Deck 3 Module 9 Infection Flashcards
Which actions should the nurse take to help the client with bowel and bladder dysfunction reduce the risk of infection? Select all that apply.
A) Isolate the client using transmission-based precautions.
B) Monitor intake and output.
C) Provide hygienic care after episodes of incontinence.
D) Use standard precautions when handling linen after episodes of incontinence.
E) Limit fluid intake.
B) Monitor intake and output.
C) Provide hygienic care after episodes of incontinence.
D) Use standard precautions when handling linen after episodes of incontinence.
Rationale: Monitoring intake and output is important because it can help reveal whether a client is experiencing dehydration. Dehydration may lead to urinary stasis, which increases the risk of infection. Similarly, intake and output levels can help reveal urinary retention, which also heightens the risk of infection. Providing hygienic care after episodes of bowel or bladder incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper biohazard precautions after episodes of incontinence will also reduce the risk of transmitting an infection. In contrast, limiting fluid intake increases infection risk by putting the client at greater risk for dehydration. Isolating the client using transmission-based precautions is not necessary because these precautions are meant to prevent the spread of infection from the client to others, and this client is not currently experiencing infection.
A nurse is planning an in-service on preventing infection for the staff nurses on a hospital’s medical-surgical unit. Which of the following should be the priority teaching point for this in-service?
A) Raising the temperature in each client’s room
B) Assessing vital signs once daily
C) Wearing a mask for client care
D) Performing hand hygiene
D) Performing hand hygiene
Rationale: Hand hygiene is always the first and best way to stop the spread of microorganisms, which cause infections. Raising the temperature in a client’s room would contribute to the growth of microorganisms. Assessing vital signs is important but should be done more frequently than once daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.
The nurse is assessing a client who is recovering following surgery. Which factor would increase this client’s susceptibility to infection?
A) Intact mucous membranes
B) Presence of an incision
C) Dry skin
D) Active bowel sounds
B) Presence of an incision
Rationale: This client has a surgical incision, so the body’s first line of defense, the skin, is not intact. Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the body against infection.
The nurse is caring for a client who is being discharged following abdominal surgery with an incision. Which instruction is most important for the nurse to teach this client regarding wound healing?
A) “Thoroughly irrigate the wound with hydrogen peroxide once a day.”
B) “Apply a lubricating lotion to the edges of the wound twice a day.”
C) “Add more fruits and vegetables to your diet.”
D) “Notify the healthcare provider if you notice swelling, warmth, or tenderness at the wound site.”
D) “Notify the healthcare provider if you notice swelling, warmth, or tenderness at the wound site.”
Rationale: A client being discharged with a surgical wound has to be instructed on the detection of infection, as the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing. Applying lubricating lotion to the edges of a wound would impede the healing process.
The nurse is caring for a client who is exhibiting signs of a systemic infection following surgery. Which diagnostic tests would the nurse anticipate being ordered? Select all that apply.
A) Serum electrolyte levels B) Urinalysis C) White blood cell differential D) White blood cell count E) Wound culture
B) Urinalysis
C) White blood cell differential
D) White blood cell count
E) Wound culture
Rationale: Serum electrolyte levels are not used to determine the presence of a systemic infection. Urinalysis is used to assess for the presence of bacteria or blood in the urine. An elevated WBC and 15% bands are indicative of an infection. Wound cultures are used to identify probable microorganisms.
The nurse is teaching a class on infection control. Which nursing measure is most appropriate in breaking a link in the chain of infection?
A) Place contaminated linens in a paper bag.
B) Use personal protective equipment (PPE).
C) Cover one’s cough by placing the mouth in the hand.
D) Wear sterile gloves for client care.
B) Use personal protective equipment (PPE).
Rationale: PPE, according to Occupational Safety and Health Administration (OSHA) standards, has to be used whenever the situation dictates and is a nursing measure to break a link in the chain of infection. Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue. Covering one’s mouth when coughing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. However, the cough should be covered in the elbow, not in the hand. Non-sterile gloves have to be worn when providing certain aspects of client care. The gloves should be changed between clients, and hands are to be washed.
The nurse is teaching a child care class for mothers of young children. What should the nurse teach as being the most common mode of transmission of infectious disease?
