Nursing interventions are appropriate for the NANDA-I nursing diagnosis In effective Airway Clearance for the patient with pneumonia

Which nursing interventions are appropriate for the NANDA-I nursing diagnosis Ineffective Airway Clearance for the patient with pneumonia? Select all that apply.

Encourage 2 to 3 liters of fluid per day.

Assist with deep breathing and coughing.

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Provide small meals frequently.

Change position frequently.

Maintain bed rest.

You have used 0 of 1 attemptNUR211_M5CQ0039

5.0 points possible (graded, results hidden)

Which outcome is appropriate for a patient with chronic obstructive pulmonary disease that has a NANDA-I nursing diagnosis of Activity Intolerance?

The patient will:

Use pursed-lip breathing when short of breath.

Have an oxygen saturation of 95%.

Have clear breath sounds in both upper and lower lobes.

Perform activities without shortness of breath.

You have used 0 of 1 attemptNUR211_M5CQ0022

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Which nursing interventions would the RN implement to prevent atelectasis? Select all that apply.

Change patient position frequently.

Elevate the head of the bed.

Assist with coughing and deep breathing exercises.

Encourage early ambulation.

Obtain order for daily chest x-ray.

You have used 0 of 1 attemptNUR211_M5CQ0045

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The RN is reviewing the management of a patient with a chest tube and wet chest drainage system with a student nurse. Which intervention should the RN emphasize to the student?

Educate the patient about how to perform incentive spirometry.

Gently massage the chest tube hourly to promote drainage.

Report fluctuations in the water seal section of the chest drainage system.

Clamp the chest tube if the tubing disconnects from the drainage system.

You have used 0 of 1 attemptNUR211_M5CQ0009

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A patient with community acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?

Obtain a sputum specimen for culture and sensitivity.

Order a meal tray to be delivered as soon as possible.

Administer the ordered oral antibiotic.

Ask the unlicensed assistive personnel (UAP) to weigh the patient.

You have used 0 of 1 attemptNUR211_M5CQ0046

5.0 points possible (graded, results hidden)

Which intervention would the RN implement to reduce the incidence of pneumonia in the older adult population?

Airborne precautions.

Pneumococcal vaccination.

Rigorous hand washing.

Prophylactic antibiotics.

You have used 0 of 1 attemptNUR211_M5CQ0040

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Which data finding indicates to the RN that the prescribed antibiotic therapy has been effective for a patient diagnosed with pneumonia?

Frequent cough with thick, green sputum.

Orthopnea and tachypnea.

Breath sounds are clear bilaterally in all lobes.

Fever and chills.

You have used 0 of 1 attemptNUR211_M5CQ0051

5.0 points possible (graded, results hidden)

Which instruction should the nurse provide to the client being discharged with a prescription for a glucocorticoid inhaler following an exacerbation of chronic obstructive pulmonary disease (COPD)?

Stop taking this medication if a noticeable weight gain occurs.

Use the glucocorticoid inhaler prior to the bronchodilator inhaler.

This medication should never be stopped suddenly.

Rinse the mouth with water after each dose.

You have used 0 of 1 attemptNUR211_M5CQ0013

5.0 points possible (graded, results hidden)

What is the most appropriate response for the RN to make when the patient with end-stage chronic obstructive pulmonary disease (COPD) asks about lung volume reduction surgery?

“You and your family should discuss treatment options with your physician.”

“You are not a candidate because your disease is too advanced.”

“You would have a difficult time recovering from this procedure.”

“At this point, do you really want to go through major surgery?”

You have used 0 of 1 attemptNUR211_M5CQ0041

5.0 points possible (graded, results hidden)

Which intervention would the RN implement for the patient with chronic obstructive pulmonary disease that has a NANDA-I nursing diagnosis of Ineffective breathing pattern?

Provide fluids to maintain hydration.

Plan rest periods between activities.

Maintain oxygen at 2 L per minute.

Teach the patient pursed-lip breathing.

You have used 0 of 1 attemptNUR211_M5CQ0015

5.0 points possible (graded, results hidden)

Which assessment finding would the RN observe when a client is experiencing acute respiratory distress syndrome (ARDS)?

Cough with blood tinged sputum.

Hypoxemia unresponsive to supplemental oxygen.

Shortness of breath and expiratory wheeze.

Fever, chills and pleuritic chest pain.

You have used 0 of 1 attemptNUR211_M5CQ0034

5.0 points possible (graded, results hidden)

The charge nurse is making patient assignments. Which patient should the RN assign to the licensed practical nurse (LPN)?

The patient with a chest tube who has jugular venous distention and a blood pressure of 96/60.

The patient who had a bronchoscopy 1 hour ago reporting chest pain and dyspnea.

The patient with pneumonia who has a pulse oximetry reading of 98%.

The patient with a hemothorax who has a hemoglobin of 9 g/dL and hematocrit of 20%.

You have used 0 of 1 attemptNUR211_M5CQ0048

5.0 points possible (graded, results hidden)

Which assessment finding indicates to the nurse that the insertion of a chest tube for a simple pneumothorax has been effective?

The client has bilateral breath sounds.

The suction chamber has vigorous bubbling.

The trachea is midline and chest expansion is decreased.

There is crepitus at the chest tube insertion site.

You have used 0 of 1 attemptNUR211_M5CQ0049

5.0 points possible (graded, results hidden)

Which intervention should the nurse implement first for the client diagnosed with acute respiratory distress syndrome (ARDS) that has an arterial oxygen level of 54% on oxygen at 10 liters per minute?

Prepare the client for intubation.

Administer a sedative.

Initiate cardiopulmonary resuscitation.

Start an IV with an 18-gauge catheter.

You have used 0 of 1 attemptNUR211_M5CQ0052

5.0 points possible (graded, results hidden)

Which instructions would the RN provide to the client for collecting a sputum specimen for culture? Select all that apply.

Label the specimen.

Rinse the mouth with water.

Breathe deeply several times.

Cough deeply.

Expectorate the sputum into the sterile container.

 
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