A nurse is assisting with the plan of care for a client who has aspirated pneumonia and hypoxia. Which of the following actions should the nurse plan to take?

Apply petroleum jelly to the client's nares.

Initiate fall precautions.

Maintain the client in a supine position.

Implement contact precautions.

Answer and Explanation

The Correct Answer is B

Choice A: This is incorrect because applying petroleum jelly to the client's nares can interfere with oxygen delivery and cause skin breakdown. The nurse should use water-soluble lubricant or saline spray to moisten the nares and prevent dryness from oxygen therapy.

Choice B: This is correct because initiating fall precautions can prevent injury and complications for the client who has aspirated pneumonia and hypoxia. The client may have altered mental status, weakness, or dizziness due to hypoxia, infection, or medications. The nurse should use bed alarms, side rails, and assistive devices as needed.

Choice C: This is incorrect because maintaining the client in a supine position can worsen hypoxia and pneumonia by decreasing lung expansion and increasing secretions. The nurse should elevate the head of the bed at least 30 degrees and encourage frequent position changes to improve ventilation and drainage.

Choice D: This is incorrect because implementing contact precautions is not indicated for the client who has aspirated pneumonia and hypoxia. Aspirated pneumonia is caused by inhalation of foreign material into the lungs, not by transmission of microorganisms from person to person. The nurse should use standard precautions and droplet precautions if the client has a cough or sputum production.

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Correct Answer is D

Explanation

Choice A: This is incorrect because weight loss is not the highest priority finding for the nurse to report to the provider. Weight loss can be a common symptom of leukemia due to decreased appetite, increased metabolism, or malabsorption.

Choice B: This is incorrect because fatigue is not the highest priority finding for the nurse to report to the provider. Fatigue can be a common symptom of leukemia due to anemia, infection, or poor nutrition.

Choice C: This is incorrect because dysuria is not the highest priority finding for the nurse to report to the provider. Dysuria can indicate a urinary tract infection, which can be treated with antibiotics and fluids.

Choice D: This is correct because elevated temperature is the highest priority finding for the nurse to report to the provider. Elevated temperature can indicate a serious infection, which can be life-threatening for a client who has leukemia and a compromised immune system.

A. Analgesia should be used around the clock to promote pain control. B. Pain patches are applied each morning and removed at bedtime. C. We will use intramuscular medications to control your pain. D. A medication dose must be decreased if you develop tolerance.

Correct Answer is A

Explanation

Choice A reason: Using analgesia around the clock is an appropriate action. The nurse should follow the principle of prevention rather than rescue when managing pain for a client who has terminal cancer. The nurse should administer analgesics on a regular schedule to maintain a steady level of pain relief and prevent breakthrough pain.

Choice B reason: Applying pain patches each morning and removing them at bedtime is not an appropriate action. The nurse should follow the manufacturer's instructions for applying and removing pain patches. Some patches are designed to be worn for 24 hours, while others are worn for 72 hours. Removing the patches too soon can cause inadequate pain control and withdrawal symptoms.

Choice C reason: Using intramuscular medications to control pain is not an appropriate action. The nurse should avoid using intramuscular route for administering analgesics to a client who has terminal cancer. Intramuscular injections are painful, unreliable, and increase the risk of infection and bleeding. The nurse should use oral, transdermal, or subcutaneous routes whenever possible.

Choice D reason: Decreasing a medication dose if the client develops tolerance is not an appropriate action. The nurse should understand that tolerance is a normal physiological response to long-term opioid use and does not indicate addiction or abuse. The nurse should adjust the medication dose according to the client's level of pain and response to treatment.

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A nurse is assisting with the plan of care for a client who has aspirated pneumonia and hypoxia. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has leukemia. Which of the following findings is the highest priority for the nurse to report to the provider?

Correct Answer is D

Explanation

A nurse in a long-term care facility is reinforcing teaching about pain control with a client who has terminal cancer. Which of the following information should the nurse include?

Correct Answer is A

Explanation

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