Question

A nurse is planning care for a client who has community-acquired pneumonia. Which of the following intervention should the nurse include in the plan of care?

A. Monitor the client for confusion
B. Encourage the client to use an incentive spirometer every 8 hr
C. Instruct the client to drink 1 L of fluids daily
D. Titrate the oxygen to maintain SaO2 level at 92%

Answer 1

The nurse should monitor the client for confusion as it is an essential intervention in the care of a client with pneumonia, which can indicate hypoxia or worsening illness. Titration of oxygen to maintain an appropriate SaO2 level is also important.

Step-by-step explanation:

When a nurse is planning care for a client with pneumonia, several interventions should be considered to optimally manage the client's health. One important intervention is option A: Monitor the client for confusion. This is critical as confusion can be a sign of hypoxia or worsening illness, particularly in older adults. Conversely, using an incentive spirometer is often recommended more frequently than every 8 hours to help keep the lungs clear and prevent atelectasis, making option B less appropriate. Ensuring adequate hydration is important, but instructing the client to drink 1 L of fluids daily may not meet the individual's needs, so option C also may not be adequate. Lastly, option D to titrate the oxygen to maintain an SaO2 level at 92% is generally a good practice, as it ensures the client maintains an adequate level of oxygen in the blood, which can be essential for recovery from pneumonia.