A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?

Monitors the patient's temperature, heart rate, respiratory rate and blood pressure.

Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums.

C Encourages the patient to perform cough, deep breathing, postural drainage every 2 to 4 hours.

Provides nutritional support if patient is unable to take sufficient amounts by mouth.

Answer and Explanation

The Correct Answer is C

A. Monitors the patient's temperature, heart rate, respiratory rate, and blood pressure:
Monitoring vital signs is crucial for assessing the patient's overall condition, including respiratory status. However, while changes in vital signs may indicate respiratory distress, they do not directly address the need to ensure clear breath sounds. This intervention alone does not actively promote airway clearance or improve breath sounds.

B. Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums:
This intervention focuses on reducing the risk of exposure to potential pathogens that could worsen the patient's respiratory condition. While important for infection control, it does not directly address the need to ensure clear breath sounds. Environmental precautions, although necessary, do not actively promote airway clearance or improve breath sounds.

C. Encourages the patient to perform cough, deep breathing, and postural drainage every 2 to 4 hours:
This intervention directly targets promoting airway clearance and improving breath sounds in a patient with pneumonia. Coughing helps mobilize secretions, deep breathing promotes lung expansion and ventilation, and postural drainage assists in the drainage of secretions from different lung segments. Regular performance of these interventions prevents secretion accumulation, thereby improving breath sounds and respiratory function.

D. Provides nutritional support if the patient is unable to take sufficient amounts by mouth:
While nutritional support is important for overall patient care, especially during illness or compromised nutritional intake, it does not directly address the need to ensure clear breath sounds in a patient with pneumonia. Although adequate nutrition supports immune function and overall recovery, it does not directly impact respiratory clearance or breath sounds.

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Correct Answer is A

Explanation

A. Review serum electrolytes: Muscle cramps can be associated with electrolyte imbalances, such as hypokalemia (low potassium levels), which can occur as a side effect of ARB medications. Therefore, reviewing the patient's serum electrolyte levels, including potassium, can help identify any abnormalities that may be contributing to the muscle cramps. If hypokalemia is present, appropriate interventions such as potassium supplementation or adjustment of the ARB dosage may be necessary to alleviate the muscle cramps.

B. Request the patient's food diary: While assessing the patient's food diary may provide information about their dietary habits and potential factors contributing to muscle cramps (such as dehydration or inadequate nutrient intake), it may not directly address the potential electrolyte imbalance associated with ARB use. Therefore, while obtaining a food diary may be relevant, it is not the priority action in this scenario.

C. Place the patient on bed rest: Placing the patient on bed rest is not indicated solely based on complaints of muscle cramps. Muscle cramps can have various causes, and restricting the patient's activity may not address the underlying issue. Additionally, bed rest could lead to other complications such as deconditioning or venous thromboembolism, which are not warranted in this situation.

D. Observing vital signs: While monitoring vital signs is a routine nursing intervention, it may not directly address the patient's complaint of muscle cramps. Vital signs may be relevant in assessing overall health status, but they may not provide specific information about the cause of muscle cramps or guide appropriate interventions.

A. Continue to administer the metoprolol tartrate as ordered. B. Ask the patient if her pulse is within the normal range C. Hold the medication and call the provider D. Ask the patient to eat salty foods

Correct Answer is C

Explanation

A. Continue to administer the metoprolol tartrate as ordered:
Metoprolol is a beta-blocker commonly used to treat hypertension, angina, and heart failure. One of its main effects is to decrease heart rate and blood pressure. In this scenario, the patient's vital signs reveal a low heart rate (48 bpm) and relatively low blood pressure (100/50 mmHg). Given that metoprolol can further reduce heart rate and blood pressure, it would be prudent for the nurse to withhold the medication until further assessment is conducted.

B. Ask the patient if her pulse is within the normal range:
While it's essential to assess the patient's understanding of her condition, asking if her pulse is within the normal range is not sufficient. The nurse should perform a more thorough assessment and consider the clinical significance of the vital signs obtained. In this case, a heart rate of 48 bpm is lower than the typical normal range for adults (60-100 bpm), indicating bradycardia, which may be symptomatic or concerning in the context of administering a beta-blocker like metoprolol.

C. Hold the medication and call the provider:
Given the patient's low heart rate (bradycardia) and relatively low blood pressure, holding the metoprolol tartrate and contacting the healthcare provider is the most appropriate action. Bradycardia and hypotension can be signs of excessive beta-blockade, especially with medications like metoprolol, which can further lower heart rate and blood pressure. The nurse should notify the provider promptly to discuss the patient's condition and determine the appropriate course of action.

D. Ask the patient to eat salty foods:
Encouraging the patient to eat salty foods would not address the underlying issue of bradycardia and hypotension. While increasing salt intake may help raise blood pressure in some cases, it is not a standard intervention for managing symptomatic bradycardia or low blood pressure caused by medication effects.

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A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?

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Naxlex Comprehensive Predictor Exams

A patient taking an angiotensin receptor blocker (AR) to control blood pressure is now complaining of muscle cramps which action will the nurse implement?

Correct Answer is A

Explanation

The nurse takes a patient's vital signs prior to giving metoprolol tartrate and obtains the following results: T 98 degrees F, P 48, R 16 bpm, BP 100/50 and a pulse oximeter of 98%. What action will the nurse take?

Correct Answer is C

Explanation

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