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

[Haya94]

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.

Question 2

A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.)
 
  a. Visual hallucinations
  b. Tachycardia
  c. Decreased cravings
  d. Impaired judgment
  e. Increased thirst

[phuda]

Answer to Question 1

ANS: A, C, D
Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection. A client at high risk for a pulmonary infection may need a specialty bed to help with postural drainage or percussion; this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol would not decrease the risk of a pulmonary infection.

Answer to Question 2

ANS: A, D
Varenicline (Chantix) has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse should assess for changes in behavior and thought processes, including impaired judgment and visual hallucinations. Tachycardia and increased thirst are not adverse effects of this medication. Decreased cravings is a therapeutic response to this medication.

[Haya94]

TYSM

[matt95]

Gracias!