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 A
Explanation
Choice A rationale:
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
Choice B rationale:
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
Choice C rationale:
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
Choice D rationale:
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
Correct Answer is A
Explanation
Choice A rationale:
Hemorrhagic stroke is characterized by sudden, severe headache, vomiting, and a significant increase in blood pressure, all of which are present in the client. This type of stroke occurs when a weakened blood vessel ruptures and bleeds into the surrounding brain.
Choice B rationale:
Thrombotic stroke is caused by a clot that develops in a blood vessel within the brain. It typically presents with less severe symptoms and a gradual onset, not a sudden one.
Choice C rationale:
Embolic stroke is caused by a clot that travels to the brain from another part of the body. Like thrombotic stroke, it typically has a more gradual onset.
Choice D rationale:
Transient ischemic attack (TIA) is a temporary blockage of blood flow to the brain. It usually lasts less than an hour and does not cause permanent damage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.