A nurse is assisting in the plan of care for a client showing signs of pneumonia. Which of the following nursing actions should be included?

Obtain a sputum culture.

Cough and deep breathe every 6 hours.

Encourage fluid intake of 1500 mL/day.

Position the client prone.

Answer and Explanation

The Correct Answer is A

A.   Obtain a sputum culture: Obtaining a sputum culture helps identify the causative organism of pneumonia, which guides appropriate antibiotic therapy.
B.   Cough and deep breathe every 6 hours: While coughing and deep breathing exercises are important for preventing complications such as atelectasis, they are not specific to pneumonia treatment and may not be appropriate for all patients with pneumonia.
C.   Encourage fluid intake of 1500 mL/day: Adequate fluid intake is generally recommended for overall health but is not a specific intervention for pneumonia treatment.
D.   Position the client prone: Positioning the client prone is not a standard intervention for pneumonia treatment. Depending on the severity and type of pneumonia, the client's positioning may vary, but prone positioning is not routinely recommended.

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Correct Answer is A

Explanation

A. Place a N95 mask on the patient: Tuberculosis (TB) is an airborne infectious disease, and N95 masks are specifically designed to filter out airborne particles, including those that may carry TB bacteria. Therefore, placing an N95 mask on the patient helps prevent the spread of TB to others during transportation.

B. Place a surgical mask on the patient: While a surgical mask may provide some level of
protection, it is not as effective as an N95 mask in filtering out airborne particles, particularly those associated with TB transmission.
C. Be sure the patient is wearing a protective gown: Protective gowns are typically used to
prevent the transmission of infection through contact with body fluids or contaminated surfaces. However, in the case of TB, airborne precautions, including respiratory protection with masks, are more crucial.
D. Instruct the patient to wear gloves to radiology: Gloves are not necessary for respiratory protection against TB during transportation to radiology.

A. Endogenous Infection B. Systemic Infection C. Exogenous Infection D. Health Care-Associated Infection

Correct Answer is D

Explanation

A. Endogenous Infection: Endogenous infections originate from the client's own microbiota and typically do not involve medical interventions such as urinary catheterization.
B. Systemic Infection: Systemic infections affect the entire body and may not necessarily be related to the urinary tract.
C. Exogenous Infection: Exogenous infections originate from sources outside the client's body.
While the urinary tract infection could be caused by bacteria from the environment, it is more specifically categorized as a healthcare-associated infection (HAI) due to the indwelling urinary catheter being a risk factor.
D. Health Care-Associated Infection: A healthcare-associated infection (HAI) occurs as a result of healthcare interventions and can include infections related to urinary catheterization, surgery, or other medical procedures.

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A nurse is assisting in the plan of care for a client showing signs of pneumonia. Which of the following nursing actions should be included?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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