A) Children who are playing board games
B) Children who are sitting together eating meals
C) Children who are playing with the same toy
D) Children who don’t wash their hands after using the bathroom
D) Children who don’t wash their hands after using the bathroom
Rationale: The fecal-oral and respiratory routes are the most common sources of transmission in children. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. Playing with board games will not transmit infectious disease. Eating together will not transmit infectious disease. Poor hand hygiene is a common source of transmission.
A client is receiving IV antibiotics for the treatment of a Staphylococcus aureus infection. Which nursing interventions are appropriate when providing care to this client? Select all that apply.
A) Encourage adequate fluid intake. B) Monitor for allergic reaction. C) Assess renal and liver function. D) Assess pain level. E) Monitor vital signs.
A) Encourage adequate fluid intake.
B) Monitor for allergic reaction.
C) Assess renal and liver function.
E) Monitor vital signs.
Rationale: Nursing interventions to support antibiotic therapy include encouraging adequate fluid intake, monitoring for manifestations of an allergic reaction, assessing renal and hepatic function, and assessing vital signs. Although some clients may experience pain related to staph infection, antibiotics do not address pain, so assessment of pain levels is not related to administration of these medications.
The healthcare provider prescribes a client to have peak and trough blood levels drawn to evaluate the therapeutic effect of an IV antibiotic. When should the nurse schedule the blood samples to be drawn? Select all that apply.
A) Prior to the discontinuing the antibiotic
B) A few minutes before the next scheduled dose of medication
C) During the infusion of the antibiotic
D) 30 minutes after the IV administration
E) 1 to 2 hours after the oral administration of the medication
B) A few minutes before the next scheduled dose of medication
D) 30 minutes after the IV administration
Rationale: Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range–that is, the minimum and maximum blood levels at which the drug is effective–is known for a given drug. By measuring blood levels at the predicted peak (1-2 hours after oral administration, 1 hour after intramuscular administration, and 30 minutes after IV administration) and trough, usually a few minutes before the next scheduled dose, it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects.
A pregnant client tested positive for group B streptococcus during her 36-week checkup. For which intervention should the nurse prepare the client in order to prevent transmission of infection to the neonate?
A) Not breastfeeding the neonate during the first week after birth
B) Administration of antibiotics to the neonate after birth
C) Delivery by cesarean section
D) Administration of antibiotics to the client during labor
D) Administration of antibiotics to the client during labor
Rationale: Group B streptococcus (GBS) can be transmitted to the newborn during delivery. Administration of antibiotics during labor and delivery can prevent this transmission, so the nurse should prepare the mother for this intervention. GBS is not transmitted to the neonate through breastfeeding, antibiotics are not given to the neonate after birth, and a positive GBS test does not require cesarean delivery.
A type of infection that is associated with the delivery of healthcare services in a facility such as a hospital or nursing home is called a(n)
A) etiologic infection.
B) latent infection.
C) healthcare-associated infection.
D) hospital-associated infection.
C) healthcare-associated infection.
Rationale: A healthcare-associated infection, not a hospital-associated infection, is an infection that is associated with the delivery of healthcare services in a facility such as a hospital or nursing home. Nurses must be diligent about hand hygiene and other safety practices to prevent healthcare-associated infections. A latent infection is an infection that is present but not active. All infections are etiologic; they are produced by a specific organism.
Which agent can be used to destroy pathogens other than spores?
A) Antiseptic
B) Disinfectant
C) Sterilizing agent
D) Isolating agent
B) Disinfectant
Rationale: Disinfectants destroy pathogens other than spores. Antiseptics only inhibit the growth of some organisms. A sterilizing agent destroys all pathogens, including spores. Isolation is used to prevent the spread of infection but does not destroy any pathogens.
Which client should the nurse anticipate will have the greatest psychosocial needs?
A) A client under standard precautions
B) A client taking antibiotics
C) A client under droplet precautions
D) A client in isolation
D) A client in isolation
Rationale: Clients requiring isolation precautions can develop psychosocial problems related to their separation from other people, including sensory deprivation and decreased self-esteem. The nurse will need to provide additional care for these clients to promote their psychosocial health. Clients taking antibiotics or under standard or droplet precautions may have psychosocial needs as well, but they will not be as severe as those of the client in isolation.
The nurse is caring for a client with gangrene of the toe. Which collaborative intervention should the nurse anticipate preparing the client for?
