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 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.

A. Restrict the client's calorie intake to no more than 2,000 calories per day. B. Change sterile gloves between caring for wounds on different areas of the body. C. Limit movement or bending of the client's affected extremities. D. Administer a diuretic if the client's urine output falls below 30 mL/hr.

Correct Answer is B

Explanation

Choice A reason: Restricting the client's calorie intake to no more than 2,000 calories per day is not an appropriate action, as it can impair wound healing and increase the risk of infection or malnutrition. The nurse should provide adequate calories and protein to meet the increased metabolic demands and support tissue repair and regeneration.

Choice B reason: Changing sterile gloves between caring for wounds on different areas of the body is an appropriate action, as it can prevent cross-contamination and infection of the burn wounds, which are susceptible to bacterial colonization and sepsis.

Choice C reason: Limiting movement or bending of the client's affected extremities is not an appropriate action, as it can cause contractures, joint stiffness, or muscle atrophy in the burned areas. The nurse should encourage early and frequent range of motion exercises and use splints or positioning devices to maintain functional alignment and mobility.

Choice D reason: Administering a diuretic if the client's urine output falls below 30 mL/hr is not an appropriate action, as it can worsen dehydration, electrolyte imbalance, or renal failure that can occur after severe burns. The nurse should monitor fluid status and urine output closely and administer intravenous fluids as prescribed to maintain adequate hydration and perfusion.

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