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 B

Explanation

A. Respond to ventilator alarms: Responding to ventilator alarms is important but may not be the priority if the client is not spontaneously breathing.

B. Report the absence of spontaneous respirations: This is the priority action because the absence of spontaneous respirations may indicate inadequate ventilation or respiratory arrest, requiring immediate intervention.

C. Encourage the client to take spontaneous breaths: While encouraging spontaneous breaths is beneficial, it is not appropriate if the client is paralyzed due to neuromuscular blockade.

D. Place the call bell within reach: Ensuring the call bell is within reach is important for communication but may not be the priority if the client is not breathing spontaneously.

A. The client has a history of bronchial asthma. B. The client has a history of migraine headaches. C. The client has a history of hypertension. D. The client has a history of hypothyroidism.

Correct Answer is A

Explanation

A. The client has a history of bronchial asthma: Propranolol is a non-selective beta-blocker and can potentially exacerbate bronchospasm in individuals with asthma due to its beta-blocking effects on beta-2 receptors in the bronchioles. Therefore, this finding should be reported to the provider for further assessment and consideration of alternative medications.

B. The client has a history of migraine headaches: Propranolol is commonly used prophylactically to prevent migraine headaches, so this finding is not a contraindication for its use and does not require immediate reporting to the provider.

C. The client has a history of hypertension: Propranolol is often prescribed for hypertension, so this finding is expected and not a cause for concern.

D. The client has a history of hypothyroidism: While propranolol can affect thyroid function tests, a history of hypothyroidism alone is not a contraindication for its use, and it does not

require immediate reporting to the provider. However, thyroid function should be monitored during therapy.

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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 caring for a client on a mechanical ventilator receiving a neuromuscular blockade agent. The nurse should prioritize which action?

Correct Answer is B

Explanation

A nurse is reviewing the health history of a client diagnosed with angina pectoris and has a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the client's health history should the nurse report to the provider?

Correct Answer is A

Explanation

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