The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a client with pneumonia who is experiencing copious amounts of respiratory secretions. Which intervention should the nurse include in this client's plan of care?
A) Perform chest percussion every 4 hours and prn.
B) Administer the pneumococcal vaccine prior to discharge.
C) Limit fluid intake to 1,000 mL per day.
D) Provide the client with smoking cessation education.
Question 2
The nurse is caring for an older adult client who is hospitalized with a second episode of pneumonia in the past 18 months. The client has expressed frustration to the nurse and states, I never got sick when I was younger.
Why is this happening? Which response by the nurse is most appropriate?
A) As you grow older, your immune system just quits working.
B) As you grow older, there is a decrease in the immune response, which puts you at greater risk for developing an infection.
C) As you grow older, there in an overall increase in the speed and strength of your immune response.
D) As you grow older, there is an increase in the number of B cells in the circulation, which hinders the immune response.
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
Building a Client Base Cont.
Measuring the client’s weight with a standard platform scale
Measuring the client’s blood pressure
RFLP diagnosis of sickle-cell anemia