The nurse determines that an elderly patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient?

Correct Answer: A

Rationale: The correct answer is A: Encourage the patient to stay up to date on all vaccinations. This is the best plan of care because vaccines help boost immunity and protect against various infections. By staying current on vaccinations, the elderly patient can prevent contracting preventable diseases. Annual tuberculosis skin testing (C) is important for detecting TB but does not directly address prevention. Finishing antibiotics (B) is important for treating infections but does not prevent them. Creating an exercise routine (D) is beneficial for overall health but does not specifically target preventing infections.

Correct Answer: D

Rationale: The correct answer is D: Short-acting beta2-adrenergic agonists. In acute asthma exacerbation, rapid bronchodilation is crucial for symptom relief. Short-acting beta2-agonists like albuterol act quickly to dilate the airways, providing immediate relief of bronchospasm and improving airflow. This medication is the first-line treatment for acute asthma attacks as it targets the underlying issue of bronchoconstriction. A: Inhaled anti-inflammatories, like corticosteroids, are essential for long-term control of asthma but are not used as rescue medications for acute exacerbations. B: Mucolytics help in thinning mucus but do not address the bronchoconstriction seen in acute asthma exacerbations. C: Long-acting beta2-agonists are used for maintenance therapy in asthma management and are not intended for quick relief during acute attacks.

Correct Answer: C

Rationale: The correct answer is C: To promote lung expansion. Placing the client in a semi-Fowler's position helps improve ventilation by allowing the lungs to expand more fully, aiding in gas exchange. This position also optimizes diaphragmatic function. A is incorrect because preventing atelectasis is more related to deep breathing exercises. B is incorrect as reducing pressure on the suture line is not the primary purpose of semi-Fowler's position. D is incorrect as preventing aspiration of secretions is not directly related to the positioning of a client recovering from a pneumonectomy.

Correct Answer: D

Rationale: The correct answer is D because postural drainage therapy helps mobilize and clear secretions from the bronchiectatic areas, reducing the risk of infection from stagnant sputum. It is a priority intervention to improve airway clearance and prevent further lung damage. Encouraging frequent coughing and deep breathing (A) may help clear secretions but may not be as effective as postural drainage. Increasing fluid intake (B) may help liquefy secretions, but without proper clearance, it may not address the underlying issue. Administering antibiotics (C) is important if there is an infection, but it does not directly address the need for sputum clearance in bronchiectasis.

Correct Answer: C

Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). Monitoring aPTT is essential for evaluating the effectiveness of heparin therapy because heparin primarily affects the intrinsic pathway of the coagulation cascade, which is reflected in the aPTT value. By monitoring aPTT levels, the nurse can ensure that the heparin dosage is within the therapeutic range to prevent clot formation without causing excessive bleeding. Platelet count (A) is important to monitor for heparin-induced thrombocytopenia but does not directly evaluate the effectiveness of heparin therapy. Prothrombin time (PT) (B) and International normalized ratio (INR) (D) are used to monitor warfarin therapy, which acts on the extrinsic pathway of the coagulation cascade, not heparin therapy.