the nurse is caring for a client with a diagnosis of pneumonia which intervention is most effective in promoting airway clearance
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Nursing Elites

HESI LPN

Adult Health 1 Exam 1

1. The client is diagnosed with pneumonia. Which intervention is most effective in promoting airway clearance?

Correct answer: B

Rationale: Encouraging increased fluid intake is the most effective intervention in promoting airway clearance for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making it easier for the client to clear the airways. Administering bronchodilators may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy may be beneficial but is not the first-line intervention for promoting airway clearance in pneumonia. Providing humidified oxygen can improve oxygenation but does not directly address airway clearance.

2. The nurse is caring for a client with a history of seizure disorder who is receiving phenytoin (Dilantin). Which laboratory value is most important to monitor?

Correct answer: A

Rationale: Corrected Rationale: Monitoring the phenytoin level is crucial to ensure it is within the therapeutic range and to prevent toxicity. Monitoring sodium level is important in clients receiving lithium, not phenytoin. Hemoglobin level and white blood cell count are not directly related to phenytoin therapy monitoring.

3. A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy at 2 liters per minute via nasal cannula. What is the most important instruction the nurse should provide?

Correct answer: C

Rationale: The most important instruction the nurse should provide to a client with COPD prescribed oxygen therapy is not to adjust the oxygen flow rate without consulting a healthcare provider. This is crucial because too much oxygen can suppress the client's respiratory drive, leading to further complications. Choice A is incorrect because increasing the oxygen flow rate without medical advice can be harmful. Choice B is incorrect as oxygen therapy should be used as prescribed, not just when symptoms occur. Choice D is incorrect as the priority is to ensure the correct oxygen flow rate rather than using a humidifier.

4. When preparing to administer blood to a client, what is the most important action to ensure client safety during this procedure?

Correct answer: D

Rationale: The most important action to ensure client safety during a blood transfusion is to implement multiple safety checks. Checking the client’s blood type compatibility is crucial as it helps prevent major transfusion reactions. Monitoring the client for signs of transfusion reaction is essential to detect any adverse reactions early. Verifying the correct client and blood product with another healthcare professional adds an extra layer of safety by ensuring the right blood is administered to the right patient. Choosing 'All of the above' (Option D) is the correct answer because each action plays a vital role in ensuring the safety and well-being of the client during a blood transfusion. Options A, B, and C are not exclusive; they complement each other to provide comprehensive safety measures.

5. The nurse is caring for a client who has just undergone a total hip replacement. Which intervention is most important to prevent postoperative complications?

Correct answer: A

Rationale: Encouraging early ambulation is crucial following a total hip replacement surgery as it helps prevent complications such as deep vein thrombosis (DVT) by promoting circulation. Early ambulation also aids in preventing pneumonia, muscle atrophy, and pressure ulcers. Applying ice to the surgical site may help with pain and swelling, but it is not as critical in preventing complications as early ambulation. While monitoring the surgical site for signs of infection is important, it is not as crucial in preventing postoperative complications compared to early ambulation. Administering pain medication as prescribed is essential for comfort and pain management but does not directly prevent postoperative complications like early ambulation does.

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