Exam 2- In Class Questions

A 23-year-old patient with a history of type 1 diabetes is admitted to the ED with nausea and abdominal pain. His respiratory rate is 34/min with deep breaths and a fruity smell to his breath. He is responsive, but drowsy. 1.What does the nurse suspect is happening with this patient? 2.What serum glucose level would the nurse expect to see with this patient?

1. DKA 2. high

You are called to the patient's room by the patient's spouse while the patient experiences a seizure. Upon finding the patient in a clonic reaction, which should the nurse do first? a.Turn the patient to the side. b.Start oxygen by mask at 6 L/min. c.Restrain the patient's arms and legs to prevent injury. d.Record the time sequence of the patient's movements and responses as they occur.

A

An 18-year-old male with a history of tonic-clonic seizures was brought to the emergency department by his mother because he has been vomiting and unable to keep any fluids down for almost 24 hours. She states that he has not had his antiseizure medications since yesterday morning and this morning he had a "very bad" seizure. An intravenous line is inserted, and during the assessment, the patient begins to have a tonic-clonic seizure that continues for almost 6 minutes. Which actions should be implemented by the nurse? 1.Ensure an airway 2.Restrain the patient's limbs to prevent injury 3.Remove or loosen any tight clothing 4.Insert a padded tongue blade into the mouth 5.Anticipate a stat dose of IV lorazepam 6.Protect the patient's head during the seizure 7.Ensure the patient is lying on his back during the seizure

1356

A 78-year-old woman is at her annual checkup and asks if it's normal to "leak" urine when coughing or laughing, especially at her age and knowing she has given birth to five children. What is the nurse's best response to this question? A."Involuntary loss of urine or incontinence is not a normal consequence of childbirth or aging." B."As we get older, our bodies do not function as well as when we were younger." C."The unintentional loss of urine can be temporary or permanent depending on the cause." D."The most likely cause of your urine leakage is obstruction of the urethra with a kidney stone."

A

A patient asks the nurse why a glycosylated hemoglobin study would be performed. The nurse tells the patient that this test: a.Provides information about blood sugar control over the previous 8-10 weeks. b.Determines if a change in insulin should be made. c.Assesses the risk for diabetic ketoacidosis d.Monitors daily blood glucose levels.

A

A patient is admitted to the ICU for DKA management. The patient is receiving IV regular insulin with frequent blood draws to check his glucose level. His potassium level is 2.5 and an IV potassium rider of 20 meq/100 mLs NSS over 2 hours has been ordered. What assessment must be made before giving the IV potassium? A.Production of at least 30 mL/hr of urine B.Level of consciousness and orientation C.Finger stick glucose of less than 200 mg/dL D.Respiratory rate of less than 24/min

A

A patient is admitted to the emergency department with a severe exacerbation of asthma. Which finding is of most concern to the nurse? a.Unable to speak and sweating profusely b.PaO2 of 80 mm Hg and PaCO2 of 50 mm Hg c.Presence of inspiratory and expiratory wheezing d.Peak expiratory flow rate at 60% of personal best

A

A patient is ordered 28 units NPH and 10 units Regular insulin. To prepare this medication, the nurse would: a.Draw up the Regular and then the NPH insulin in the same syringe. b.Prepare two (2) syringes, as these insulins can't be mixed. c.Draw up the NPH and then the Regular insulin in the same syringe. d.Mix both insulins in the same syringe, the order doesn't matter.

A

After seeing the ophthalmologist, the patient is scheduled for cataract surgery. What preoperative teaching should the nurse provide? A.Instruct him that after surgery, different types of eyedrops will be prescribed for 2 to 4 weeks. B.Remind him that immediately after surgery he will have his best vision. C.Tell him that after surgery he will no longer need to wear eyeglasses for reading. D.Caution him to avoid wearing dark glasses because the retina needs a direct source of light for best vision.

