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. Positioning the head of the bed at 10 degrees is not sufficient for optimizing respiratory function. Typically, the head of the bed should be elevated to 30–45 degrees to help with breathing and reduce the risk of aspiration.
B. Encouraging fluid intake of 1500 mL/day may be too low for a client with pneumonia. Adequate hydration is important to thin mucus and help with expectoration, especially in the context of pneumonia. Typically, fluid intake should be higher unless contraindicated.
C. Coughing and deep breathing every 8 hours is insufficient. To prevent atelectasis and promote effective clearance of secretions in clients with pneumonia, coughing and deep breathing should be done more frequently, typically every 2 hours.
D. Obtaining a sputum culture is a priority for determining the specific pathogen causing the pneumonia and guiding antibiotic treatment. A sputum culture helps identify bacterial, viral, or fungal organisms that may be present, which is crucial for managing recurrent pneumonia, especially in an immunocompromised client with AIDS.

A. Administer anticoagulant medications. B. Monitor vital signs every 4 hours. C. Encourage the patient to consume a high-fiber diet. D. Assist with the insertion and removal of the balloon tamponade device.

Correct Answer is B

Explanation

A. Administering anticoagulant medications is contraindicated in patients with bleeding esophageal varices. Anticoagulants could worsen bleeding and complicate the condition further. The goal in managing esophageal varices is to control the bleeding, not to increase the risk of bleeding.
B. Monitoring vital signs frequently is critical in patients with bleeding esophageal varices, as they are at risk for hypovolemic shock. Vital signs should be monitored closely to assess for signs of bleeding, hemodynamic instability, and response to interventions. Typically, more frequent monitoring (every 15 minutes initially, then every hour) is indicated, not just every 4 hours.
C. A high-fiber diet is not appropriate for patients with bleeding esophageal varices. This can increase intra-abdominal pressure and may worsen bleeding. The diet should be tailored to the patient's needs, typically involving low-residue or soft foods depending on their condition.
D. Assisting with the insertion and removal of the balloon tamponade device should be done by a skilled provider, not the nurse. The nurse's role involves monitoring for complications, ensuring proper positioning, and assessing the patient's response to treatment.

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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 is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which of the following nursing actions will the nurse include in the plan of care?

Correct Answer is B

Explanation

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