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 B

Explanation

Choice A Reason:

Increasing the client’s intake of Vitamin C can help with wound healing due to its role in collagen formation. However, this is not an immediate action to prevent wound dehiscence. While important for overall recovery, it does not directly address the mechanical stress on the incision site that can lead to dehiscence.

Choice B Reason:

Teaching the client to splint the incision when coughing is the most effective immediate action to prevent wound dehiscence. Splinting provides support to the incision site, reducing the risk of the wound opening due to the pressure exerted during coughing or other activities that increase intra-abdominal pressure. This method directly addresses the mechanical stress that can cause dehiscence.

Choice C Reason:

Having the client do abdominal exercises is not appropriate in the immediate postoperative period as it can increase the risk of wound dehiscence. Abdominal exercises can put additional strain on the incision site, potentially leading to separation of the wound edges.

Choice D Reason:

Performing passive range of motion exercises is beneficial for preventing complications such as joint stiffness and muscle atrophy. However, it does not specifically address the prevention of wound dehiscence. These exercises do not provide the necessary support to the incision site to prevent it from opening.

A. Initiate droplet precautions. B. Consider standard precautions to be sufficient. C. Transfer the client to a positive pressure room. D. Initiate airborne precautions. E. Transferring the client to a positive pressure room is inappropriate. Positive pressure rooms are designed to keep contaminants out and are used for protecting immunocompromised patients from infections. For a client with suspected TB, a negative pressure room is required to prevent the spread of infectious particles to other areas.

Correct Answer is D

Explanation

Choice A reason:

Initiating droplet precautions is not sufficient for a client presenting with symptoms such as coughing up blood, productive cough, and night sweats. These symptoms are indicative of possible tuberculosis (TB), which is an airborne disease. Droplet precautions are used for infections spread through large respiratory droplets, such as influenza or pertussis, but not for TB.

Choice B reason:

Considering standard precautions to be sufficient is incorrect. Standard precautions are the basic level of infection control that should be used in the care of all patients to prevent the spread of infections. However, for a client with symptoms suggestive of TB, additional airborne precautions are necessary to prevent the spread of the disease.

Choice C reason:

Transferring the client to a positive pressure room is inappropriate. Positive pressure rooms are designed to keep contaminants out and are used for protecting immunocompromised patients from infections. For a client with suspected TB, a negative pressure room is required to prevent the spread of infectious particles to other areas.

Choice D reason:

Initiating airborne precautions is the correct intervention. Airborne precautions are necessary for diseases that are transmitted through smaller respiratory droplets that can remain suspended in the air and be inhaled by others. Tuberculosis is one such disease, and initiating airborne precautions helps to prevent the spread of the infection to healthcare workers and other patients.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

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