A

The lab calls to report his blood glucose is 874 and he has ketonuria. What is the nurse's highest priority for managing this patient's condition? A.Airway assessment B.Fluid and electrolyte correction C.Administration of insulin Administration of IV potassium

A

The nurse is caring for a patient who is receiving antiretroviral therapy (ART) for treatment of HIV. Which assessment best indicates that the patient's condition is improving? A.Decreased viral load B.Increased drug resistance C.Decreased CD4+ T-cell count D.Increased aminotransferase levels

A

The nurse is caring for a patient with type 1 diabetes mellitus who is admitted for diabetic ketoacidosis. The nurse would expect which laboratory test result? a. Hypokalemia b. Hyperkalemia c. Hypoglycemia d. Hypercalcemia

A

The nurse teaches a patient to do pursed-lip breathing. As educator, the nurse recognizes that the rationale for this is which of the following? a.Increase airway pressure to prevent bronchial collapse and air trapping b.Decrease fatigue by using abdominal muscles instead of accessory muscles c.Increase the oxygen concentration for the patient d.Assist with mobilizing secretions

A

The nursing teaching plan for the patient with acute glomerulonephritis includes which appropriate intervention? a.Conservative treatment with frequent rest periods b.IV antibiotics to treat the infectious process c.Kidney dialysis to improve renal function d.High protein diet and exercise

A

What conditions might the nurse expect to see in a patient with complaints of restless leg syndrome? A.Diabetes and kidney failure B.Peripheral vascular disease and multiple sclerosis C.Myasthenia gravis and decreased vision D.Trigeminal neuralgia and facial paralysis

A

What health history question will give the nurse the most information when evaluating a patient for Guillain-Barré syndrome (GBS)? A."Have you had a respiratory virus in the past 2 weeks?" B."Have you ever been exposed to Epstein-Barr virus?" C."Has anyone else in your family ever had GBS?" D."Did you get a flu vaccine in the past year?"

A

When teaching the diabetic client about foot care, the nurse should instruct the client to do which of the following? a.Avoid going barefoot. b.Buy shoes a half size larger c.Cut toenails at angles d.Use heating pads for sore feet.

A

Which nursing intervention would enhance an older adult's sensory perception and thereby help prevent injury when walking from the bed to the bathroom? a.Providing adequate lighting b.Raising the pitch of the voice c.Holding onto the patient's arm d.Removing environmental hazards

A

Which symptom requires immediate intervention during a hypoglycemic episode? A.Confusion B.Hunger C.Headache Tachycardia

A

A patient that had been admitted for DKA during a GI virus is recovered and is preparing for discharge. His wife asks about what they can do to prevent this from happening again. What should the nurse teach the patient and his wife? (Select all that apply.) A.Check blood glucose levels every 2 to 4 hours if anorexia, nausea, or vomiting is experienced. B.Check urine ketones when blood glucose is greater than 240 mg/dL. C.Decrease fluid intake when nausea and vomiting occur. D.Watch for and report any illness lasting more than 1 to 2 days. E.Monitor glucose whenever the patient is ill.

ABDE

While caring for a patient with Myasthenia Gravis, you note that the patient is having difficulty mobilizing secretions. Which interventions should be implemented for this problem? Select all that apply. A.Oropharyngeal suctioning as needed B.Coughing and deep breathing C.Oxygen at 2 L per nasal cannula D.Chest physiotherapy Plasmapheresis

ABDE

A 64-year-old woman is brought to her primary care provider's office because her husband has noticed that she has not been active during the past few months, and that she "seems depressed." She tells the nurse that her mother died fromParkinson's disease, and she is worried that she is developing the disease because her brother was just diagnosed with it last year. A. Shuffling gait B. Bradykinesia C. Intentional tremors D. Dry mouth E. Increased muscle rigidity F. Hyperreflexia G. Blurred or double vision H. Postural instability I. Sleep problems

ABEH

A 74-year old male comes to the clinic for an eye and ear exam. For which reasons would the nurse involve the wife in the assessment. Select all that apply. A.The patient may not realize his deficits B.A woman provides greater detail C.His wife may notice things he does not D.The wife may add history he forgets to add E.His age keeps him from being accurate

ACD

A patient complains of partial loss of vision on the right side. The nurse should perform which of the following assessments? a.Administer the Snellen test b.Perform the confrontation test c.Examine the pupil response to accommodation Use tonometry to evaluate intraocular pressures

B

A patient has a Mantoux test that measured 20 mm and was red, firm and raised on the 3rd day. The nurse interprets the result as which? a.The patient has active TB. b.The patient has been exposed to TB. c.The patient has a negative test. d.The patient has a borderline result and should have a second test.

