The practical nurse (PN) knows that AIDS is a viral infection that compromises the effectiveness of the immune system. Which component of the immune system is characteristically affected?

Choice A reason: Demonstrating the use of an incentive spirometer is a valuable intervention for encouraging deep breathing and preventing atelectasis. However, in the context of a client with absent breath sounds on one side, the priority is to monitor for signs of respiratory distress or complications such as a pneumothorax. While using an incentive spirometer may be beneficial in other scenarios, it is not the immediate priority in this case.
Choice B reason: Monitoring the client for increasing respiratory distress is the most critical action to take. The absence of breath sounds on the left side could indicate a serious complication such as a pneumothorax, hemothorax, or other issues that can compromise respiratory function. By closely monitoring the client, the practical nurse can detect signs of worsening condition, such as increased work of breathing, cyanosis, or changes in vital signs, and provide timely intervention or support while awaiting the healthcare provider's arrival.
Choice C reason: Administering a PRN dose of a diuretic medication is not appropriate in this context. Diuretics are used to manage fluid balance and treat conditions such as heart failure or hypertension but are not relevant for addressing the immediate concern of absent breath sounds and potential respiratory distress. The focus should remain on monitoring the client's respiratory status and ensuring appropriate interventions are available if needed.
Choice D reason: Encouraging the client to use pursed-lip breathing can be beneficial for clients experiencing shortness of breath or for managing chronic obstructive pulmonary disease (COPD). However, in the case of absent breath sounds on one side, it is more important to monitor for signs of respiratory compromise and ensure the client receives prompt medical evaluation and intervention. Pursed-lip breathing is not the immediate priority in this scenario.

Choice A reason: Reinforcing the expected outcomes of surgery is important in the preoperative phase to ensure the client understands the procedure, risks, and expected results. However, once the IV sedative has been administered, the client may be in a sedated state and may not be able to retain this information effectively. Therefore, this action is more appropriate before administering the sedative rather than after. The focus should shift to monitoring the client's vital signs and ensuring their safety.
Choice B reason: Determining if the client needs to void is generally part of the preoperative preparations to ensure that the bladder is empty, reducing the risk of complications during the procedure. While it is important, this step should be completed before administering the sedative to ensure the client is alert and able to communicate their needs. Once sedated, the client’s immediate needs should focus on their vital signs and overall stability.
Choice C reason: Auscultating all lung fields is a valuable assessment to ensure the client has clear airways and adequate ventilation. However, once the client is sedated, continuous monitoring of vital signs, including respiration, is more critical. Auscultating lung fields might be appropriate before the procedure to establish a baseline, but it is not the immediate priority after administering sedation.
Choice D reason: Monitoring blood pressure is the most crucial action to implement after administering the IV sedative. Sedatives can cause changes in cardiovascular stability, including hypotension or hypertension. Continuous monitoring of blood pressure helps detect any adverse effects of the sedation and ensures prompt intervention if necessary. Maintaining stable blood pressure is vital for the safety and well-being of the client during and after the procedure.