A nurse is writing a care plan for a client hospitalized with pneumonia. The priority nursing diagnosis is ineffective airway clearance. Which intervention should the nurse include in the plan of care?
1. Administer the pneumococcal vaccine
2. Provide smoking cessation education
3. Limit fluid intake
4. Perform chest percussion
4. Perform chest percussion
Rationale:
Chest percussion can help clear secretions. Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a client with pneumonia; however, they would be aligned with a different nursing diagnosis. Clients with pneumonia are encouraged to increase fluid intake.
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The thymus gland secretes thymosin and thymopoietin, which aid in developing T lymphocytes, a type of white blood cell involved in immunity. Identify the location of the gland
A) Attached to the thalamus in the brain B) Above the kidneys C) Connected by a stalk to the hypothalamus in the brain D) In the upper part of the chest above or near the heart
The nurse is monitoring a client in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action?
a. Administer oxygen with a face mask at 8 to 10 L/min. b. Reposition the fetal monitor ultrasound transducer. c. Assist the client to the bathroom to empty her bladder . d. Continue to monitor the client and fetal heart rate patterns.
The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which of the following nursing interventions is most appropriate at this time?
A. Reinforcing the pressure dressing as needed B. Encouraging range-of-motion exercises of the involved arm C. Assessing the incision for any redness, swelling, or discharge D. Applying wet-to-dry dressings every 4 hours to the insertion site
If a patient experiences a wound dehiscence, which description illustrates what is happening with the wound?
a. Purulent drainage is present at incision site because of infection b. Extreme pain is present at incision site c. A partial or complete separation of outer layers is present at incision site d. The inner and outer layers of the incision are separated