B

A patient has just arrived on the unit from the PACU after abdominal surgery. As the nurse is assessing the patient, he vomits. Which potential complication should become the highest priority for the nurse? a.Incisional pain b.Aspiration pneumonia c.Opening of the incision d.Dehydration

B

A patient has the following VS and labs upon arrival in the unit. BG - 239 mg/dL BP - 138/88 mm Hg HR - 128 RR - 36 breaths/min O2 saturation - 88% (room air) Temp - 101.6° F Which vital sign or test result takes priority when consulting the health care provider? A.Blood pressure B.Respiratory rate C.Temperature Blood glucose

B

A patient is fearful that he has been infected with HIV. The nurse recognizes that which manifestation is the first sign of HIV infection? A.Opportunistic infections B.Fever, night sweats, and muscle aches C.Lymphocytopenia (decreased lymphocyte count) D.Reduced numbers of CD4+ T-cells

B

A patient is ordered chest physiotherapy every four hours. To achieve best results, the nurse does the chest physiotherapy after nebulizer treatment because: a.Beta stimulation decreases the amount of secretions b.Bronchodilation allows for secretions to be expelled more easily c.The sedative effect improves the patient's tolerance d.Induced bronchospasm enhances drainage

B

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmoL/L). Which statement by the nurse is most appropriate? a. "You will develop type 2 diabetes within 5 years." b. "You are at increased risk for developing diabetes." c. "The test is normal, and diabetes is not a problem." d. "The laboratory test result is positive for type 2 diabetes."

B

A patient with a tension pneumothorax has a chest tube inserted, attached to a Pleuro-vac drainage system. Several hours later, the nurse notices the water in the water seal chamber is not moving with the patient's breathing and interprets this to mean: a.there is a chest tube leak. b.the tubing is obstructed. c.the lung has re-expanded. d.more water needs to be added to the water seal chamber.

B

At a local health fair, a patient remarks to the nurse that his urine occasionally appears pink. He wonders if this is anything to be concerned about. What should the nurse respond? a.Instruct the man to notify his physician if he experiences pain or difficulty urinating. b.Advise the man to make an appointment with his health care provider. c.Instruct the man to track the relationship between his activities and urine color. d.Tell the man to increase his fluid intake to 2 ½ to 3 liters/day.

B

During morning care for a patient with Myasthenia Gravis, the patient is able to brush her teeth, wash her face, and brush her hair but then becomes fatigued after performing these actions. What would be the nurse's best action? A.Encourage her to continue with her own morning care to increase her strength. B.Let her rest for 15 minutes and then continue self morning care. C.Document that the patient refuses morning care because of fatigue. DProvide assistance in completing the patient's morning care

B

Following cataract surgery, the nurse provides patient teaching. Which statement by the patient indicates a need for further teaching? A."I will wear dark sunglasses." B."Aspirin will help decrease discomfort." C."My daughter will help me if I need to lift something." D."My surgeon needs to know if I am experiencing reduced vision."

B

For a patient with Bell's palsy, when are symptoms the most severe? A.12 hours after onset B.48 hours after onset C.96 hours after onset D.1 week after onset

B

In planning care for residents at a homeless shelter, the nurse understands that IV drug users and alcoholics are at higher risk for TB for which reason? A.Increased presence of liver disease. B.they tend to be malnourished. C.they generally have concurrent infections. D.They cannot afford healthcare.

B

The nurse informs the patient with a bacterial pneumonia that the most important factor in antibiotic treatment is a. antibiotics should have been used to prevent pneumonia. b. all of the supplied antibiotics should be taken even when symptoms have resolved. c.enough antibiotics for 2 days' treatment should be reserved in case symptoms recur. d. patients should request antibiotics for upper respiratory infections to prevent development of streptococcal-related diseases.

B

The nurse instructs a patient with primary open-angle glaucoma about the disorder. Which of the following statements, if made by the nurse, is most appropriate? a."The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." b."Aqueous humor cannot drain from the eye, causing pressure damage to the optic nerve." c."As the lens enlarges with aging, it pushes the iris forward, covering the outflow channels of the eye." d."The lens blocks the pupillary opening, preventing the flow of aqueous humor into the anterior chamber. "

B

The patient's mother asks why the patient is breathing so rapidly and deeply. What is the nurse's best response? A."His serum pH is high and this is a compensatory mechanism." B."His serum pH is low and this is a compensatory mechanism." C."His serum potassium is high and this is a compensatory mechanism." D."His serum potassium is low and this is a compensatory mechanism."

B

When leaving a patient's room, his roommate who is admitted with exacerbation of COPD calls out and says "Nurse, I'm having trouble breathing." As the caregiver, what should be the initial nursing action? a.Call for help b.Place the patient in full Fowler's position c.Increase the patient's oxygen flow d.Give him water to loosen secretions and clear his airway

B

Which is a priority intervention after a patient has cataract surgery? A.Keeping the eye covered for the first 24 hours postoperatively B.Avoiding straining to have a bowel movement C.Keeping the eye moist D.Assessing the eye for signs of blindness

B

Which of the following indicates a potential complication of DM? a.Inflamed, painful joints b.Blood pressure of 160/100 mm hg c.Stooped appearance d.Hemoglobin of 9g/dl.

B

Which of the following statements by a female patient indicate that instruction in ways to prevent urinary tract infection was understood? a."I should limit intake of water so I won't need to urinate so often." b."I should drink 8-10 glasses of fluid per day." c." I should only wear nylon underpants." d."I should void every 6 hours while I am awake."

B

Which patient is at greatest risk of developing a kidney stone? A.African-American female with family history of kidney stones B.Caucasian male with BMI of 27 C.Female with thin appearance and history of frequent UTIs D.Hispanic/Latino female who eats animal protein at every meal

B

You call the medical resident for a patient with emphysema that is severely short of breath on 1 liter nasal cannula with an O2 saturation of 83%. He arrives and writes the following orders. Which order should the nurse implement first? A.Transfer to ICU B.Increase O2 to 2 L per nasal cannula C.ABGs 30 min after oxygen is increased D.Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP stat

B

A 67 year old patient with a long history of smoking is admitted with SOB. Which clinical manifestations make the nurse suspect COPD? Select all that apply. A.Funnel chest appearance B.Sitting in a forward posture C.Shortness of breath D.Bradycardia E.Use of accessory muscles

BCE

A 21-year-old female reports burning and difficulty with urination. What priority question would obtain the most useful information about the patient's chief complaint? A."How long have you had these symptoms?" B."Do you have low back pain?" C."Are you sexually active?" D."Have you had a fever in the past 24 hours?"

C

A client with type 1 DM who jogs daily is given which of the following education regarding the preferred sites for insulin absorption? a.The preferred sites are the arms b.The legs are the preferred sites of injection since the client is a jogger. c.The abdomen would provide a consistent and effective absorption site. d.Jogging does not cause altered insulin absorption so preferred sites is not a concern

C

A diagnosis of AIDS can be made for a patient with HIV with A.a CD4+ T-cell count <500/µL. B.a WBC count <3000/µL (3 × 109/L). C.development of oral candidiasis (thrush). D. onset of Pneumocystis jirovecipneumonia

C

A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What should be the nurse's first action? A.Repeat the PEF reading to verify the results. B.Take the patient's vital signs. C.Administer the rescue drugs. D. Notify the patient's prescriber.

C

A patient with a history of seizures is scheduled for an arteriogram at 10am and is ordered NPO. The client has a 9am dose of phenytoin (Dilantin) 100mg PO due. What should the nurse do? a.Omit the 9am dose of the medication. b.Give the same dose of the medication rectally. c.Contact the physician to see if the medication can be given IVPB. d.Administer the medication with 30 mL of water at 9am.

C

A patient with myasthenia gravis asks the nurse "What is going to happen to me?" When formulating a response, the nurse understands which about the prognosis of this disease? a.It is very good with proper treatment b.It is slowly progressive without remissions c.It is a chronic condition marked by remissions and exacerbations d.It is poor with death occurring in a few months

C

A patient with possible kidney stones develops sudden complaints of acute crampy pain on the left side that radiates into the groin. He is nauseated and vomits. On voiding, his urine is pink. What should be the nurse's initial action? a.Obtain a bladder scan to assess for residual urine b.Administer the prescribed analgesic c.Notify the physician d.Strain the urine

C

A patient with type 1 diabetes calls the clinic with complaints of nausea, vomiting, and diarrhea. His blood glucose is 138. Which instruction is most important for the nurse to give the patient? a. Withhold the regular dose of insulin. b. Drink cool fluids with high glucose content. c. Check the blood glucose level every 2 to 4 hours. d. Use a less strenuous form of exercise than usual until the illness resolves.

