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.

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Correct Answer is D

Explanation

Choice A reason: Airborne precautions are used for diseases that are spread through the air over long distances, such as tuberculosis, measles, or chickenpox. VRE is not typically spread through the air.

Choice B reason: Droplet precautions are used for diseases that are spread through large droplets in the air, such as influenza or pertussis. VRE is not spread through droplets but through contact with contaminated surfaces or equipment.

Choice C reason: A protective environment is designed to protect immunocompromised patients from infection and is not typically used for patients with VRE. This type of precaution includes the use of HEPA filters, laminar air flow, and other strategies to maintain a sterile environment.

Choice D reason: Contact precautions are the appropriate measures for a patient with a VRE infection. VRE can be spread from one person to another through contact with contaminated surfaces or equipment or through person-to-person spread, often via contaminated hands. It is not spread through the air by coughing or sneezing. Therefore, contact precautions, including the use of gloves and gowns, are necessary when caring for patients with VRE to prevent the spread of the bacteria.

A. "I will avoid drinking large amounts of fluids immediately before bedtime." B. "I will limit having a glass of wine to just before bedtime." C. "I will walk briskly for 30 minutes before bedtime." D. "I will do my muscle relaxation techniques in the afternoon." E. Instruct the client about taking antifungal medications.

Correct Answer is A

Explanation

Choice A reason: Avoiding large amounts of fluids before bedtime can help prevent disruptions in sleep due to the need to urinate during the night.

Choice B reason: Consuming alcohol, even in the form of a glass of wine, just before bedtime can interfere with the sleep cycle and lead to disrupted sleep.

Choice C reason: Engaging in brisk exercise before bedtime can be stimulating and may make it more difficult to fall asleep.

Choice D reason: Performing muscle relaxation techniques in the afternoon can help reduce overall tension but doing them closer to bedtime would be more beneficial for promoting sleep.

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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?

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