The client diagnosed with pneumonia develops pleuritic chest pain. Which nursing action should the nurse implement at this time?

Notify the physician immediately.

Increase the oxygen from 2 to 4 liters/minute.

Teach about splinting the chest when coughing.

Obtain an electrocardiogram.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Notifying the physician immediately is not the first action to take. While it is important to keep the physician informed, the nurse should first implement measures to alleviate the client’s pain and discomfort.

Choice B reason:

Increasing the oxygen from 2 to 4 liters/minute may be necessary if the client is experiencing hypoxia, but it is not directly related to managing pleuritic chest pain. The primary focus should be on pain relief and comfort.

Choice C reason:

Teaching about splinting the chest when coughing is the most appropriate action. Splinting helps to reduce pain by stabilizing the chest wall during coughing, which can be particularly painful for clients with pleuritic chest pain.

Choice D reason:

Obtaining an electrocardiogram (ECG) is not immediately necessary for managing pleuritic chest pain caused by pneumonia. An ECG may be indicated if there are concerns about cardiac issues, but it is not the primary intervention for pleuritic pain.

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Correct Answer is ["A","C","D"]

Explanation

Choice A reason:

Avoiding crowds during the cold and flu season is crucial for a client recovering from pneumonia. Pneumonia weakens the lungs and the immune system, making the client more susceptible to infections. Crowded places increase the risk of exposure to respiratory infections, which can complicate recovery. According to UpToDate, patients with pneumonia should avoid exposure to infectious agents to prevent further complications.

Choice B reason:

Increasing activities to the previous level as soon as you get home is not advisable. Clients recovering from pneumonia need to gradually return to their normal activities. Overexertion can lead to fatigue and delay recovery. The Mount Sinai Health Library advises patients to rest and gradually increase activity levels as they regain strength.

Choice C reason:

Reporting temperature elevations to the healthcare provider is essential. Fever can be a sign of an ongoing infection or a complication. Normal body temperature ranges from 97°F to 99°F (36.1°C to 37.2°C). Any elevation above this range should be reported to ensure timely intervention.

Choice D reason:

Finishing taking oral antibiotics as prescribed is critical to ensure the infection is fully treated and to prevent antibiotic resistance. Incomplete antibiotic courses can lead to a resurgence of the infection and contribute to the development of resistant bacteria.

Choice E reason:

Electronic cigarettes are not a recommended alternative to tobacco while trying to quit. The safety and efficacy of e-cigarettes as a smoking cessation tool are still under investigation. The American Lung Association advises against using e-cigarettes due to potential health risks.

A. Have a pulse oximetry reading of 95% or greater by discharge. B. Exhibit a respiratory rate of 12-20/minute by discharge. C. Perform self-care activity without dyspnea by discharge. D. Have clear breath sounds bilaterally by discharge.

Correct Answer is C

Explanation

Choice A reason:

Have a pulse oximetry reading of 95% or greater by discharge: While maintaining a pulse oximetry reading of 95% or greater is important, it may not fully address the client’s activity intolerance. Pulse oximetry measures the oxygen saturation in the blood, and normal readings typically range from 95% to 100%. However, achieving this reading alone does not ensure that the client can perform activities without experiencing dyspnea or fatigue.

Choice B reason:

Exhibit a respiratory rate of 12-20/minute by discharge: A normal respiratory rate for adults is between 12 and 20 breaths per minute. While this is a good indicator of respiratory function, it does not directly address the client’s ability to perform self-care activities without dyspnea. The goal should focus on the client’s functional ability rather than just physiological parameters.

Choice C reason:

Perform self-care activity without dyspnea by discharge: This outcome directly addresses the client’s activity intolerance. Dyspnea, or difficulty breathing, is a significant symptom that affects the client’s ability to perform daily activities. By setting a goal for the client to perform self-care activities without dyspnea, the care plan focuses on improving the client’s functional status and quality of life.

Choice D reason:

Have clear breath sounds bilaterally by discharge: Clear breath sounds are an important indicator of improved lung function and resolution of pneumonia. However, this outcome does not specifically address the client’s activity intolerance. While clear breath sounds are desirable, the primary goal should be to ensure the client can perform activities without experiencing dyspnea.

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The client diagnosed with pneumonia develops pleuritic chest pain. Which nursing action should the nurse implement at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge teaching for a client diagnosed with right lower lobe pneumonia. What information should be provided for this client? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is C

Explanation

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