C

A student nurse is caring for a patient with a chest tube. Which action by the student nurse alerts the RN that further instruction is needed? a.The student auscaltates lung sounds from side to side. b.The student records the drainage amounts on the apparatus each shift. c.The student raises the Pleuro-vac to her eye level to determine the drainage amount. d.The students assures the tubing is laying straight on the bed.

C

In caring for the patient with TB, the nurse understands that TB is spread by which? A.contact with clothing, bedding or food. B.eating from utensils used by an infected person. C.inhaling the TB bacteria after a person coughs, speaks, or sneezes. D.talking in close contact with an individual with TB.

C

The nurse can best increase the ventilatory efficiency of a patient with COPD by positioning the patient in which position? A.High Fowler's B.Prone C.Sitting up and leaning slightly forward D.Trendelenberg

C

The nurse is caring for a patient with emphysema. The nurse plans care around the fact that the patient is prone to which of these complications? a.Subcutaneous emphysema b.Elevated blood pH c.Spontaneous pneumothorax d.Lung cancer

C

The nurse plans a class for patients who have newly diagnosed type 2 diabetes mellitus. Which goal is most appropriate? a. Make all patients responsible for the management of their disease. b. Involve the family and significant others in the care of these patients. c. Enable the patients to become active participants in the management of their disease. d. Provide the patients with as much information as soon as possible to prevent complications.

C

What does the nurse understand that patients with myasthenia gravis, Guillain-Barre syndrome, and ALS share in common? a.Progressive deterioration until death b.Deficiencies of essential neurotransmitters c.Increased risk for respiratory complications d.Involuntary twitching of small muscle groups

C

What is the primary responsibility of the nurse during a patient's generalized motor seizure? a.Inserting a plastic airway between the teeth. b.Determining whether an aura was experienced. c.Clearing the immediate environment for patient safety. d.Administering phenytoin (Dilantin).

C

When should a patient with type 1 diabetes avoid exercise? A.When serum glucose is less than 150 B.During colder months C.When ketones are present in the urine D.When emotional stressors are high for the patient

C

When teaching care at home for a client with multiple sclerosis, what would be the highest priority to discuss? a.Preventing overdose of the medications b.Avoiding daily baths and showers c.Preventing falls d.Increasing the patient's appetite

C

Which circumstance places the patient at the greatest risk for developing vision disturbances? A.History of working with computer B.Advanced age C.History of diabetes mellitus D.Retired landscaper

C

Which is a priority nursing intervention when providing care to an older patient who has problems with vision? A.Review the medication administration record for artificial tears B.Review medications before administration C.Ensure adequate, nonglare lighting in the patient's room D.Provide written and verbal instruction for nursing education interventions

C

A new patient admitted with pneumonia arrives on your unit. You receive the following orders: A.Full liquid diabetic diet B.IV fluids 1000 mL .9 NS at 60 mL/hr C.Oxygen at 2 L per nasal cannula D.Blood cultures x 3 and urinalysis E.Tylenol grain x every 4 hr for temp above 101° F F.Cefazolin (Ancef) 1 g IVP every 8 hr In what order should the nurse complete these order?

CBDFAE

A patient with exacerbation of COPD is in the ICU for 3 days and then transferred back to the pulmonary stepdown unit. She arrives still slightly short of breath with exertion. Her O2 saturation is 99% on oxygen at 2 L per nasal cannula. She denies any shortness of breath during your assessment. The provider plans to discharge the patient on home oxygen in the morning. What should you include in this patient's discharge teaching?

Call provider if feel SOB don't incr oxygen on your own Don't have fire anywhere (no candle, smoke) Exercise - walking 15-20 mins 6 small meals throughout day high protein high calorie Meds: bronchodilator (teaching use as rescue, hold away from mouth)

A patient's Pleur-evac drainage system falls over and breaks. Which initial action by the nurse is most appropriate? a.Order a new Pleur-evac system b.Try to reconnect the chest tube to the drainage system. c.Cover the end of the chest tube with a sterile gauze. d.Place the end of the chest tube in a glass of water.

