A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia.
Which of the following actions should the nurse take?
Obtain a sputum culture.
Position head of bed at 10 degrees.
Cough and deep breathe every 8 hr.
Encourage fluid intake of 1500 mL/day.
The Correct Answer is A
Choice A rationale:
Obtaining a sputum culture helps identify the causative organism and guide treatment.
Choice B rationale:
Positioning the head of bed at 10 degrees is not beneficial for pneumonia patients.
Choice C rationale:
Coughing and deep breathing every 8 hours is not frequent enough for pneumonia patients.
Choice D rationale:
Encouraging fluid intake of 1500 mL/day is not sufficient for pneumonia patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Cataract extraction is a minor procedure and does not pose a significant risk for DVT.
Choice B rationale:
Myringotomy, a procedure to drain fluid from the middle ear, also does not significantly increase DVT risk.
Choice C rationale:
Laparoscopic appendectomy, while more invasive, still carries a lower DVT risk compared to major orthopedic surgeries.
Choice D rationale:
Hip arthroplasty, a major orthopedic surgery, poses a high risk for DVT due to prolonged immobility and venous stasis.
Correct Answer is A
Explanation
Choice A rationale:
Airway obstruction is the immediate life-threatening risk due to swelling and blistering in the airway.
Choice B rationale:
Paralytic ileus is a potential complication, but it is not the immediate priority.
Choice C rationale:
Infection is a risk due to loss of skin integrity, but it is not the immediate priority.
Choice D rationale:
Fluid imbalance is a risk due to fluid loss from the burns, but airway management is the immediate priority.
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