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. "Weigh yourself after breakfast every morning": Hydrochlorothiazide, a diuretic, can lead to fluid and electrolyte imbalances, including hyponatremia and hypokalemia. Monitoring weight daily, particularly after breakfast, helps detect any sudden weight changes that could indicate fluid retention or loss, allowing for timely intervention.

B. "Check your blood pressure anytime during the day": While monitoring blood pressure regularly is important for patients with hypertension, it is not a specific safety precaution related to taking hydrochlorothiazide. Blood pressure monitoring may be recommended, but it is not the primary safety precaution associated with this medication.

C. "Call the primary care provider if you experience any seizures": Seizures are not a common side effect of hydrochlorothiazide. Therefore, while it is important for patients to report any unusual symptoms to their healthcare provider, seizures are not specifically associated with this medication.

D. "Exercise at least twice a week": While regular exercise is beneficial for overall health, it is not a specific safety precaution related to taking hydrochlorothiazide. However, lifestyle modifications such as diet and exercise may complement medication therapy in managing hypertension.

A. Using appropriate personal protective equipment (PPE). B. Placing patient in positive pressure isolation room C. Placing patient in contact precautions D. Wearing gloves at all times.

Correct Answer is A

Explanation

A. Using appropriate personal protective equipment (PPE): Standard precautions include the use of PPE such as gloves, masks, gowns, and eye protection when caring for all patients, regardless of their known or suspected infectious status. This helps prevent the transmission of pathogens between the patient and the healthcare provider.

B. Placing patient in positive pressure isolation room: Placing a patient in a positive pressure isolation room is not a component of standard precautions. Positive pressure rooms are typically used for patients with compromised immune systems to protect them from exposure to airborne pathogens. Standard precautions should be followed regardless of the patient's room type.

C. Placing patient in contact precautions: Contact precautions involve specific measures to prevent the transmission of pathogens through direct or indirect contact with the patient or their environment. While contact precautions may be necessary for certain infectious diseases, they are not a component of standard precautions.

D. Wearing gloves at all times: While wearing gloves is part of standard precautions, it is not the only key element. Standard precautions also include other forms of PPE such as masks, gowns, and eye protection, as well as other infection control practices such as hand hygiene and environmental cleaning.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

The nurse is applying standard precautions in the care of a patient who has a history of human immunodeficiency virus. What key element of standard precaution?

Correct Answer is A

Explanation

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