A) Surgery
B) Debridement
C) Myringotomy
D) Wound irrigation
A) Surgery
Rationale: Surgical intervention is the primary collaborative treatment for gangrene. Wound irrigation and debridement are used to remove dead tissue and debris from a wound. They are not used for gangrenous infections. Myringotomy is used to remove infected inner ear drainage, not for infected toes.
The nurse is caring for a client who is admitted with cellulitis of the foot. Which assessment findings support this diagnosis?
A) Blood urea nitrogen (BUN) and creatinine
B) Breath sounds
C) Blood cultures
D) Redness, pain, and edema at the site
D) Redness, pain, and edema at the site
Rationale: Classic signs of cellulitis are swelling, pain, redness, and edema at the site. BUN, creatinine, and blood cultures are ordered by the physician and are not nursing assessments. Breath sounds are not indicated at present, as the infection is in the foot.
The nurse is teaching a group of adolescents at a local high school about skin infections. Which students should the nurse identify as being at increased risk for developing cellulitis? Select all that apply.
A) A student who plucks her eyebrows
B) A student with diabetes
C) A student who is a member of the golf team
D) A student who squeezes pimples
E) A student who applies moisturizer on a daily basis
A) A student who plucks her eyebrows
B) A student with diabetes
D) A student who squeezes pimples
Rationale: The student who plucks her eyebrows risks an infected hair follicle, which can lead to cellulitis, as can squeezing pimples. The student with diabetes has a weakened immune system and increased risk for nerve damage and vascular changes in the extremities, which can lead to increased potential for skin injury and cellulitis. Non-contact sports like golf do not pose a risk for cellulitis. Keeping the skin well moisturized can protect against skin breakdown and thus reduce the risk for cellulitis.
The nurse is caring for a client who is hospitalized for cellulitis of the foot. Which nursing diagnoses should the nurse use to plan this client’s care? Select all that apply.
A) Social Isolation related to skin infection
B) Impaired Skin Integrity related to skin infection
C) Acute Pain related to skin infection
D) Disturbed Sleep Pattern related to skin infection
E) Powerlessness related to inability to control the infection
B) Impaired Skin Integrity related to skin infection
C) Acute Pain related to skin infection
Rationale: Clients with cellulitis have Impaired Skin Integrity and will also have Acute Pain at the site. Controlling pain is a priority. Disturbed Sleep Pattern, Social Isolation, and Powerlessness are not supported by the information given.
The nurse is teaching a client with cellulitis about ways to promote healing and avoid future infections. Which client statements indicate that the teaching has been effective? Select all that apply.
A) “I should use antibiotic soap to cleanse my wound.”
B) “I must keep my wound completely dry between cleansings.”
C) “I should contact the doctor if I have a temperature of 99.5°F or higher.”
D) “I should avoid swimming in lakes when I have a wound.”
E) “I can stop taking antibiotics when the swelling subsides.”
A) “I should use antibiotic soap to cleanse my wound.”
D) “I should avoid swimming in lakes when I have a wound.”
Rationale: Clients with cellulitis should wash affected areas with antibacterial soap to prevent the spread of infection. They should also avoid swimming in lakes when wounded, as the water may be contaminated and could cause an infection. The healthcare provider should be contacted for a body temperature of 101°F or higher. Antibiotics are taken for the full course ordered, not just until the swelling subsides. Wounds should be kept at a proper moisture level as instructed, because wet or moist wounds heal faster than dry wounds.
A client receiving intravenous antibiotics for 3 days as treatment for cellulitis is being prepared for discharge. Which discharge order should the nurse anticipate for this client?
A) Low-sodium diet prescribed
B) Home healthcare aide for the client
C) Oral antibiotics to be continued at home
D) Orders for evaluation by physical therapy
C) Oral antibiotics to be continued at home
Rationale: Antibiotics should be taken for 10 days; therefore, the nurse anticipates oral antibiotics to be continued at home. A low-sodium diet is not indicated for cellulitis. The client may or may not need a home health aide. There is no evidence to suggest the client needs physical therapy.
The nurse is providing discharge instructions to a client recovering from cellulitis. Which client statement indicates that this teaching has been effective?
A) “I will monitor for signs of infection such as fever, chills, malaise, and redness or tenderness at the site.”
B) “If the lesion looks healed, I will stop taking the antibiotics so that I will not develop resistance to antibiotics.”
