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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

Offering mouthwash for thorough cleansing after brushing teeth can be too harsh for clients with painful mouth ulcers caused by Candida albicans. It may cause further irritation and discomfort.

Choice B rationale

While assistive personnel can help with personal care, oral care should not be left solely to the nurse. Providing appropriate tools and guidance for the client to perform oral care is essential.

Choice C rationale

Providing a soft-bristled toothbrush is appropriate for clients with oral Candida albicans. It helps in gentle cleaning without causing additional pain or damage to the mucosa.

Choice D rationale

Wearing sterile gloves is not necessary for routine oral care. Clean gloves are sufficient unless there is a specific need for sterility, such as in surgical procedures.

Correct Answer is A

Explanation

Choice A rationale

Postural drainage involves placing the client in various positions to facilitate the drainage of secretions from different parts of the lungs. Typically, the client may be placed in five positions: head down, prone, right and left lateral, and sitting upright.

Choice B rationale

Performing postural drainage immediately after meals is not recommended as it can cause nausea, vomiting, and aspiration. It is best to perform the procedure before meals.

Choice C rationale

Obtaining an arterial blood gas (ABG) prior to the procedure is not a standard requirement for postural drainage. ABGs are typically obtained to assess the client’s respiratory status but are not necessary for the procedure itself.

Choice D rationale

Instructing the client to breathe shallow and fast is not appropriate for postural drainage. The client should be encouraged to breathe slowly and deeply to help keep the airways open and facilitate the drainage of secretions.

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