A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?
Explanation & Rationale
A. Apply petroleum jelly to the client's nares: Petroleum jelly is used to prevent nasal dryness from oxygen therapy, but it does not address hypoxia or aspiration risk. It is not a priority intervention in the care of a client with aspiration pneumonia. B. Maintain the client in a supine position: Keeping the client supine increases the risk of further aspiration and can worsen hypoxia. Elevating the head of the bed is recommended to reduce aspiration risk and promote oxygenation. C. Initiate fall precautions: Hypoxia can cause dizziness, confusion, or weakness, increasing the client’s risk for falls. Implementing fall precautions ensures safety while addressing potential complications of decreased oxygenation. D. Implement contact precautions: Aspiration pneumonia is not typically transmitted via direct contact; standard precautions are usually sufficient. Contact precautions are not required unless there is a known multidrug-resistant organism present.