C) “If pustules develop, I will squeeze the lesion to remove the pus.”
D) “Drainage from the site is an expected finding, and I should not be concerned.”
A) “I will monitor for signs of infection such as fever, chills, malaise, and redness or tenderness at the site.”
Rationale: The client will need to be taught to monitor for the signs and symptoms of infection. Infection may be manifested by fever, chills, erythema, tenderness, and drainage at the site, especially if it is cloudy or serous. Changes in the color, amount, and odor from drainage are cause for concern and should be monitored. The physician must be notified if these symptoms occur. Pustules are never to be squeezed open, as there is risk of greater infection. Stopping antibiotics before the doses are complete causes resistance.
When providing care to a client with a wound, which evidence-based interventions should the nurse anticipate carrying out? Select all that apply.
A) Keeping the wound dry
B) Only covering the wound if a scab forms
C) Ensuring that the wound remains moist
D) Keeping the wound covered
E) Teaching the client that proper wound management can reduce scarring
C) Ensuring that the wound remains moist
D) Keeping the wound covered
E) Teaching the client that proper wound management can reduce scarring
Rationale: Individuals with open wounds are more susceptible to contracting a skin infection, such as cellulitis. Many people believe that wounds should be kept dry and should not be covered until a scab forms. However, this slows wound healing and leaves the wound exposed to potential pathogens if the scab comes off. Wound covering helps maintain a moist environment, decreasing the chance of infection. Proper wound moisture management also reduces pain and improves the cosmetic outcome.
On which region of the body would the nurse most expect to observe erysipelas?
A) Abdomen
B) Ankles
C) Neck
D) Back
B) Ankles
Rationale: Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders.
The nurse is caring for a client who has been diagnosed with orbital cellulitis. Which assessment finding should the nurse anticipate?
A) Sunken eyes
B) Edema of the affected eye
C) Increased acuity of the affected eye
D) Elevated blood pressure
B) Edema of the affected eye
Rationale: Edema of the affected site is a common symptom of cellulitis. This may cause bulging eyes, not sunken eyes. The client may complain of decreased vision, not increased acuity of vision. Blood pressure is unrelated to orbital cellulitis.
What organism is most commonly responsible for cellulitis?
A) Staphylococcus epidermidis
B) Streptococcus pneumoniae
C) Streptococcus viridans
D) Staphylococcus aureus
D) Staphylococcus aureus
Rationale: The most common causative organism of cellulitis is Staphylococcus aureus, followed by group A Streptococcus. The other bacteria produce other types of infections.
A nurse caring for a client with cellulitis can expect to collaborate with which other member of the healthcare team?
A) Clinical psychologist
B) Social worker
C) Wound care specialist
D) Respiratory therapist
C) Wound care specialist
Rationale: Cellulitis is an acute bacterial infection of the dermis and underlying connective tissue. It usually occurs as a complication of a wound infection; thus, a wound care specialist is often used to promote a positive wound care plan. Social workers, clinical psychologists, and respiratory therapists are typically not involved in the care of most clients with cellulitis.
The nurse is assessing a college student who presents with red, swollen eyes; photophobia; and yellowish drainage from the conjunctiva. Which question should the nurse ask the client first?
A) “Have you had extra caffeine this week?”
B) “Did you get sand in your eye recently?”
C) “Have you been exposed to HIV?”
D) “Have any of your friends experienced these symptoms?”
D) “Have any of your friends experienced these symptoms?”
Rationale: The client is exhibiting signs and symptoms of conjunctivitis. The nurse should explore ways in which the client may have been exposed. Most cases of conjunctivitis are spread by hand to eye contact. Exposure to HIV, sand in the eye, and caffeine are not known causes of conjunctivitis and would not be appropriate questions to ask this client to determine the cause of the symptoms.
When planning care for a client with trachoma, which potential complication should the nurse consider?
A) Scarring of the cornea
B) Eye muscle weakness
C) Damaged iris
D) Retinal detachment
A) Scarring of the cornea
Rationale: Trachoma is a chronic form of conjunctivitis that causes the formation of granulation tissue that is abraded by the lashes, leading to scarring of the cornea and eventual blindness. The other options are not potential complications to this type of conjunctivitis.
The nurse is teaching a mother how to administer optical antibiotics to her child who has conjunctivitis. Which statement made by the mother indicates teaching has been effective?
