A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

Initiate humidification therapy.

Encourage the client to cough and deep breathe.

Increase the client's oral fluid intake.

Raise the head of the bed.

Answer and Explanation

The Correct Answer is D

Choice A reason: Initiating humidification therapy can be beneficial for a client with pneumonia. Humidified air can help loosen respiratory secretions, making them easier to expectorate. However, while this intervention is helpful, it is not typically the first action a nurse should take. The priority is to address the client's immediate need for adequate oxygenation and ventilation.

Choice B reason: Encouraging the client to cough and perform deep breathing exercises is an essential part of care for patients with pneumonia. These actions help to clear mucus from the lungs and improve ventilation. Deep breathing helps to fully expand the alveoli, which can be compromised in pneumonia, and coughing helps to expel secretions that may be blocking the airways. However, this is not the most immediate action when the oxygen saturation is borderline normal.

Choice C reason: Increasing the client's oral fluid intake is important in the management of pneumonia. Adequate hydration thins respiratory secretions, making them easier to clear. It also supports overall bodily functions, which can be taxed during illness. Nonetheless, this intervention is not the most critical initial step in managing a client's immediate respiratory needs.

Choice D reason: Raising the head of the bed is the correct and immediate action to take for a client with pneumonia and an oxygen saturation of 88%. This position helps to improve chest expansion, promotes better lung aeration, and facilitates easier breathing. It also reduces the risk of aspiration, which is particularly important in clients with pneumonia. Elevating the head of the bed is a simple yet effective way to enhance oxygenation and should be the first step taken.

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 D

Explanation

Choice A reason: Gloves are typically removed first because they are likely to be the most contaminated. They should be removed carefully to avoid contaminating the hands, using the glove-in-glove or beak method.

Choice B reason: The gown should be removed after the gloves because it may also be contaminated. The nurse should reach up to the shoulders and carefully pull the gown forward and away from the body, touching only the inside of the gown.

Choice C reason: Eyewear is removed after the gown. The nurse should handle the eyewear by the arms, avoiding touching the front part that has been exposed to contaminants.

Choice D reason: The mask should be removed last because it protects the mucous membranes of the mouth and nose from infectious droplets. It should be taken off by handling the ties or elastic bands from behind the head and pulling it away from the face without touching the front of the mask.

A. Urinary catheterization B. Malnutrition C. Multiple caregivers D. Chlorhexidine washes

Correct Answer is A

Explanation

Choice A reason: Urinary catheterization is a well-known risk factor for HAIs, particularly catheter-associated urinary tract infections (CAUTIs). The use of indwelling urinary catheters can introduce bacteria into the urinary tract and is associated with a significant proportion of HAIs.

Choice B reason: While malnutrition can affect the immune system and increase the risk of infections, it is not a direct cause of HAIs. Good nutritional status is important for wound healing and infection prevention, but it does not cause HAIs by itself.

Choice C reason: Having multiple caregivers can increase the risk of transmitting infections, especially if hand hygiene and other infection control practices are not consistently followed. However, it is not considered a direct cause of HAIs like urinary catheterization is.

Choice D reason: Chlorhexidine washes are actually used as a preventive measure against HAIs, particularly in reducing the risk of surgical site infections. They are not a cause of HAIs but rather part of the solution to prevent them.

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 caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?

Correct Answer is D

Explanation

A nurse is preparing an in-service presentation about preventing healthcare-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

Correct Answer is A

Explanation

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client?

A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

A nurse is caring for a group of clients on an infectious disease unit. The nurse should wear an N95 respirator when caring for a client who has which of the following disorders?

For the client with obstructive sleep apnea (OSA), the nurse should expect the following findings:

For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching: