A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?

Encourage fluid intake of 2.5 L per day.

Assist the client to cough and deep breathe every 4 hr.

Encourage independence in completing ADLs.

Use an N-95 respirator when providing client care.

Answer and Explanation

The Correct Answer is A

A. Encourage fluid intake of 2.5 L per day.

This is an appropriate intervention for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making them easier to cough up and clear from the airways. Adequate hydration also supports overall health and immune function. However, the nurse should consider the client's individual fluid tolerance and any comorbid conditions such as heart failure that may necessitate fluid restriction.

B. Assist the client to cough and deep breathe every 4 hr.

This intervention is also appropriate for a client with pneumonia. Coughing and deep breathing exercises help to mobilize and clear respiratory secretions, preventing complications such as atelectasis and pneumonia. However, the frequency of coughing and deep breathing may need to be tailored to the client's tolerance and respiratory status.

C. Encourage independence in completing ADLs.

While promoting independence in activities of daily living (ADLs) is generally beneficial for older adult clients, in the context of pneumonia, the priority is to ensure adequate rest and conserve energy for recovery. Depending on the severity of the illness, the client may experience fatigue and dyspnea, making it challenging to perform ADLs independently. The nurse should assess the client's functional status and provide assistance as needed while promoting independence to the extent possible.

D. Use an N-95 respirator when providing client care.

This intervention is not directly relevant to the care plan for a client with pneumonia. N-95 respirators are primarily used for respiratory protection against airborne infectious agents such as tuberculosis or certain viral infections like COVID-19. While standard precautions should be followed when caring for a client with pneumonia to prevent the spread of infection, including hand hygiene and appropriate use of personal protective equipment (PPE), an N-95 respirator is not typically indicated unless the client has a specific respiratory pathogen requiring airborne precautions.

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Correct Answer is B

Explanation

A. Administer IV morphine.

IV morphine may be indicated to relieve pain and anxiety associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

B. Begin oxygen therapy.

The priority intervention for a client who develops a pulmonary embolism is to begin oxygen therapy. Pulmonary embolism (PE) is a life-threatening condition characterized by a blockage in one or more of the pulmonary arteries, usually due to a blood clot. This blockage can lead to impaired gas exchange and decreased oxygenation of the blood, resulting in hypoxemia (low blood oxygen levels) and potentially leading to respiratory failure. Administering oxygen therapy promptly helps to improve oxygenation and support vital organ function. Therefore, it is the priority intervention to address the immediate respiratory distress associated with a pulmonary embolism.

C. Start an IV infusion of lactated Ringer's.

Intravenous fluid administration may be necessary to maintain hemodynamic stability and support perfusion in a client with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

D. Initiate cardiac monitoring.

Cardiac monitoring is important to assess for signs of cardiac compromise or dysrhythmias associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

A. Assess the patient; check to see if the oxygen is flowing correctly B. Page the MD STAT C. Put up the patient's side rails and apply soft restraints D. Administer an IM sedative

Correct Answer is A

Explanation

A. Assess the patient; check to see if the oxygen is flowing correctly:

This option involves assessing the patient's condition promptly, particularly focusing on the adequacy of oxygenation. Checking the oxygen delivery system ensures that the patient is receiving the prescribed oxygen therapy at the appropriate flow rate. In a patient with shortness of breath (SOB) and increasing confusion and combativeness, hypoxemia (low oxygen levels) could be a contributing factor. Therefore, assessing the oxygen delivery system is crucial to ensure proper oxygenation and address potential causes of the patient's symptoms.

B. Page the MD STAT:

Paging the MD STAT may be necessary after assessing the patient's condition, especially if the patient's symptoms indicate a medical emergency or require immediate intervention. However, in this scenario, the priority is to assess the patient's condition and address any immediate concerns related to oxygenation and respiratory status. While paging the healthcare provider may be necessary, it should not delay the initial assessment and interventions needed to stabilize the patient.

C. Put up the patient's side rails and apply soft restraints:

Applying side rails and soft restraints should not be the first action in response to the patient's symptoms. While patient safety is important, these measures should only be implemented after other interventions have been attempted, and there is a risk of harm to the patient or others due to agitation or combativeness. In this case, the patient's confusion and combativeness may be secondary to hypoxemia, so addressing oxygenation and assessing the patient's condition are the immediate priorities.

D. Administer an IM sedative:

Administering a sedative should not be the first action in this scenario. Sedation may be considered if the patient's agitation or combativeness poses a risk to their safety or interferes with assessment and treatment. However, the underlying cause of the patient's symptoms, such as hypoxemia, should be addressed first. Administering a sedative without addressing the potential cause of the patient's symptoms could mask important clinical indicators and delay appropriate treatment.

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A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?

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