A nurse plans care for a client who is at high risk for a pu...

A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

A. Encourage deep breathing and coughing
B. Implement an air mattress overlay
C. Ambulate the client three times each day
D. Provide a diet high in protein and vitamins
E. Administer acetaminophen (Tylenol) twice daily

Correct Answer: A,C,D

Rationale: Deep breathing and coughing, ambulation, and a nutrient-rich diet promote respiratory health and prevent infection. An air mattress overlay is for pressure relief, not respiratory health, and acetaminophen does not reduce infection risk.

You may also like to solve these questions

A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?

A. Encourage the client to increase fluid intake
B. Assess the clients level of consciousness
C. Raise the head of the bed to at least 45 degrees
D. Provide the client with humidified oxygen

Correct Answer: B

Rationale: Assessing the client's level of consciousness is critical as it indicates how the client is responding to the infection and its impact on overall health. While encouraging fluid intake, raising the head of the bed, and providing humidified oxygen are important interventions, they are secondary to assessing consciousness, which can reveal urgent changes in the client's condition.

While obtaining a client's health history, the client states, 'I am allergic to avocados.' Which responses by the nurse are best? (Select all that apply.)

A. What response do you have when you eat avocados?
B. I will remove any avocados that are on your food tray
C. Ask about the last time you ate avocados
D. I will document this in your record so all of your providers will know
E. Have you ever been treated for this allergic reaction?

Correct Answer: A,D,E

Rationale: Assessing the specific allergic response, documenting the allergy, and inquiring about past treatments are critical for safe care. Removing avocados is practical but secondary, and asking about the last time eaten is less relevant.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has to exposed your smoking history. Which action is most important for the nurse to take when interviewing this client?

A. Tell a client that he needs to quit smoking to stop further cancer development
B. Encourage the client to be completely honest about both tobacco and marijuana use
C. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty
D. Avoid giving the client false hope regarding cancer treatment and prognosis

Correct Answer: C

Rationale: Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have quit or be in denial about this habit, a nonjudgmental attitude during the interview encourages honesty about exposure. Asking about current or past use and passive exposure is important, but maintaining a nonjudgmental attitude is the priority to facilitate open communication.

A nurse auscultates a harsh hollow sound over a clients trachea and larynx. Which action should the nurse take first?

A. Document the findings
B. Administer oxygen therapy
C. Position the client in high-Fowler's position
D. Administer prescribed albuterol

Correct Answer: A

Rationale: Harsh, hollow sounds over the trachea and larynx are normal breath sounds. The nurse should document this finding. No interventions like oxygen, positioning, or albuterol are necessary for a normal finding.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

A. Oxygen saturation is 92% after a 12-minute walk
B. A small amount of drainage from the site is noted
C. Pulse oximetry is 95% on 2 liters of oxygen
D. The trachea is deviated toward the opposite side of the neck

Correct Answer: D

Rationale: A deviated trachea indicates a tension pneumothorax, a medical emergency requiring immediate intervention. Other findings, such as small drainage or 95% pulse oximetry, are normal or near-normal and do not require urgent action.