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 maintaining the client on bed rest can increase the risk of complications such as pneumonia, thromboembolism, or pressure ulcers. The nurse should encourage early ambulation and frequent position changes to promote healing and prevent complications.

Choice B: This is correct because repositioning the client can help relieve pressure and discomfort from the incision site. The nurse should assist the client to change positions every 2 hours and use pillows or splints to support the incision.

Choice C: This is incorrect because applying a warm, moist compress to the incision area can interfere with wound healing and increase the risk of infection. The nurse should keep the incision site clean and dry and follow the provider's orders for dressing changes.

Choice D: This is incorrect because administering an additional dose of pain medication is not necessary when the client reports a pain level of 2 on a scale of 0 to 10. The nurse should monitor the client's pain level and administer pain medication as prescribed and as needed.

A. Vegetable shortening B. Lard C. Canola oil D. Butter

Correct Answer is C

Explanation

Choice A: This is incorrect. Vegetable shortening is high in saturated fat and trans fat, which can increase the risk of cardiovascular disease by raising the LDL (bad) cholesterol and lowering the HDL (good) cholesterol.

Choice B: This is incorrect. Lard is animal fat that is high in saturated fat and cholesterol, which can also increase the risk of cardiovascular disease by raising the LDL cholesterol and lowering the HDL cholesterol.

Choice C: This is correct. Canola oil is low in saturated fat and high in monounsaturated fat and omega-3 fatty acids, which can lower the risk of cardiovascular disease by lowering the LDL cholesterol and raising the HDL cholesterol.

Choice D: This is incorrect. Butter is dairy fat that is high in saturated fat and cholesterol, which can also increase the risk of cardiovascular disease by raising the LDL cholesterol and lowering the HDL cholesterol

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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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