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 B

Explanation

A. Loss of hair over toes:
Loss of hair over the toes is not typically associated with deep vein thrombosis (DVT). Instead, it may be indicative of peripheral arterial disease (PAD) or poor peripheral circulation. In DVT, symptoms are more related to venous congestion and inflammation rather than hair loss.

B. Tenderness in the thigh:
Tenderness in the thigh is a common clinical manifestation of deep vein thrombosis (DVT). It occurs due to the presence of a thrombus within the deep veins of the thigh, causing local inflammation and irritation of the vessel wall. This tenderness may be elicited by palpation along the course of the affected vein.

C. Rest pain:
Rest pain is not typically associated with deep vein thrombosis (DVT). Rest pain is more commonly seen in conditions such as peripheral arterial disease (PAD), where inadequate blood supply to the extremities leads to ischemic pain at rest, especially during periods of reduced blood flow.

D. Auscultation of bruit over pedal pulse:
Auscultation of a bruit over the pedal pulse is not typically associated with deep vein thrombosis (DVT). A bruit is an abnormal sound caused by turbulent blood flow through a narrowed or obstructed vessel, commonly heard in arterial conditions such as atherosclerosis. In DVT, venous obstruction does not typically produce bruits.

A. Apply a heating pad to the lower extremities for pain. B. Always wear sot shoes or slippers when out of bed. C. Wear knee high sight socks D. Put cream or lotion between the toes

Correct Answer is B

Explanation

A. Apply a heating pad to the lower extremities for pain: Heat application can increase vasodilation and worsen symptoms in patients with peripheral arterial disease (PAD). Therefore, it is not recommended as a pain management strategy for PAD.

B. Always wear soft shoes or slippers when out of bed: This instruction is important for patients with PAD to protect their feet from injury and provide adequate support. Soft shoes or slippers help prevent trauma and pressure ulcers, which are common complications in patients with reduced peripheral circulation.

C. Wear knee-high tight socks: Tight socks can restrict blood flow and exacerbate symptoms in patients with PAD. It is important to encourage patients to wear loose-fitting socks to promote adequate circulation.

D. Put cream or lotion between the toes: Moisture between the toes can increase the risk of fungal infections, which can be particularly problematic in patients with compromised circulation. It is important to keep the feet clean and dry and avoid applying cream or lotion between the toes.

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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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