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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Discouraging reminiscing about the past is not a helpful strategy for a client who has dementia and confusion. Reminiscing can stimulate memory, enhance mood, and promote social interaction.

Choice B reason: Asking open-ended questions that encourage the client to express their feelings is not appropriate for a client who has dementia and confusion. Open-ended questions can increase frustration and anxiety for the client who may have difficulty finding words or recalling events. The nurse should use simple, direct, and closed-ended questions instead.

Choice C reason: Using holiday decorations to provide orientation to the time of the year is a beneficial action for a client who has dementia and confusion. Holiday decorations can help the client recognize familiar cues and reduce disorientation.

Choice D reason: Encouraging multiple family members to visit the client at the same time is not advisable for a client who has dementia and confusion. Multiple visitors can overwhelm and agitate the client who may have trouble recognizing faces or voices. The nurse should limit the number of visitors and ensure they are calm and supportive.

A. Place electrical cords against the wall. B. Place a throw rug next to the bathtub. C. Keep pot handles turned toward the edge of the stove. D. Store extra blankets in a box on the steps.

Correct Answer is A

Explanation

Choice A: This is correct because placing electrical cords against the wall can prevent tripping and falling, which can cause injury or dislocation of the hip prosthesis. The nurse should instruct the client to remove any clutter or obstacles from the floor and use assistive devices such as a walker or cane.

Choice B: This is incorrect because placing a throw rug next to the bathtub can increase the risk of slipping and falling, especially when the floor is wet. The nurse should instruct the client to avoid using throw rugs or mats and install grab bars and non-skid mats in the bathroom.

Choice C: This is incorrect because keeping pot handles turned toward the edge of the stove can cause burns or spills, which can also lead to falls or infections. The nurse should instruct the client to turn pot handles inward or use the back burners of the stove.

Choice D: This is incorrect because storing extra blankets in a box on the steps can obstruct the access to the stairs and pose a hazard for falling. The nurse should instruct the client to store extra blankets in a closet or drawer and use handrails when using the stairs.

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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?

Nursing Test Bank

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