A nurse is caring for a client with a history of advanced HIV who was admitted with a diagnosis of Pneumocystis jirovecci pneumonia. The nurse should prioritize which nursing care goal?

Assist with passive range of motion exercises.

Monitor the pulse oximetry every two hours.

Encourage 1 liter of fluid intake in 24 hours.

Encourage the client to focus efforts on discharge.

Answer and Explanation

The Correct Answer is B

A. Assist with passive range of motion exercises: While promoting mobility is important for overall well-being, it may not be the priority in a client with Pneumocystis jirovecii pneumonia, which requires respiratory support and oxygenation.

B. Monitor the pulse oximetry every two hours: Monitoring oxygen saturation is crucial in clients with Pneumocystis jirovecii pneumonia to assess respiratory status and the effectiveness of treatment. Hypoxemia is a common complication and requires prompt intervention.

C. Encourage 1 liter of fluid intake in 24 hours: Encouraging adequate fluid intake is important for hydration, but it may not be the priority over monitoring respiratory status in a client with pneumonia.

D. Encourage the client to focus efforts on discharge: Discharge planning is important but should not take precedence over immediate nursing care priorities such as respiratory assessment and monitoring.

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Correct Answer is C

Explanation

A. Joint contractures: Joint contractures are a common manifestation of systemic scleroderma, but they are not directly related to altered tissue perfusion. They are more related to skin and tissue fibrosis.

B. Peripheral arterial dilation: Peripheral arterial dilation is not typically associated with systemic scleroderma. Instead, peripheral vasoconstriction, such as in Raynaud's phenomenon, is more common.

C. Raynaud's phenomenon: Raynaud's phenomenon, characterized by episodic vasospasm of small arteries in response to cold or stress, can lead to impaired tissue perfusion, especially in the extremities.

D. Pulmonary fibrosis: Pulmonary fibrosis is a complication of systemic scleroderma that affects lung tissue, but it is not directly related to altered tissue perfusion. It may lead to impaired gas exchange rather than altered perfusion.

A. Isolation gown B. Contact isolation C. Standard precautions D. Respiratory isolation

Correct Answer is C

Explanation

A. Isolation gown: Isolation gowns are used as part of contact precautions or airborne precautions for specific infectious diseases that require additional transmission-based precautions beyond standard precautions. However, standard precautions are generally sufficient for caring for clients with HIV receiving antiretroviral therapy.

B. Contact isolation: Contact isolation is used for patients with known or suspected infections that can be transmitted by direct or indirect contact with the patient or their environment. HIV does not require contact isolation unless there are additional infections or conditions present that warrant contact precautions.
C. Standard precautions: Standard precautions are the basic infection prevention practices that apply to all patient care, regardless of the suspected or confirmed infection status of the patient. This includes practices such as hand hygiene, the use of personal protective equipment (e.g., gloves, gown, mask, eye protection) when indicated, and safe injection practices. Standard precautions should be used for all patients, including those with HIV, to prevent the transmission of infectious agents.
D. Respiratory isolation: Respiratory isolation is used for patients with known or suspected respiratory infections that are transmitted through respiratory droplets. HIV is not transmitted through respiratory droplets and does not require respiratory isolation.

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A nurse is caring for a client with a history of advanced HIV who was admitted with a diagnosis of Pneumocystis jirovecci pneumonia. The nurse should prioritize which nursing care goal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client diagnosed with systemic scleroderma. The nurse recognizes that an appropriate nursing diagnosis for systemic scleroderma is altered tissue perfusion secondary to which of the following?

Correct Answer is C

Explanation

A nurse is providing direction to a nursing assistant who will be caring for a client with human immunodeficiency virus (HIV) and receiving azidothymidine (AZT) antiretroviral therapy. The nurse should instruct the nursing assistant to implement which of the following actions?

Correct Answer is C

Explanation

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