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

Obtain a sputum culture.

Position the client prone.

Cough and deep breathe every 4 hr.

Encourage fluid intake of 1500 mL/day.

Answer and Explanation

The Correct Answer is A

A. Obtain a sputum culture:
This is essential before starting antibiotics to identify the causative organism and guide treatment.

B. Position the client prone:
Prone positioning is not appropriate for pneumonia; upright or semi-Fowler's helps with lung expansion and drainage.

C. Cough and deep breathe every 4 hr:
This is not frequent enough. The recommended frequency is at least every 2 hours to improve ventilation and secretion clearance.

D. Encourage fluid intake of 1500 mL/day:
While hydration is important, the intake should be at least 2,000–3,000 mL/day to thin secretions unless contraindicated.

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Correct Answer is C

Explanation

A. A client who is of Asian ethnicity: While Asians may have health risks, African Americans have a statistically higher risk for developing hypertension.

B. A female client who is 44-years-old: Middle-aged women can develop hypertension, but other groups are at greater risk.

C. A client who is African American: African Americans are at higher risk of hypertension due to genetic, environmental, and socioeconomic factors.

D. A male client who is 53-years-old: Age and gender are risk factors, but race/ethnicity (African American) carries a higher relative risk for hypertension.

A. A client who has brown crusting over the wound B. A client who has urticaria and itching around the wound C. A client who has swelling and tenderness around the wound D. A client who has serosanguineous drainage from the wound

Correct Answer is C

Explanation

A. A client who has brown crusting over the wound: May be dried blood or scab; not necessarily infected.

B. A client who has urticaria and itching around the wound: Suggests allergic reaction or irritation, not infection.

C. A client who has swelling and tenderness around the wound: Classic signs of infection include swelling, tenderness, warmth, and erythema.

D. A client who has serosanguineous drainage from the wound: This is normal early drainage; not indicative of infection.

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

Nursing Test Bank

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