A client who has been diagnosed with acquired immunodeficiency syndrome (AIDS) presents with the following signs/symptoms; vital signs are: temperature, 102.8°F; pulse, 88 beats per minute; respirations 26 breaths per minute; blood pressure, 144/76; and oxygen saturation of 85%. The client complains of difficulty breathing, shortness of breath, and a productive cough. The nurse notes crackles bilaterally. The client denies nausea, vomiting, and diarrhea. Based on these findings, the nurse would anticipate which of the following orders? Select all that apply.
prepare the client for chest x-ray
obtain a sputum culture
antibiotic therapy as prescribed
insert a Foley catheter
nasogastric tube to suction for decompression
apply O2 at 2L per nasal cannula as needed
Correct Answer : A,B,C,F
A. The client's signs and symptoms, including crackles on auscultation and difficulty breathing, warrant a chest x-ray to assess for possible pneumonia or other respiratory conditions.
B. Obtaining a sputum culture can help identify the causative organism and guide antibiotic therapy for respiratory infection.
C. Antibiotic therapy is indicated for the treatment of respiratory infection, especially if the sputum culture indicates bacterial involvement.
D. There is no indication for inserting a Foley catheter based on the client's signs and symptoms.
E. Nasogastric tube insertion for decompression is not indicated based on the client's respiratory symptoms.
F. Oxygen therapy is indicated for the client's low oxygen saturation level and respiratory distress. Applying oxygen at 2L per nasal cannula can help improve oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Staphylococcus aureus is often susceptible to antibiotics, so supportive interventions without antibiotics would not be appropriate.
B. The most appropriate action for treating an infection caused by Staphylococcus aureus would be to administer an antibiotic to which the organism is sensitive.
C. While wound irrigation may be part of the treatment plan for wound infections, using a hypotonic solution to wash out elevated electrolytes is not specifically indicated for Staphylococcus aureus infections.
D. Applying cold to the wound site would not be the primary treatment for a wound infection caused by Staphylococcus aureus. Antibiotic therapy is necessary to address the bacterial infection.
Correct Answer is B
Explanation
A. HEPA filtration is not typically required for clients on droplet precautions.
B. Droplet precautions require healthcare workers to wear a mask when providing care to prevent the transmission of respiratory droplets.
C. Gowns are not typically required for clients on droplet precautions unless there is potential for contact with body fluids.
D. Negative airflow is not specifically indicated for clients on droplet precautions; it is more commonly associated with airborne precautions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.