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 D

Explanation

A. Urinary retention: While urinary retention can occur in conditions such as benign prostatic hyperplasia or neurogenic bladder, it is not a typical manifestation of hypertensive emergency. Hypertensive emergencies primarily involve acute and severe elevations in blood pressure, which can lead to target organ damage, but urinary retention is not a direct consequence.

B. Headache: Headache is a common symptom associated with hypertension, especially during hypertensive emergencies. However, it is not specific to hypertensive emergencies and can occur in less severe cases of hypertension as well.

C. Jaundice: Jaundice is not a typical manifestation of hypertensive emergency. It is more commonly associated with liver dysfunction or hemolytic disorders rather than acute elevations in blood pressure.

D. Tachycardia: Tachycardia, or an elevated heart rate, is a hallmark sign of hypertensive emergency. When blood pressure rises significantly, the heart may respond by increasing its rate to maintain cardiac output. Tachycardia is indicative of the body's compensatory mechanisms in response to the acute hypertension and can be a sign of impending cardiovascular complications.

A. A "Warfarin takes several days to work, so the heparin will be used until the warfarin reaches a therapeutic level." B. "The heparin increases the effects of the warfarin and decreases the length of your hospital stay." C. "I will call the provider to discontinue the heparin." D. "Both medications work together to dissolve the clots."

Correct Answer is A

Explanation

A. "Warfarin takes several days to work, so the heparin will be used until the warfarin reaches a therapeutic level":
This response is correct because warfarin, an oral anticoagulant, takes several days to reach its full therapeutic effect due to its mechanism of action on vitamin K-dependent clotting factors. Therefore, heparin, which has an immediate onset of action, is used concurrently to prevent new clot formation until warfarin reaches therapeutic levels. Once warfarin reaches its therapeutic range, heparin is typically discontinued.

B. "The heparin increases the effects of the warfarin and decreases the length of your hospital stay":
This statement is incorrect. While heparin and warfarin both act as anticoagulants, they have different mechanisms of action. Heparin works rapidly by inhibiting thrombin, while warfarin acts more slowly by inhibiting vitamin K-dependent clotting factors. The concurrent use of heparin and warfarin is not to increase the effects of warfarin but rather to bridge the gap until warfarin reaches therapeutic levels.

C. "I will call the provider to discontinue the heparin":
Discontinuing heparin without a clear order from the provider could be inappropriate and potentially dangerous. Abrupt discontinuation of heparin before warfarin reaches therapeutic levels could increase the risk of thrombus formation or embolization. The decision to discontinue heparin should be made by the provider based on the patient's individual clinical status and response to therapy.

D. "Both medications work together to dissolve the clots":
While both heparin and warfarin are anticoagulants used to prevent further clot formation and propagation, they do not directly dissolve existing clots. Instead, they prevent the formation of new clots and allow the body's natural fibrinolytic system to gradually break down existing clots. Therefore, this statement is not entirely accurate in describing the mechanism of action of these medications.

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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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Explanation

Correct Answer is A

Explanation

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