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 D
Explanation
Choice A reason: Discarding soiled wound care supplies in a trash receptacle outside the client's room is not an appropriate action. The nurse should dispose of contaminated materials in a biohazard container inside the client's room to prevent the spread of infection.
Choice B reason: Administering antibiotic therapy before culturing the client's wound is not an appropriate action. The nurse should obtain a wound culture before starting antibiotic therapy to ensure accurate results and avoid altering the microorganisms present in the wound.
Choice C reason: Instructing visitors to perform hand hygiene for 15 seconds after leaving the client's room is not an appropriate action. The nurse should instruct visitors to perform hand hygiene for at least 20 seconds before and after entering the client's room to reduce the risk of transmitting infection.
Choice D reason: Placing the client in a private room with a private bathroom is an appropriate action. The nurse should implement contact precautions for a client who has an infectious wound with foul-smelling drainage to prevent cross-contamination and protect other clients and staff from exposure.
Correct Answer is C
Explanation
Choice A reason: Taking the medication right before eating breakfast is not an appropriate instruction, as it can reduce the absorption and effectiveness of alendronate, which is a bisphosphonate drug that inhibits bone resorption and increases bone density. The client should take the medication at least 30 min before eating or drinking anything other than water.
Choice B reason: Drinking milk with the medication is not an appropriate instruction, as it can interfere with the absorption and effectiveness of alendronate, which can bind to calcium and other minerals and form insoluble complexes that are excreted in feces. The client should avoid consuming dairy products or supplements that contain calcium, iron, magnesium, or aluminum for at least 30 min after taking the medication.
Choice C reason: Staying upright for 30 to 60 min after taking the medication is an appropriate instruction, as it can prevent esophageal irritation or ulceration that can be caused by alendronate, which can be corrosive to the mucosa if it remains in contact with it for too long. The client should not lie down or bend over until after their first food of the day.
Choice D reason: Chewing the tablets thoroughly is not an appropriate instruction, as it can increase the risk of esophageal irritation or ulceration that can be caused by alendronate, which can be abrasive to the mucosa if it is not swallowed whole with a full glass of water. The client should not crush, break, or dissolve the tablets in any liquid.
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