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. Skin lesions are seen as solid predictors of the general health state: While skin lesions can provide valuable information about a patient's health, they are not the only indicator. Changes in the skin can indicate various health conditions, not just lesions.
B. The patient's psychological health is best predicted by the skin: While changes in the skin can sometimes be associated with psychological health conditions, they are not the sole predictors. Psychological health is assessed through a comprehensive evaluation, including observation, interview, and assessment tools.
C. Detection of skin cancer is the only reason to assess the client's skin: While skin cancer detection is an important aspect of skin assessment, it is not the only reason. Skin assessment provides valuable information about overall health, hydration status, circulation, and potential systemic conditions.
D. The skin is a good communicator regarding the client's overall health: The skin can provide valuable clues about a patient's overall health status. Changes in skin color, texture, moisture, and integrity can indicate underlying health conditions, nutritional deficiencies, circulation problems, or systemic diseases. Therefore, focusing on any changes noted in the patient's skin is essential for comprehensive assessment and early detection of potential health issues.

A. Place all clients who have manifestations on contact precautions. B. Obtain stool cultures from all clients on the nursing unit. C. Request the providers to initiate antibiotic therapy for every client on the unit. D. Perform hand hygiene with an alcohol-based agent.

Correct Answer is A

Explanation

A. Place all clients who have manifestations on contact precautions: Given the suspicion of Clostridium difficile infection due to the development of watery diarrhea in multiple clients, it is appropriate to place these clients on contact precautions until the diagnosis is confirmed or ruled out. Contact precautions help prevent the spread of the infection by requiring healthcare workers to wear gloves and gowns when entering the room.
B. Obtain stool cultures from all clients on the nursing unit: While obtaining stool cultures may be necessary to confirm the diagnosis of C. difficile infection, implementing contact precautions is more immediate and necessary to prevent transmission.
C. Request the providers to initiate antibiotic therapy for every client on the unit: Initiating antibiotic therapy for every client on the unit without confirmation of C. difficile infection is not appropriate and may contribute to antibiotic resistance.

D. Perform hand hygiene with an alcohol-based agent: Hand hygiene is essential in preventing the spread of infection, but in the case of C. difficile, handwashing with soap and water is recommended over alcohol-based hand sanitizers due to the spore-forming nature of the bacteria.

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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

The nurse in a healthcare provider's (HCP's) office is reassessing a patient's skin and making a comparison with the information from the patient's last visit. For which reason does the nurse focus on any changes noted in the patient's skin?

Correct Answer is D

Explanation

A nurse working on a medical-surgical unit suspects that several clients have Clostridium Difficile (C-Diff) when they all develop watery diarrhea. Which of the following actions should the nurse plan to take while waiting for the client's lab results?

Correct Answer is A

Explanation

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