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: Providing the client with small-handled adaptive utensils is not necessary for a visually impaired client. The client may prefer to use their own utensils or regular ones that they are familiar with.
Choice B reason: Describing the food placement as though the plate were a clock is a helpful technique to orient the client to their meal and avoid spills or accidents. The nurse should also ask the client about their preferences and needs before serving the food.
Choice C reason: Discouraging conversations during the client's mealtime is not appropriate for a visually impaired client. The nurse should encourage social interactions and respect the client's dignity and autonomy.
Choice D reason: Arranging for an assistive personnel to feed the client is not indicated for a visually impaired client. The nurse should promote the client's independence and self-care abilities as much as possible.
Correct Answer is B
Explanation
Choice A: This is incorrect because feeling bloated after the procedure is not a reason to call the doctor. Feeling bloated after a colonoscopy is normal due to air being introduced into the colon during the procedure. The client can relieve bloating by passing gas or walking.
Choice B: This is correct because making arrangements for a ride home indicates an understanding of the procedure. The client will receive sedation during a colonoscopy, which can impair their judgment and coordination. The client should not drive or operate machinery until fully recovered from sedation.
Choice C: This is incorrect because eating a light breakfast the morning of the procedure indicates a lack of understanding of the procedure. The client should have nothing by mouth after midnight before a colonoscopy, unless instructed otherwise by the provider. The client should follow a clear liquid diet and take bowel preparation agents as prescribed before the procedure.
Choice D: This is incorrect because having a sore throat from the breathing tube indicates a lack of understanding of the procedure. The client will not have a breathing tube during a colonoscopy, as it does not involve intubation or ventilation. The client may have a mouth guard or bite block to protect their teeth and prevent biting on the endoscope.
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