A client with pneumonia is placed on a fluid restriction of 1500 mL per day. How should the nurse manage the fluid intake?

Correct Answer: C

Rationale: The correct answer is C because allowing more fluids during the day helps prevent fluid overload and promotes optimal kidney function during waking hours. This approach also reduces the risk of nocturia. Providing fluids mainly at night (Choice A) can lead to disrupted sleep due to frequent bathroom trips. Dividing fluids equally across meals (Choice B) may not be appropriate as it could exceed the daily restriction. Limiting fluid intake to meals only (Choice D) may not provide enough hydration throughout the day, risking dehydration.

Correct Answer: D

Rationale: The correct answer is D. Positioning the client to promote lung expansion is the priority intervention for a client experiencing respiratory acidosis as it helps improve ventilation and oxygenation. This intervention helps optimize lung function and can aid in correcting the acidosis by increasing the efficiency of gas exchange. Administering a bronchodilator (A) may help with bronchoconstriction but is not the priority in this situation. Initiating deep breathing exercises (B) may be helpful in some cases but may not be appropriate for a client in respiratory distress. Providing supplemental oxygen (C) may help improve oxygenation, but without addressing the underlying cause of the acidosis, it may not fully resolve the issue.

Correct Answer: C

Rationale: The correct answer is C: Oxygen saturation of 87%. In pulmonary embolism, decreased oxygen saturation indicates impaired gas exchange due to reduced blood flow to the lungs. This is concerning as it can lead to hypoxemia and tissue damage. Respiratory rate (choice B) and heart rate (choice D) can be elevated in response to hypoxemia but are not as direct indicators of impaired gas exchange. Chest pain and hemoptysis (choice A) are common symptoms of pulmonary embolism but do not directly reflect the severity of oxygenation impairment.

Correct Answer: A

Rationale: The correct answer is A: Administering prescribed bronchodilators. The priority intervention for a client with chronic bronchitis experiencing worsening shortness of breath is to address the underlying cause, which is airway obstruction due to inflammation and mucus production. Bronchodilators help to open up the airways and improve airflow, providing immediate relief for shortness of breath. This intervention directly targets the client's respiratory distress and is essential for managing exacerbations of chronic bronchitis. Choice B: Encouraging pursed-lip breathing may be beneficial for some clients with chronic bronchitis but is not the priority intervention in this case. It is more of a supportive measure to help manage symptoms. Choice C: Positioning the client in high Fowler's position can help improve breathing by maximizing lung expansion, but it is not the priority intervention when the client is experiencing worsening shortness of breath. Choice D: Monitoring oxygen saturation levels is important in assessing the client's respiratory status

Correct Answer: B

Rationale: The correct answer is B, peripheral edema and dyspnea on exertion. In pulmonary hypertension, increased pressure in the pulmonary arteries can lead to right-sided heart failure, causing symptoms like peripheral edema and dyspnea on exertion. Productive cough with green sputum (A) is more commonly associated with respiratory infections. Frequent upper respiratory infections (C) may indicate issues with the upper airways, not specifically pulmonary hypertension. Intermittent chest pain at rest (D) is less likely to be associated with pulmonary hypertension, as it is more commonly seen with other cardiovascular conditions.