A) “I will drop the medication onto the eyeball.”
B) “I will wait 10 seconds between drops.”
C) “I will wash my hands before instilling the medication.”
D) “I will rub the eye with a cotton ball after I administer the medication.”
C) “I will wash my hands before instilling the medication.”
Rationale: Teach the client to wash hands thoroughly before and after instilling eye medications. Handwashing is the single most important means of preventing transmission of infection. Medication is dropped into the lower conjunctival sac and should not be rubbed after instillation. The time between drops is 1 to 5 minutes, depending on the type of medication.
The nurse is providing care for a pediatric client with bacterial conjunctivitis. Which interventions should the nurse use as part of the collaborative management of the client? Select all that apply.
A) Recommending dark sunglasses B) Recommending removing contacts at night C) Contacting the client's school nurse D) Performing careful hand hygiene E) Administering antiviral therapy
A) Recommending dark sunglasses
C) Contacting the client’s school nurse
D) Performing careful hand hygiene
Rationale: Dark glasses will help to reduce the photophobia that many clients with conjunctivitis experience. It is often appropriate for the nurse to contact the client’s school nurse to discuss increased prevention and student education. Careful hand hygiene is a standard method for managing the client with conjunctivitis. Antibiotics, not antiviral medications, are prescribed with conjunctivitis. Contacts should not be worn during conjunctivitis.
The nurse is providing discharge instructions for a client who has acute conjunctivitis from Staphylococcus. Which should the nurse include when teaching this client? Select all that apply.
A) “It is OK to share makeup once the infection has resolved.”
B) “Do not share towels, makeup, or contact lenses with anyone else, as this can spread the infection.”
C) “You can soak your eyelids with a warm cloth to soften crusts and exudates that may form.”
D) “Wash your hands before cleansing the eye and administering eye drops.”
E) “You may go back to sharing towels when the infection is gone.”
B) “Do not share towels, makeup, or contact lenses with anyone else, as this can spread the infection.”
C) “You can soak your eyelids with a warm cloth to soften crusts and exudates that may form.”
D) “Wash your hands before cleansing the eye and administering eye drops.”
Rationale: Sharing supplies, such as towels, makeup, or contact lenses, is never a good idea even after the infection is cleared, due to potential for cross-contamination. Handwashing (hand hygiene) will minimize the risk of bringing in other organisms to an already infected eye. Soaking the lids with a warm cloth will soften the crusts from exudates that accompany the Staphylococcus infection. The action of rubbing one’s eyes can traumatize the eyes further and increase the risk of cross-contamination.
The nurse is assessing a client who presents with purulent drainage and crusting of the eye. The nurse should recognize that these findings are most consistent with which type of infection?
A) Viral conjunctivitis
B) Allergic conjunctivitis
C) Bacterial conjunctivitis
D) Fungal conjunctivitis
C) Bacterial conjunctivitis
Rationale: The major difference between bacterial and viral conjunctivitis is that bacterial conjunctivitis has a purulent discharge that may result in crusting, whereas the discharge from viral conjunctivitis is serous (watery). Allergic conjunctivitis produces watery to thick drainage and is characterized by itching. Fungi do not cause conjunctivitis.
Which term is commonly used by clients to describe conjunctivitis?
A) Stye
B) Pink eye
C) Red eye
D) Retinitis
B) Pink eye
Rationale: Clients commonly refer to conjunctivitis as “pink eye,” not red eye. Retinitis is a disease related to the retina, not the conjunctiva of the eye. Retinitis causes vision loss, not inflammation, redness, and discharge. A stye is a pimple-like infected oil gland on or near the edge of the eyelid.
A client who uses extended-wear contact lenses should be taught measures for reducing the risk of which of the following conditions?
A) Conjunctivitis
B) Cataracts
C) Glaucoma
D) Macular degeneration
A) Conjunctivitis
Rationale: Individuals who use extended-wear contact lenses are at higher risk of developing conjunctivitis. Therefore, client teaching should include prevention of eye infections. These individuals are not at specific risk for other types of eye conditions, such as cataracts, glaucoma, or macular degeneration.
A labor and delivery nurse is providing care for a neonate in the first few minutes after birth. One action the nurse will take to promote eye health and prevent conjunctivitis in the infant is administration of
A) oral tetracycline.
