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. Having the primary provider prescribe a CT:
Prescribing a CT scan is not the initial action for assessing nonpalpable pedal pulses. CT scans are typically used for imaging purposes and are not the primary diagnostic tool for assessing peripheral pulses.

B. Apply a tourniquet for 3 to 5 minutes and then reassess:
While applying a tourniquet may increase the visibility of pulses in some cases, it is not the recommended method for assessing pedal pulses, especially if they are nonpalpable. Tourniquet use carries risks, such as tissue damage or ischemia, and is not a standard practice for assessing pulses.

C. Elevate the extremity and attempt to palpate the pulses:
Elevating the extremity may improve blood flow and make pulses easier to palpate, but if the pulses are nonpalpable, simply elevating the extremity may not be sufficient for assessment. Additionally, palpation alone may not accurately detect pulses in some cases.

D. Use the doppler ultrasound to detect pedal pulses:
This is the most appropriate action. Doppler ultrasound is a non-invasive diagnostic tool commonly used to assess peripheral pulses, especially when they are nonpalpable. It uses sound waves to detect blood flow and can provide accurate information about the presence and strength of pedal pulses. Using a doppler ultrasound can help confirm the status of pedal pulses and guide further management.

A. Following proper handwashing and use of masks. B. Avoiding chemicals that are toxic and polluted air. C. Public health education and vaccination. D. Limiting alcohol intake of red and white wine.

Correct Answer is C

Explanation

A. Following proper handwashing and use of masks: While handwashing and wearing masks are important infection control measures, they are not specific to preventing hepatitis B virus (HBV) infection. While HBV can be present in blood and certain body fluids, such as semen and vaginal fluids, the primary modes of transmission are through activities that involve percutaneous or mucosal exposure to infected blood or body fluids, such as unprotected sex, sharing needles, or accidental needlesticks. While hand hygiene and mask use are crucial in healthcare settings to prevent the transmission of various infections, including HBV, they may not offer sufficient protection against HBV transmission in all situations.

B. Avoiding chemicals that are toxic and polluted air: While avoiding toxic chemicals and polluted air is important for overall health and may support liver health indirectly, it is not directly related to preventing HBV infection. HBV is primarily transmitted through exposure to infected blood or body fluids rather than environmental factors such as air pollution or exposure to toxic chemicals.

C. Public health education and vaccination: This is the most appropriate measure for preventing HBV infection. Public health education plays a crucial role in raising awareness about the risks of HBV transmission and promoting behaviors that reduce the risk of exposure, such as safe sex practices, avoiding sharing needles, and seeking medical care for potential exposures. Additionally, vaccination against HBV is highly effective in preventing infection and is recommended for all individuals, particularly those at increased risk of exposure, such as healthcare workers, people with multiple sexual partners, and individuals who inject drugs. Vaccination not only protects vaccinated individuals but also contributes to herd immunity, reducing the overall prevalence of HBV in the population.

D. Limiting alcohol intake of red and white wine: While limiting alcohol intake is important for liver health, particularly in individuals with liver disease, it is not specifically aimed at preventing HBV infection. Excessive alcohol consumption can contribute to liver damage and may exacerbate liver disease in individuals infected with HBV. However, it does not directly address the risk of HBV transmission.

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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

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