A nurse is assisting with the plan of care for a client who has aspirated pneumonia and hypoxia. Which of the following actions should the nurse plan to take?
Apply petroleum jelly to the client's nares.
Initiate fall precautions.
Maintain the client in a supine position.
Implement contact precautions.
The Correct Answer is B
Choice A: This is incorrect because applying petroleum jelly to the client's nares can interfere with oxygen delivery and cause skin breakdown. The nurse should use water-soluble lubricant or saline spray to moisten the nares and prevent dryness from oxygen therapy.
Choice B: This is correct because initiating fall precautions can prevent injury and complications for the client who has aspirated pneumonia and hypoxia. The client may have altered mental status, weakness, or dizziness due to hypoxia, infection, or medications. The nurse should use bed alarms, side rails, and assistive devices as needed.
Choice C: This is incorrect because maintaining the client in a supine position can worsen hypoxia and pneumonia by decreasing lung expansion and increasing secretions. The nurse should elevate the head of the bed at least 30 degrees and encourage frequent position changes to improve ventilation and drainage.
Choice D: This is incorrect because implementing contact precautions is not indicated for the client who has aspirated pneumonia and hypoxia. Aspirated pneumonia is caused by inhalation of foreign material into the lungs, not by transmission of microorganisms from person to person. The nurse should use standard precautions and droplet precautions if the client has a cough or sputum production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Pupillary dilation is not a sign of opioid toxicity, but rather of opioid withdrawal or stimulant overdose. Opioid toxicity causes pupillary constriction or miosis.
Choice B reason: Hypotension is a sign of opioid toxicity sign of opioid toxicity, as opioids can depress the central nervous system and reduce cardiac output and peripheral resistance.
Choice C reason: Chest pain is not a sign of opioid toxicity, but rather of cardiac ischemia or infarction, which can be caused by cocaine or other stimulants.
Choice D reason: Diaphoresis is not a sign of opioid toxicity, but rather of opioid withdrawal or hyperthermia, which can be caused by ecstasy or other stimulants.
Correct Answer is B
Explanation
Choice A: This is incorrect because client status unchanged throughout shift is too vague and does not provide specific details about the client's condition and progress. The nurse should document any changes or interventions that occurred during the shift, such as vital signs, pain level, activity, and drainage.
Choice B: This is correct because abdominal wound dry, without redness is a clear and objective description of the client's wound appearance and healing. The nurse should document any signs of infection or complications, such as redness, swelling, warmth, or purulent drainage.
Choice C: This is incorrect because client received an adequate amount of fluid is too general and does not indicate the exact amount and type of fluid that the client received. The nurse should document the intake and output of the client, including any IV fluids, oral fluids, urine, stool, and drainage.
Choice D: This is incorrect because incision healing well is too subjective and does not reflect the actual assessment of the incision site. The nurse should document the size, color, and condition of the incision, as well as any sutures or staples.
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