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.
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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Related Questions
Correct Answer is B
Explanation
A. Bullae: Bullae are fluid-filled lesions larger than 0.5 cm in diameter.
B. Nodules: Nodules are elevated, solid lesions deeper and firmer than papules, typically larger than 0.5 cm in diameter.
C. Papules: Papules are elevated, solid lesions smaller than 0.5 cm in diameter.
D. Macules: Macules are flat, colored lesions that are smaller than 1 cm in diameter.
Correct Answer is C
Explanation
A. Potassium: Potassium levels are not typically used to diagnose infection. Elevated potassium levels may indicate other health conditions such as kidney dysfunction.
B. BUN (Blood Urea Nitrogen): BUN levels assess kidney function and are not directly related to the presence of infection.
C. WBC count (White Blood Cell count): An elevation in the WBC count, specifically the neutrophil count (neutrophilia), is indicative of the body's response to infection or inflammation.
D. RBC count (Red Blood Cell count): RBC count is not typically used to diagnose infection.
Elevated RBC count may indicate conditions such as dehydration or polycythemia.
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