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 A

Explanation

A. Swelling, tenderness, and purulent drainage around the wound are classic signs of a wound infection. Swelling and tenderness indicate inflammation, while purulent drainage (pus) suggests the presence of infection.
B. Urticaria and itching around the wound are more indicative of an allergic reaction or hypersensitivity rather than a wound infection.
C. Serosanguineous drainage (clear to blood-tinged fluid) is a normal finding in the early stages of wound healing and does not necessarily indicate infection.
D. Brown crusting over the wound may indicate the formation of an eschar, which can occur in wounds undergoing healing, particularly in wounds with necrotic tissue. It is not necessarily indicative of infection unless accompanied by other signs such as erythema, warmth, or purulent drainage.

A. When the patient will be resting for at least an hour B. In the evening before bed C. In the morning before the patient dresses D. After the patient bathes

Correct Answer is D

Explanation

A. When the patient will be resting for at least an hour: There is no specific requirement for the patient to rest after applying ointment to an inflamed skin rash.
B. In the evening before bed: While applying ointment before bed may be convenient for some patients, it may not be the best time for all patients, especially if the rash requires more frequent application.
C. In the morning before the patient dresses: Applying ointment in the morning may be appropriate, but it depends on the specific needs of the patient and the frequency of application recommended by the healthcare provider.
D. After the patient bathes: Applying ointment after the patient bathes can help ensure that the skin is clean and dry, maximizing the effectiveness of the ointment. Additionally, bathing can
help remove any debris or irritants from the skin, preparing it for the application of the ointment.

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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

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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