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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Align the client's joints with the joints on the frame. B. Pad the CPM device with a thick pillow. C. Place the client in high-Fowler's position. D. Set the degree of flexion and extension as tolerated by client.

Correct Answer is A

Explanation

Choice A: This is correct because aligning the client's joints with the joints on the frame can ensure proper functioning and comfort of the CPM device. The nurse should adjust the length and width of the device to fit the client's leg and secure it with straps.

Choice B: This is incorrect because padding the CPM device with a thick pillow can interfere with its movement and cause pressure on the leg. The nurse should use only thin padding or no padding at all for the CPM device.

Choice C: This is incorrect because placing the client in high-Fowler's position can cause flexion contractures and impair circulation in the leg. The nurse should place the client in supine or semi-Fowler's position with the leg elevated on pillows.

Choice D: This is incorrect because setting the degree of flexion and extension as tolerated by client can cause excessive pain and damage to the joint. The nurse should set the degree of flexion and extension according to the provider's prescription and gradually increase it as ordered.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy. Which of the following client statements indicates an understanding of the procedure?

Correct Answer is B

Explanation

A nurse is initiating the use of a continuous passive motion (CPM) device for a client following a total knee arthroplasty. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left foot for 20 min." Which of the following actions should the nurse take?

A nurse is reinforcing teaching about saturated fats with a client who is at risk for cardiovascular disease. Which of the following cooking fats should the nurse recommend the client use?

A nurse is caring for a client who is 3 days postoperative following an ileostomy placement. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client in hospice care who is dying. The client's partner says to the nurse, "I don't know how I will cope after he's gone." Which of the following is an appropriate response by the nurse?

A nurse is caring for a client who has a closed head injury. In which of the following positions should the nurse place the client?

A nurse is providing care to a client who has sustained deep partial-thickness burns to the back of both legs. Which of the following actions should the nurse anticipate taking?

A nurse is reinforcing teaching about breast health with a client who has a family history of breast cancer. Which of the following instructions should the nurse include?

A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take?