B) erythromycin as an eye ointment.
C) ceftriaxone as an eye drop.
D) parenteral acyclovir.
B) erythromycin as an eye ointment.
Rationale: Prevention of conjunctivitis in a newborn is provided by the administration of an antibiotic eye ointment, usually erythromycin. Tetracycline may be used instead of erythromycin immediately after birth, but it will be used as an eye ointment, not as an oral formulation. Ceftriaxone is only administered for a confirmed case of gonococcal conjunctivitis. Parenteral acyclovir is only administered for a confirmed case of conjunctivitis due to herpes simplex virus.
The nurse is caring for a client who presents with acute malaise, muscle aches, and fever. Which additional assessment findings should the nurse recognize as consistent with influenza? Select all that apply.
A) No history of vaccinations within the past 12 months B) Nonproductive cough C) Hypotension D) Difficulty urinating E) Dizziness
A) No history of vaccinations within the past 12 months
B) Nonproductive cough
Rationale: Based on the presenting symptoms, the nurse would ask whether the client has had a seasonal flu shot or recently been exposed to the flu. Usually, the cough of a client with influenza is nonproductive. A productive cough may indicate a different diagnosis. Insufficient voiding, hypotension, and dizziness are not routine manifestations of influenza.
The nurse is working in a primary care setting. Which clients should the nurse identify as being at high risk for influenza or its complications? Select all that apply.
A) A 25-year-old pregnant woman at 20 weeks’ gestation
B) A 65-year-old woman
C) A 3-year-old with cystic fibrosis
D) A 35-year-old man with a severe allergy to eggs
E) A 20-year-old healthcare worker
A) A 25-year-old pregnant woman at 20 weeks’ gestation
B) A 65-year-old woman
C) A 3-year-old with cystic fibrosis
E) A 20-year-old healthcare worker
Rationale: People at increased risk of influenza or its complications include infants, young children, pregnant women, and anyone age 50 or older. Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary diseases, are more susceptible as well. Healthcare workers have increased risk of exposure to influenza. A man with an allergy to eggs is not at increased risk for influenza or its complications.
What information should the nurse include when teaching parents of pediatric clients about ways to decrease the spread of influenza? Select all that apply.
A) “Cover your cough” education
B) An explanation of appropriate hand hygiene
C) Methods for safe food preparation and storage
D) Where to obtain the influenza vaccine
E) The importance of withholding immunizations for children with compromised immune systems
A) “Cover your cough” education
B) An explanation of appropriate hand hygiene
D) Where to obtain the influenza vaccine
Rationale: Teaching children to wash their hands and to use respiratory etiquette helps control the growth and spread of microorganisms. The influenza vaccine can decrease each child’s susceptibility to influenza infection. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms, but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children.
Which interventions should the nurse anticipate carrying out to promote effective breathing in a client with respiratory manifestations of the flu? Select all that apply.
A) Maintain adequate hydration.
B) Teach the client coughing and deep breathing.
C) Prepare the client for the possibility of a tracheostomy tube.
D) Keep the head of the bed elevated.
E) Administer antitussives during the day.
A) Maintain adequate hydration.
B) Teach the client coughing and deep breathing.
D) Keep the head of the bed elevated.
Rationale: Keeping the head of the bed elevated improves lung excursion and reduces the work of breathing. Coughing and deep breathing are essential for achieving airway clearance. Hydration thins the mucus and also aids in clearing the airway. Insertion of a tracheostomy and oxygen are not primary treatments for ineffective airway clearance. Antitussives should be administered at night to promote sleep but should not be administered during the day to promote airway clearance through coughing.
The nurse makes a home visit to a client recovering from influenza. Which client statements indicate that desired outcomes have been met? Select all that apply.
A) “I’m eating healthy foods now.”
B) “I went back to work.”
C) “I haven’t had chills since I left the hospital.”
D) “I slept the whole night without coughing.”
E) “I was able to take a walk today.”
C) “I haven’t had chills since I left the hospital.”
D) “I slept the whole night without coughing.”
Rationale: Desired outcomes for a client recovering from the flu include absence of symptoms of acute infection (such as fever and chills), resolution of respiratory symptoms, and resumption of normal sleep-rest patterns. The facts that the client has returned to work, is able to walk, and is eating a healthy diet do not indicate that the client’s flu has resolved.
