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A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath and a productive cough with thickened, tenacious mucus. The client reports difficulty walking up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?

A.

Teach anxiety reduction methods for feelings of suffocation.

B.

Increase the daily intake of oral fluids to liquefy secretions.

C.

Call the clinic if undesirable side effects of medications occur.

D.

Avoid crowded enclosed areas to reduce pathogen exposure.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.

 

Choice B rationale

 

Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.

 

Choice C rationale

 

Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.

 

Choice D rationale

 

Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Securing tracheostomy ties by making knots close to the tube can cause irritation and pressure on the skin.

Choice B rationale

Removing ties to secure a disposable, soft foam collar with hook and loop fastener is not the most important action when changing the ties of the tracheostomy tube.

Choice C rationale

Leaving the old ties in place until the new ones are secure is the most important action to prevent accidental dislodgement of the tracheostomy tube.

Choice D rationale

Placing knots of the ties laterally to prevent irritation and pressure is important but not the most critical action when changing the ties of the tracheostomy tube.

Correct Answer is C

Explanation

Choice A rationale

Anxiety and grieving are important issues but are not the priority when the client is at risk for aspiration.

Choice B rationale

Chronic pain is significant, but the immediate risk of aspiration due to dysphagia takes precedence.

Choice C rationale

Risk for aspiration related to difficulty swallowing is the priority nursing problem. Aspiration can lead to serious complications such as pneumonia.

Choice D rationale

Imbalanced nutrition is important but is secondary to the immediate risk of aspiration.

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