentrated and has had time to build up, providing a more substantial and representative sample of what is in the lungs.
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
- A. Examine personal values about the issue.
- B. Tell the parents that this is a necessary procedure.
- C. Inform the parents that the staff does not require their consent.
- D. Contact a spiritual support person to explain the importance of the procedure.
Correct Answer: A
Rationale: Examine personal values about the issue. Nurses should give care that is without bias. The nurse should provide information but not push care as 'necessary', parents must give consent for blood transfusions, and the provider should give information about the procedure not a spiritual support person.
The nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client’s vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
- A. Document the provider’s statement in the medical record
- B. Complete an incident report
- C. Consult the facility’s risk manager
- D. Notify the nursing manager.
Correct Answer: D
Rationale: Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status, therefore the next action is to activate the chain of command to ensure the client receives care.
A nurse is reinforcing teaching with the parents of a child who is starting to use a spacer with a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?
- A. The spacer increases the amount of medication delivered to the oropharynx.
- B. Cover exhalation slots of the spacer with lips when inhaling.
- C. The spacer increases the amount of medication delivered to the lungs.
- D. Inhale rapidly when using the spacer with the MDI.
Correct Answer: C
Rationale: The spacer helps to deliver more medication to the lungs by holding the medication in the chamber, allowing the patient to inhale it more slowly and deeply. This results in better deposition of the medication in the lower airways and reduces the amount of medication that is deposited in the mouth and throat.