Difficulty: Medium
Average Score: 91%
Simulated
A 72 year-old male patient who is diagnosed with bilateral lower lobe pneumonia is admitted to your unit. The patient has a history of systolic heart failure and arthritis. On assessment, you note the patient has a respiratory rate of 21 , oxygen saturation $93 \%$ on $2 \mathrm{~L}$ nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. Which of the following nursing interventions will you provide to this patient based on your assessment findings and the patient's diagnosis? Select-all-that-apply:
Correct answer
B,D
Rationale
Sputum cultures identify the causative organism, and incentive spirometer use promotes lung expansion. Head-of-bed <30 degrees increases aspiration risk, 3L fluids may overload heart failure patients, and Pneumovax is not annual.