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.
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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Related Questions
Correct Answer is A
Explanation
A. Place all clients who have manifestations on contact precautions: Given the suspicion of Clostridium difficile infection due to the development of watery diarrhea in multiple clients, it is appropriate to place these clients on contact precautions until the diagnosis is confirmed or ruled out. Contact precautions help prevent the spread of the infection by requiring healthcare workers to wear gloves and gowns when entering the room.
B. Obtain stool cultures from all clients on the nursing unit: While obtaining stool cultures may be necessary to confirm the diagnosis of C. difficile infection, implementing contact precautions is more immediate and necessary to prevent transmission.
C. Request the providers to initiate antibiotic therapy for every client on the unit: Initiating antibiotic therapy for every client on the unit without confirmation of C. difficile infection is not appropriate and may contribute to antibiotic resistance.
D. Perform hand hygiene with an alcohol-based agent: Hand hygiene is essential in preventing the spread of infection, but in the case of C. difficile, handwashing with soap and water is recommended over alcohol-based hand sanitizers due to the spore-forming nature of the bacteria.
Correct Answer is D
Explanation
A. Hand hygiene: Hand hygiene is a measure to break the chain of infection by reducing the number of microorganisms on hands. It is not a reservoir of infection.
B. Wearing personal protective equipment (PPE): PPE is used to protect healthcare workers and patients from exposure to infectious agents. It does not serve as a reservoir for infection.
C. Proper disposal of sharps: Proper disposal of sharps is important to prevent needlestick
injuries and transmission of bloodborne pathogens but does not represent a reservoir of infection.
D. A contaminated surface: A contaminated surface can serve as a reservoir for infectious agents.
Reservoirs are places where infectious agents can survive and multiply, posing a risk of transmission to susceptible individuals.
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