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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Infusion rate (mL/hr) = 100/30 × 60
Infusion rate (mL/hr) = 100/30 × 60 = 200
Therefore, the nurse should set the IV pump to deliver 200 mL/hr.
Correct Answer is C
Explanation
A. A 29-year-old female who reports drinking a glass of wine with dinner: While excessive alcohol consumption can contribute to hypertension, moderate alcohol intake, such as drinking a glass of wine with dinner, is not typically a significant risk factor for hypertension in the absence of other contributing factors. Therefore, this individual may not be considered at high risk for hypertension solely based on this information.
B. A 35-year-old male who works 50 hours a week: While chronic stress from long work hours can potentially contribute to hypertension, working 50 hours a week alone may not be sufficient to significantly increase the risk of hypertension, especially in the absence of other significant risk factors. Therefore, this individual may not be considered at high risk for hypertension solely based on this information.
C. A 50-year-old male who reports smoking 2 packs of cigarettes a day: Smoking is a significant risk factor for hypertension. Nicotine in cigarettes can cause blood vessels to narrow, leading to increased blood pressure. Smoking also damages blood vessel walls, making them more susceptible to plaque buildup and narrowing, further increasing the risk of hypertension. Therefore, this individual is at high risk for hypertension due to their smoking habit.
D. A 30-year-old female with a family history of diabetes mellitus: While a family history of diabetes mellitus may increase the risk of developing hypertension due to shared risk factors such as obesity and unhealthy lifestyle habits, it is not as directly associated with hypertension as smoking. Additionally, the individual's age and family history alone may not be sufficient to determine a significant risk for hypertension without additional information about lifestyle and other risk factors.
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