Author Question: A patient presents with pneumonia. Which priority intervention should be included in the plan of ... (Read 70 times)

lindiwe · **on:** Jul 22, 2018

A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient?

a. Observe the patient for decreased activity tolerance.
b. Assume the patient is in pain and treat accordingly.
c. Provide the patient ice chips as requested.
d. Maintain the room temperature at 65 F.

Question 2

The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection?

a. Teaching the patient about fall prevention
b. Teaching the patient to take a temperature
c. Teaching the patient to select nutritious foods
d. Teaching the patient about the effects of alcohol

chem1s3 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: A
Systemic infection, like pneumonia, causes more generalized symptoms than local infection. This type of infection can result in fever, fatigue, nausea and vomiting, and malaise; be alert for changes in the patient's level of activity and responsiveness. Nurses do not assume but assess and communicate with the patient about pain. While providing the patient with ice chips may be appropriate, it is not a priority and there is no reason for the patient to be limited to ice. Maintaining the room temperature at 65 F is too cold.

Answer to Question 2

ANS: C
A patient's nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing. This is the only teaching point that directly influences risk. Teaching the patient how to take a temperature can help the patient assess if there is a fever, but it is not related to decreasing the individual's risk for infection. Teaching the patient about fall prevention or about the effects of alcohol does not decrease the risk of infection.