Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient?

Correct Answer: A

Rationale: The correct answer is A: Assist patient to cough, turn, and deep breathe every 2 hours. This intervention helps prevent hospital-acquired pneumonia by promoting lung expansion, preventing atelectasis, and improving air exchange. Turning the patient reduces pressure ulcers. Coughing helps clear secretions, reducing the risk of pneumonia. Deep breathing strengthens respiratory muscles. Encouraging frequent movement and deep breathing prevents pooling of secretions in the lungs, which can lead to infection. Choices B, C, and D do not directly address promoting lung expansion and clearing secretions to prevent pneumonia.

Correct Answer: B

Rationale: The correct answer is B: "I should breathe in quickly when using the inhaler." This statement is incorrect because the client should actually breathe in slowly and deeply when using an inhaler to ensure proper medication delivery to the lungs. Breathing in quickly can lead to inadequate medication absorption. Choices A, C, and D are correct statements. A: Shaking the inhaler ensures proper mixing of the medication. C: Rinsing the mouth after using a steroid inhaler helps prevent oral thrush. D: Waiting at least one minute between puffs allows optimal medication delivery.

Correct Answer: B

Rationale: The correct answer is B: Avoid exposure to respiratory irritants. Emphasizing this point is crucial in preventing complications for a client with emphysema because irritants such as smoke, pollution, and dust can worsen respiratory symptoms and exacerbate the condition. By avoiding these triggers, the client can reduce the risk of flare-ups and complications. Other choices are incorrect because: A: Limiting physical activity may lead to deconditioning and weaken respiratory muscles, which can worsen the client's condition. C: Using a humidifier can help with dryness, but it does not address the primary concern of avoiding irritants that can exacerbate emphysema. D: Increasing sodium intake is not directly related to preventing complications in emphysema and can even lead to fluid retention and worsen symptoms.

Correct Answer: B

Rationale: The primary goal of oxygen therapy in pulmonary fibrosis is to reduce the work of breathing. Pulmonary fibrosis causes stiffening and scarring of the lung tissue, making breathing more difficult. Supplemental oxygen helps improve oxygen levels in the blood, reducing the effort required to breathe. This can alleviate symptoms such as shortness of breath and improve the client's quality of life. Explanation of why other choices are incorrect: A: Oxygen therapy does not cure pulmonary fibrosis. It only helps manage symptoms. C: Oxygen therapy does not eliminate the need for medications in pulmonary fibrosis. Medications may still be necessary to manage the underlying condition. D: Oxygen therapy does not aim to prevent respiratory alkalosis in pulmonary fibrosis. It primarily focuses on improving oxygenation and reducing the work of breathing.

Correct Answer: B

Rationale: The correct answer is B: "I will inhale deeply into the device to expand my lungs." This statement indicates correct understanding because using an incentive spirometer involves inhaling deeply to fully expand the lungs, promoting better lung ventilation and preventing complications like pneumonia. Choice A is incorrect because using the device once every few hours may not be frequent enough. Choice C is incorrect because the spirometer should be used proactively, not just when feeling short of breath. Choice D is incorrect because exhaling quickly is not the correct technique for using an incentive spirometer.