A nurse is assisting in the plan of care for a client showing signs of pneumonia. Which of the following nursing actions should be included?

Obtain a sputum culture.

Cough and deep breathe every 6 hours.

Encourage fluid intake of 1500 mL/day.

Position the client prone.

Answer and Explanation

The Correct Answer is A

A.   Obtain a sputum culture: Obtaining a sputum culture helps identify the causative organism of pneumonia, which guides appropriate antibiotic therapy.
B.   Cough and deep breathe every 6 hours: While coughing and deep breathing exercises are important for preventing complications such as atelectasis, they are not specific to pneumonia treatment and may not be appropriate for all patients with pneumonia.
C.   Encourage fluid intake of 1500 mL/day: Adequate fluid intake is generally recommended for overall health but is not a specific intervention for pneumonia treatment.
D.   Position the client prone: Positioning the client prone is not a standard intervention for pneumonia treatment. Depending on the severity and type of pneumonia, the client's positioning may vary, but prone positioning is not routinely recommended.

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Correct Answer is D

Explanation

A. Treatment is to continue for 7 days: This aspect of the prescription is clear and does not require clarification.
B. The appearance of the area is to be documented: Documenting the appearance of the area is a standard nursing practice and does not require clarification from the physician.
C. The procedure is performed with clean technique: The use of clean technique for the procedure is appropriate for the management of a pressure injury and does not require clarification.
D. Room temperature normal saline is prescribed: This aspect of the prescription may require clarification as the nurse needs to ensure that the prescribed solution matches the intended
treatment. Clarification may be necessary if there are specific preferences or considerations regarding the type or temperature of the saline solution to be used.

A. Place the client in a private room. B. Administer intravenous vancomycin C. Wear a cover gown when caring for the client. D. Restrict fluid intake. E. Initiate supplemental oxygen.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

Place the client in a private room.
- Essential: Placing the client in a private room helps prevent the spread of MRSA to other patients and reduces the risk of transmission.
Administer intravenous vancomycin.
- Essential: Vancomycin is an appropriate antibiotic choice for treating MRSA infections, and administering it intravenously allows for effective delivery of the medication to combat the infection.
Wear a cover gown when caring for the client.
- Essential: Wearing a cover gown provides an additional barrier of protection against potential contact with the client's infected wound and helps prevent transmission of MRSA to healthcare workers and other patients.
Restrict fluid intake.
- Contraindicated: Restricting fluid intake is not indicated in this scenario. Adequate hydration is essential for supporting the body's immune response and maintaining organ function, especially in the presence of fever and infection.
Initiate supplemental oxygen.
- Nonessential: Supplemental oxygen is not indicated based on the client's oxygen saturation of 96% on room air. Oxygen supplementation is typically reserved for clients who are hypoxic or experiencing respiratory distress, which is not the case here.

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A nurse is assisting in the plan of care for a client showing signs of pneumonia. Which of the following nursing actions should be included?

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Naxlex Comprehensive Predictor Exams

A patient is admitted for treatment for a severe ulcerated pressure injury exhibiting signs of infection. The HCP prescribes open wet dressings to be applied every 6 hours for a period of 30 minutes for one week. For which part of the prescription does the nurse clarify with the physician?

Correct Answer is D

Explanation

A nurse is caring for a client. Exhibits For each potential nursing action, click to specify if the action is essential. nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

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