A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?

Correct Answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

Correct Answer: D

Rationale: The correct answer is D because clients should continue taking clozapine even if their symptoms improve. Abruptly discontinuing the medication can lead to relapse. Choices A, B, and C are all correct statements regarding clozapine therapy. Regular blood work monitoring is necessary due to potential side effects, weight gain is a common side effect of clozapine, and reporting signs of fever is important as it can indicate a serious side effect of clozapine.

Correct Answer: A

Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.

Correct Answer: D

Rationale: The correct finding the nurse should report to the provider is decreased breath sounds in the right lower lobe. This can indicate a respiratory infection or atelectasis in clients with COPD, requiring further evaluation and intervention. Choice A, an oxygen saturation of 91%, although slightly lower than normal, does not necessarily require immediate reporting unless the client's baseline is significantly higher. Choice B, the use of pursed-lip breathing, is actually a beneficial technique for clients with COPD to improve oxygenation and reduce shortness of breath, so it does not need reporting. Choice C, a productive cough with green sputum, can be common in clients with COPD and may indicate an infection, but it is not as concerning as decreased breath sounds in a specific lung lobe which may signify a more acute issue.

Correct Answer: C

Rationale: In clients with Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the nurse should expect hyponatremia. SIADH leads to excess water retention, diluting the sodium levels in the blood, resulting in low serum sodium levels. Choice A, increased urine output, is incorrect as SIADH causes water retention, leading to decreased urine output. Choice B, increased serum sodium, is incorrect because SIADH causes a dilutional effect due to water retention, resulting in decreased serum sodium levels. Choice D, hypercalcemia, is unrelated to SIADH and not a typical finding.

Correct Answer: A

Rationale: Healthcare professionals should perform hand hygiene before and after patient contact to prevent the spread of infections. While choices B, C, and D are also important times to practice hand hygiene, they are not as crucial as before and after patient contact because patient contact poses a higher risk of transmitting infections.

Correct Answer: A

Rationale: The correct answer is to check oxygen saturation. This is because checking oxygen saturation provides a direct measure of how well the patient is oxygenating post-surgery. It helps healthcare providers assess if the patient is receiving enough oxygen to meet their body's needs. Auscultating lung sounds (choice B) is important to assess respiratory function but may not provide an immediate indication of oxygenation status. Checking for abnormal breath sounds (choice C) is relevant but does not directly assess oxygenation levels. Checking skin color (choice D) can provide some information about oxygenation, but it is not as precise or direct as measuring oxygen saturation.

Correct Answer: C

Rationale: A weight gain of 2 kg (4.4 lb) in 2 days can indicate fluid retention, which is a sign of worsening heart failure and should be reported. This rapid weight gain suggests a fluid overload, putting the client at risk for complications. A heart rate of 90/min is slightly elevated but not as concerning as a sudden significant weight gain. The serum potassium level of 4.0 mEq/L is within the normal range and does not directly indicate worsening heart failure. A heart rate of 76/min is within the normal range and does not raise immediate concerns related to heart failure.

Correct Answer: A

Rationale: The correct answer is Lisinopril. Lisinopril is an ACE inhibitor commonly prescribed to patients with hypertension to manage their blood pressure. Metformin is used to treat type 2 diabetes, not hypertension (choice B). Atorvastatin is a statin used to lower cholesterol levels, not primarily prescribed for hypertension (choice C). Aspirin is used for its antiplatelet effects and in preventing cardiovascular events, but it is not a first-line treatment for hypertension (choice D). Therefore, Lisinopril is the most suitable choice for a patient with hypertension.