A client with pneumonia has a temperature of 102.6*F (39.2*C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
A. Position changes q4h.
B. Nasotracheal suctioning to clear secretions.
C. Frequent linen changes.
D. Frequent offering of a bedpan.
Correct Answer: C. Frequent linen changes.
Frequent linen changes are appropriate for this client because of diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Adjust and monitor environmental factors like room temperature and bed linens as indicated.
Option A: Position changes need to be done every 2 hours. Room temperature may be accustomed to near normal body temperature and blankets and linens may be adjusted as indicated to regulate temperature of the patient.
Option B: Nasotracheal suctioning is not indicated with the client’s productive cough. Suctioning can cause increased hypoxemia; hyper oxygenate before, during, and after suctioning. Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions.
Option D: Frequent offering of a bedpan is not indicated by the data provided in this scenario. Assist with self-care activities as necessary. Provide for progressive increase in activities during the recovery phase. and demand. Minimizes exhaustion and helps balance oxygen supply and demand.
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