The nurse is providing care to a client admitted with a diagnosis of bacterial pneumonia. On assessment, the client has dry mucous membranes and coarse rhonchi. What nursing interventions would the nurse include in the plan of care?

Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest

Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing

Decrease activity, increase bronchodilator use, and encourage pursed lip breathing

Place in prone position, begin steroid therapy, and monitor glucose levels

Answer and Explanation

The Correct Answer is B

A) Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest:
This approach is inappropriate for a client with bacterial pneumonia. While oxygen therapy may be necessary for some clients, administering a cough suppressant in this scenario is counterproductive. Pneumonia often leads to the accumulation of secretions, and suppressing the cough would prevent the client from clearing mucus from their airways, potentially worsening the condition. Bedrest is generally indicated, but it should not be the sole intervention.

B) Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing:
This is the most appropriate plan of care. Increasing fluid intake helps to thin the mucus, making it easier to clear from the airways, which is crucial in pneumonia. Antibiotics are necessary to treat the bacterial infection causing pneumonia. Facilitating adequate coughing helps the client expel secretions, reducing the risk of airway obstruction and improving oxygenation. Coarse rhonchi indicate the presence of mucus or secretions, which should be cleared with effective coughing.

C) Decrease activity, increase bronchodilator use, and encourage pursed lip breathing:
Decreasing activity is generally appropriate for a client with pneumonia to reduce fatigue, but increasing bronchodilator use is not typically indicated unless there is underlying bronchospasm, such as in asthma or COPD. Pursed lip breathing can help improve ventilation, but it is more beneficial for clients with obstructive airway diseases, not primarily for those with bacterial pneumonia. Therefore, this option does not address the immediate needs of the client.

D) Place in prone position, begin steroid therapy, and monitor glucose levels:
While prone positioning is helpful in some conditions like acute respiratory distress syndrome (ARDS), it is not routinely used for bacterial pneumonia unless the client has severe hypoxemia and requires advanced respiratory support. Steroid therapy is generally not indicated for bacterial pneumonia unless there is a specific inflammatory component (such as a superimposed condition like asthma or COPD). Monitoring glucose levels may be important in clients on steroid therapy, but this is not a primary concern in the treatment of bacterial pneumonia.

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Correct Answer is C

Explanation

A. Wheezes on inspiration: Wheezing is typically associated with obstructive pulmonary conditions, such as asthma or chronic obstructive pulmonary disease (COPD), and is caused by narrowing of the airways. In ARDS, the pathophysiology involves inflammation and fluid accumulation in the alveoli, which leads to impaired oxygen exchange but not typically to wheezing. Instead, crackles or rales (a fine, wet sound) are more commonly heard on auscultation in ARDS, particularly as fluid builds up in the alveoli.

B. Blood pressure 170/90: Although ARDS can be associated with hemodynamic instability, elevated blood pressure (170/90 mmHg) is not a typical finding. In fact, ARDS is more commonly associated with low blood pressure or hypotension, particularly if the client is experiencing shock or is on mechanical ventilation. Elevated blood pressure could suggest another issue, such as pain, anxiety, or the use of medications like vasopressors. It is not directly related to the pulmonary edema seen in ARDS.

C. Tachypnea: Tachypnea, or rapid breathing, is a hallmark clinical manifestation of acute respiratory distress syndrome (ARDS). In ARDS, pulmonary edema (fluid accumulation in the lungs) occurs as a result of damage to the alveolar-capillary membrane, leading to impaired gas exchange. The body attempts to compensate for decreased oxygenation by increasing the respiratory rate, leading to tachypnea. This is an early sign of respiratory distress and often precedes hypoxemia and other more severe manifestations. The nurse should closely monitor for tachypnea, as it can indicate worsening respiratory compromise.

D. Bradycardia: Bradycardia, or a slow heart rate, is not typically associated with ARDS. In fact, tachycardia (an elevated heart rate) is more commonly seen in response to hypoxia, respiratory distress, or as a compensatory mechanism for low blood pressure in critical illness. Bradycardia could indicate other issues such as vagal stimulation, medication effects, or electrolyte imbalances but is not characteristic of ARDS itself. 4o mini

A. Hand washing before and after client contact B. Placement of an indwelling urinary catheter using sterile technique C. Initiate neutropenic precautions D. Clean technique with central IV line care

Correct Answer is A

Explanation

A. Hand washing before and after client contact: The most important infection control guideline when caring for a client with acute respiratory distress syndrome (ARDS) who is on a ventilator is hand hygiene. This is because ventilated patients are at high risk for ventilator-associated pneumonia (VAP) and other infections. Hand washing is the most effective method of preventing the spread of pathogens that could lead to nosocomial infections. The nurse should perform proper hand hygiene both before and after any patient interaction, as this is critical in preventing the transmission of bacteria or viruses, especially in patients with compromised respiratory systems.

Explanation of each option:

B. Placement of an indwelling urinary catheter using sterile technique:
While using sterile technique when placing an indwelling urinary catheter is essential to prevent urinary tract infections (UTIs), it is not the top priority for infection control in this situation. The primary concern for infection in ARDS patients who are on mechanical ventilation is preventing respiratory infections, particularly ventilator-associated pneumonia (VAP). Although catheter-associated infections should be prevented, the most immediate concern is preventing respiratory-related infections.

C. Initiate neutropenic precautions:
Neutropenic precautions are important for patients who have immunocompromised conditions (such as those undergoing chemotherapy or with bone marrow suppression) to protect them from infections. However, ARDS does not necessarily compromise the immune system in the same way. The priority infection control measure for a patient on a ventilator with ARDS is preventing respiratory infections. Therefore, neutropenic precautions would not be the most relevant or highest priority in this case.

D. Clean technique with central IV line care:
Maintaining clean technique with central intravenous (IV) line care is important to prevent infections, such as central line-associated bloodstream infections (CLABSI). However, the most critical infection control measure for a patient on a ventilator with ARDS is still to focus on preventing respiratory infections, particularly ventilator-associated pneumonia (VAP). While IV line care is important, it is secondary to preventing respiratory tract infections in this scenario.

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The nurse is providing care to a client admitted with a diagnosis of bacterial pneumonia. On assessment, the client has dry mucous membranes and coarse rhonchi. What nursing interventions would the nurse include in the plan of care?

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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