The nurse is caring for a client diagnosed with pneumonia. Which interventions should the nurse include in the plan of care? (Select All that Apply.)

Plan for periods of rest during activities, Monitoring the client's oxygen saturation

Place the client on strict fluid restriction

Placing the client on oxygen

Restrict the client's smoking to 5 cigarettes per day

Answer and Explanation

Correct Answer : A,C

A. Planning for periods of rest during activities and monitoring the client's oxygen saturation are essential interventions for a client with pneumonia. Rest helps conserve energy and reduces the workload on the respiratory system, while monitoring oxygen saturation ensures that the client is maintaining adequate oxygen levels, which is crucial in pneumonia.
B. Placing the client on strict fluid restriction is not appropriate for pneumonia. In fact, adequate hydration is important to help thin respiratory secretions and facilitate expectoration.
C. Placing the client on oxygen is often necessary for clients with pneumonia, especially if they are hypoxic or have difficulty maintaining adequate oxygen levels. Supplemental oxygen supports the respiratory system and improves oxygenation.
D. Restricting the client's smoking to 5 cigarettes per day is not an appropriate intervention. Smoking should be completely stopped to help reduce the risk of further respiratory complications. Smoking cessation is a priority in managing respiratory conditions like pneumonia

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Correct Answer is D

Explanation

A. Tympany upon chest percussion is typically associated with the presence of air, such as in cases of pneumothorax or gastric distention. It is not a typical finding in pneumonia.
B. Unequal pupils (anisocoria) are not a common symptom of pneumonia and may indicate a neurological issue rather than a respiratory infection.
C. Hypertension is not a characteristic finding in community-acquired pneumonia. Pneumonia may cause changes in blood pressure, but hypotension or normal blood pressure is more likely.
D. Confusion is a common finding in older adults with pneumonia. This can be due to factors such as hypoxia, dehydration, or infection-related changes in mental status, often referred to as "pneumonia delirium" or "acute confusion." Older adults are particularly susceptible to cognitive changes due to infection.

A. "I can still participate in physical activities and exercise with an ileostomy." B. "I should empty the pouch when it is about two-thirds full." C. "I should apply adhesive remover to the skin around the stoma when changing the pouch." D. "I can eat all my favorite foods now that I have an ileostomy."

Correct Answer is D

Explanation

A. This is an appropriate statement. Most patients with an ileostomy can resume physical activities and exercise, though they should be mindful of their stoma and pouch during activities.
B. This is a correct statement. The pouch should be emptied when it is about one-third to one-half full to prevent it from becoming too heavy or causing skin irritation.
C. This is also correct. Adhesive remover can be used to gently remove the pouch and adhesive, preventing irritation to the skin around the stoma.
D. This statement indicates a need for more teaching. While many foods can be eaten after an ileostomy, some foods may cause blockages or discomfort (e.g., nuts, seeds, and high-fiber vegetables). Patients need to be educated on dietary modifications and precautions post-ileostomy.

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The nurse is caring for a client diagnosed with pneumonia. Which interventions should the nurse include in the plan of care? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

The nurse is completing discharge teaching with a patient following an ileostomy. Which statement by the patient indicates the need for more teaching concerning the ileostomy?

Correct Answer is D

Explanation

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