D

After the patient's cataract surgery has been completed, he has been brought to the recovery area. You are preparing to administer eyedrops and other medications. Which order for the patient would you question? A.Antibiotic ophthalmic ointment B.Steroid ophthalmic ointment C.Acetaminophen with oxycodone D.Warfarin (Coumadin)

D

Because of the risk for urolithiasis in the immobile patient, which action by the nurse is most appropriate? a.Administer a calcium supplement b.Regularly monitor urine pH c.Maintain an indwelling urinary catheter d.Increase fluid intake to 3000 mL per day

D

The client with type 1 DM is taught to take NPH insulin at 5pm each day. The client should be instructed that the greatest risk for hypoglycemia will occur at about what time? a.7am, shortly before breakfast the next day. b.1pm, shortly after lunch c.7pm, shortly after dinner d.12am, while sleeping

D

The nurse identifies which patient with the greatest risk for a urinary tract infection? a. A 37-year-old man with renal colic associated with kidney stones. b. A 26-year-old pregnant woman who has a history of urinary tract infections. c. A 69-year-old man who has urinary retention caused by benign prostatic hyperplasia. d. A 72-year-old woman hospitalized with a stroke who has a urinary catheter because of urinary incontinence.

D

The nurse is caring for a patient with pneumonia. If a pleural effusion is developing, the nurse would expect which finding? a.Barrel shaped chest b.Paradoxical respirations c.Hyperresonance on percussion d.Localized decreased breath sounds

D

The patient complains of severe pain when the outer ear is touched. What does the nurse suspect? a.A blocked eustachian tube b.A ruptured tympanic membrane c.An infection of the mastoid bone d.Inflammation of the ear canal

D

Which is the most common manifestation of pneumonia in the older adult patient? A.Fever B.Cough C.Weakness D. Confusion

D

Which of the following restrictions is/are correct for the isolation precautions for TB? a.Masks and gowns must be worn by all personnel entering the room. b.Private or semiprivate rooms are appropriate. c.Positive air flow rooms are indicated. d.A special mask is fitted for caregivers.

D

Which of the following would be most important for the nurse to teach a young adult with MS? a.How to prevent sexually transmitted infections b.That pregnancy will improve symptoms c.What can be done to cure the disease d.Why it is important to avoid extremes of heat and cold

D

Which of the following would the nurse expect in the postoperative period for a patient who has undergone surgery for cataract removal? A.Pain early after surgery accompanied by nausea and vomiting B.Change in visual acuity accompanied by tearing and redness C.Yellowish drainage and photophobia D.Mild itching and bloodshot appearance

D

While providing education to a community group, the nurse instructs those attending that the transmission of TB requires which? A.a one-time meeting with the person infected with TB. B.occasional exposure to someone who has TB. C.contact with personal items of someone who has TB. D.prolonged exposure and close contact with someone who has TB.

D

A chest tube is inserted into a patient and attached to a water-seal drainage unit with wall suction with −20 cm of water in the suction control chamber. What would be your priority assessments post-insertion?

Mark drainage for baseline Get chest x-ray to make sure lung inflates Assess color of fluid (red, serous(Hawaiian punch), pink, yellow) Auscultate lung sounds- look at patient (breath sounds on both sides), pulse ox Chest tube always below level of chest

nE.M., an 82-year-old female, is escorted by her daughter into preoperative area for removal of cataract. nHer daughter asks you what can be done to prevent cataracts. What should you tell her?

Nothing can prevent To slow progression: Using antioxidants, take vitamins (C and E), eat carrots, good nutrient, visual enhancements (glasses), wear sunglasses

A patient with COPD arrives to the unit from the ED. The nurse conducts a focused respiratory assessment. Her respirations are labored and her respiratory rate is 34. She states that she is severely short of breath. Her O2 saturation is 86% on 2 L via nasal cannula. Based on these findings, what should the nurse do next?

Sit up Incr O2 (3L) Bronchodilator Focused assessment( listen to lungs)

Upon morning assessment, the patient has a weak cough, crackles in both lower lobes, and an SaO2 reading of 90% by pulse oximetry. What interventions should be implemented at this time?

Sit up, cough, deep breath, reevaluate pulse ox, incentive spirometer every hours, increase fluid (3L a day), possibly administer bronchodilator