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. Avoid alcohol for the first 3 weeks B. Avoid handling patient's leftover foods C. Have family members get an injection of immunoglobin D. Follow a low-protein, low carbohydrate diet

Correct Answer is B

Explanation

A. Avoid alcohol for the first 3 weeks: Avoiding alcohol may be advisable for patients with hepatitis A to prevent additional strain on the liver. However, it is not specifically related to preventing transmission of the infection to others. Therefore, it is not a transmission measure typically included in discharge instructions for the patient's family.

B. Avoid handling patient's leftover foods: Hepatitis A is primarily transmitted through the fecal-oral route, often via contaminated food or water. By avoiding handling the patient's leftover foods, the risk of transmitting the virus to family members through contaminated food is minimized. This measure helps prevent the spread of infection within the household.

C. Have family members get an injection of immunoglobulin: Immunoglobulin may be administered to individuals who have been exposed to hepatitis A to provide passive immunity and reduce the severity of the illness. However, this measure is typically recommended for individuals who have not been previously vaccinated against hepatitis A and have been in close contact with an infected person, rather than as a general preventive measure for all family members.

D. Follow a low-protein, low carbohydrate diet: While maintaining a healthy diet is important for overall health, there is no specific dietary recommendation related to protein or carbohydrate intake for patients with hepatitis A. Therefore, this measure is not directly related to preventing transmission of the infection to others and would not typically be included in discharge instructions for the patient's family.

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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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