Which measure should the nurse include in the care plan to loosen thick secretions in the patient with respiratory failure?
A) Incentive spirometry
B) Supplemental oxygen via face mask
C) Chest percussion and vibration
D) Pursed lip breathing
C) Chest percussion and vibration
Explanation: A) Use of incentive spirometry assists in maximizing diffusion and improving alveolar surface area.
B) Supplemental oxygen may help reduce hypoxemia, but will not help to loosen secretions.
C) Chest percussion or vibration can be used to loosen thick, heavy secretions so that they can be coughed or suctioned out.
D) Pursed lip breathing is beneficial to breathing in patients with chronic obstructive pulmonary disease, but it does not help to loosen secretions.
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When planning care for clients on the mental health unit, the nurse using principles of humanism would consider which of the following?
1. Clinical interventions are most effective when they focus on the current actions, feelings, and concerns of clients. 2. Clients rely on providers to develop solutions for their problems. 3. Emotional stress has a relationship to physical symptoms. 4. The mind–body relationship focuses on biological explanations of illness.
A nursing instructor is teaching about the typical grieving behaviors of Chinese Americans. Which student statement would indicate that more instruction is necessary?
1. "In this culture, the color red is associated with death and is considered bad luck." 2. "In this culture, there is an innate fear of death." 3. "In this culture, emotions are not expressed openly." 4. "In this culture, death and bereavement are centered on ancestor worship."
Which statements by a client alert the nurse that the client may have some psychosocial issues with impaired hearing? (Select all that apply.)
a. "I get so angry when I cannot hear what my daughter says." b. "When I use my hearing aids, I hear the choir so clearly." c. "I don't mind sitting in my chair all day long and not playing bingo." d. "My family never seems to visit anymore because their voices all seem so distant." e. "No one asks my opinion because I cannot hear their question." f. "My grandchildren do not think that I am funny anymore because I cannot hear their jokes."
A client brought to the emergency room after a motor vehicle accident is suspected of having internal bleeding. What initial clinical manifestation of hypovolemic shock would the nurse expect to find in this client?
A. Increased respiratory rate B. Decreased urinary output C. Increased heart rate D. Cool, pale skin