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 A
Explanation
A. The combination of fever, tachycardia, decreased urine output, and erythema and warmth at the incision site suggests the possibility of a wound infection.
B. While a urinary tract infection could cause fever and decreased urine output, the presence of erythema and warmth at the incision site suggests a localized wound infection.
C. Respiratory infection may cause fever and tachycardia but would not typically present with erythema and warmth at the incision site.
D. Dehydration may cause decreased urine output but would not typically present with fever and erythema at the incision site.
Correct Answer is D
Explanation
A. While gall bladder surgery carries a risk of infection, having osteoarthritis does not significantly increase the risk compared to other factors listed.
B. Plastic surgery and being overweight may increase the risk of surgical site infections, but age and comorbidities are more significant factors.
C. A fractured wrist may increase the risk of infection at the fracture site, but it is not as significant a risk factor as advanced age and comorbidities.
D. Advanced age, rheumatoid arthritis, foot surgery, and Foley catheter insertion are all factors that increase the risk of infection, making this client the most vulnerable.
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