A patient diagnosed with chronic bronchitis has the nursing diagnosis Ineffective Airway Clearance related to inadequate cough and excess mucus production
Which intervention would the nurse evaluate as being of the least value in addressing the nursing diagnosis? 1. Check the pulse oximetry reading.
2. Increase fluid intake up to 2 liters/day.
3. Suction the patient.
4. Provide chest physiotherapy.
1
Rationale 1: Checking the pulse oximetry reading evaluates the oxygenation status of the patient but has no value in stimulation of cough or expulsion of excess mucous secretions.
Rationale 2: Adequate hydration helps to liquefy secretions.
Rationale 3: Suctioning may be necessary to clear the airway when the cough is ineffective.
Rationale 4: Chest physiotherapy assists in the mobilization of secretions.
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A client reports morning headache that extends into the neck and goes away as the day wears on. Based on this initial data, which does the nurse suspect that the client is experiencing?
A) A symptom of hypertension B) A sinus headache C) A migraine headache D) Spinal stenosis
To detect crepitus in a patient with an esophageal perforation, the nurse should:
A) palpate the chest. B) inspect the chest. C) percuss the chest. D) auscultate the chest.
Nurses provide many interventions to prevent falls in health care settings. Which of the following would be an appropriate intervention to prevent falls?
A) Keep bed in the high position. B) Keep side rails up at all times. C) Apply restraints to all confused clients. D) Lock wheels on beds and wheelchairs.
During the process of self-exploration, it is important for a nurse to convey the message that the patient:
a. may be the victim of circumstances that created unsolvable psychosocial problems. b. is responsible for his or her own behavior, including maladaptive coping responses. c. cannot hope to make any changes without some professional, therapeutic guidance. d. needs to focus on changing the attitudes and behaviors of significant others.