A nurse is assessing a 28-year-old client with HIV who has been admitted with pneumonia. Which of the following observations should the nurse prioritize?
Tachypnea and restlessness
Weight loss of 1 pound since yesterday
Frequent loose stools
Oral temperature of 100°F
The Correct Answer is A
Rationale for Choice A:
Tachypnea and restlessness are common signs of respiratory distress, which is a potential complication of pneumonia. These signs indicate that the client's oxygenation may be compromised and require immediate attention.
Rationale for Choice B:
Weight loss of 1 pound since yesterday is a non-specific finding and could be due to a variety of factors, including poor appetite, dehydration, or muscle wasting. While weight loss can be a symptom of HIV infection, it is not an acute sign that requires immediate prioritization in this case.
Rationale for Choice C:
Frequent loose stools can be a symptom of HIV infection or a side effect of certain medications. However, it is not an acute sign that requires immediate prioritization in this case, especially in the context of the client's respiratory distress.
Rationale for Choice D:
An oral temperature of 100°F is a low-grade fever and is not a specific indicator of any serious condition. While fever can be a symptom of pneumonia, it is not the most concerning finding in this case.
Therefore, based on the client's presenting symptoms, tachypnea and restlessness are the most concerning findings and should be prioritized by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Coughing and deep breathing: These techniques directly promote airway clearance by mobilizing and expelling secretions from the lungs. They are essential for clients with pneumonia, as the buildup of secretions can obstruct the airways and impair gas exchange.
Hydration maintenance: Adequate hydration helps to thin secretions, making them easier to cough up and clear from the lungs. It also helps to prevent dehydration, which can worsen respiratory symptoms.
Choice B rationale:
Keeping the head of the bed elevated: This can help to improve breathing by decreasing the work of breathing and promoting lung expansion. However, it is not the most effective intervention for directly clearing secretions from the lungs.
Choice C rationale:
Preparation for insertion of a tracheostomy tube: This is a more invasive intervention that may be necessary in severe cases of airway obstruction. However, it is not the priority intervention for a client with ineffective airway clearance related to pneumonia.
Choice D rationale:
Providing supplemental oxygen: This can help to improve oxygenation in clients with pneumonia. However, it does not directly address the problem of ineffective airway clearance.
Correct Answer is A
Explanation
Choice A rationale:
Protecting the airway is the highest priority during a tonic-clonic seizure. Tonic-clonic seizures involve intense muscle contractions, which can lead to biting the tongue, aspiration of secretions, or even respiratory arrest if the airway is obstructed. Turning the client's head to the side helps to maintain a clear airway and prevent these complications.
It is essential to act quickly to prevent injury and ensure adequate oxygenation. Delaying airway management could have serious consequences.
Choice B rationale:
Checking motor strength is not a priority during the active phase of a seizure. It is more important to focus on protecting the airway and preventing injury.
Motor strength can be assessed after the seizure has subsided.
Choice C rationale:
Loosening clothing around the waist may be helpful to promote comfort and breathing, but it is not the first priority. It is more important to address the airway and prevent aspiration.
Choice D rationale:
Documenting the time the seizure began is important for accurate record-keeping and assessment of seizure patterns, but it is not the first priority in the immediate management of the seizure. Documentation can be done after the client's airway and safety are ensured.
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