Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient?
a. Discontinue the humidification delivery device to keep excess fluid from lungs.
b. Monitor oxygen saturation, and frequently auscultate lung bases.
c. Assist the patient to cough, turn, and deep breathe every 2 hours.
d. Decrease fluid intake to 300 mL a shift.
ANS: C
The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Humidification thins respiratory secretions, making them easier to expel and should be used. Monitoring oxygen status is important but is not a method of prevention. Hydration assists in preventing hospital-acquired pneumonia. The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 mL/day unless contraindicated by cardiac or renal status. Restricting fluids is contraindicated in this situation since there is no data indicating cardiac or renal disease.
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