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?
Teach anxiety reduction methods for feelings of suffocation.
Increase the daily intake of oral fluids to liquefy secretions.
Call the clinic if undesirable side effects of medications occur.
Avoid crowded enclosed areas to reduce pathogen exposure.
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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Correct Answer is D
Explanation
Choice A rationale
Total protein levels are not directly related to the symptoms of pallor and fatigue. While important, they do not provide immediate insight into the client’s current condition.
Choice B rationale
Sodium levels are crucial for overall health but are not directly related to the symptoms of pallor and fatigue. Monitoring sodium is important for fluid balance but not for diagnosing anemia.
Choice C rationale
Glucose levels are essential for managing diabetes and other metabolic conditions but are not directly related to the symptoms of pallor and fatigue. Monitoring glucose is important for overall health but not for diagnosing anemia.
Choice D rationale
Hemoglobin levels are directly related to the symptoms of pallor and fatigue. Diclofenac, an NSAID, can cause gastrointestinal bleeding, leading to anemia. Therefore, reviewing hemoglobin levels is crucial in this scenario.
Correct Answer is B
Explanation
Choice A rationale
Decreasing speaking speed may help with clarity, but it does not address the issue of hearing loss.
Choice B rationale
Over-enunciating word syllables can help the client understand speech better, especially if they have hearing difficulties. This technique makes it easier for the client to read lips and understand spoken words.
Choice C rationale
Raising voice volume to a shout can be uncomfortable and may not improve understanding. It can also be perceived as rude or aggressive.
Choice D rationale
Exaggerating nonverbal expressions may help with communication, but it is not as effective as over-enunciating word syllables for clients with hearing difficulties.