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    Ati lpn med surg respiratory proctored exam

    A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?

    Explanation & Rationale

    A. Assist the client to cough and deep breathe every 4 hr: While coughing and deep breathing are important to mobilize secretions, the frequency should be more frequent—typically every 1–2 hours—to effectively prevent atelectasis and promote airway clearance in a client with pneumonia. B. Encourage independence in completing ADLs: Encouraging independence is important for overall function, but during acute illness like pneumonia, rest and energy conservation are critical. Overexertion could worsen fatigue and respiratory distress. C. Encourage fluid intake of 2.5 L per day: Adequate hydration helps thin mucus, making it easier to expectorate, and supports overall recovery. Encouraging sufficient fluid intake is a key intervention in managing pneumonia, especially in older adults. D. Use an N-95 respirator when providing client care: N-95 respirators are required for airborne precautions, such as with tuberculosis. Pneumonia caused by typical bacteria or viruses is usually spread via droplets, so standard precautions with a surgical mask are generally sufficient.

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