What intervention should the nurse identify as a priority for a client with a nursing diagnosis of ineffective airway clearance related to HIV related pneumonia?
Coughing and deep breathing and hydration maintenance
Keep the head of the bed elevated
Preparation for insertion of a tracheostomy tube
Provide supplemental oxygen
The Correct Answer is A
Choice A rationale:
Coughing and deep breathing are essential for mobilizing and removing secretions from the airways, which is crucial for improving airway clearance in patients with pneumonia. These techniques help to loosen mucus and bring it up from the lungs, allowing it to be expelled through coughing.
Hydration maintenance is also critical because it helps to thin secretions, making them easier to cough up. Adequate hydration helps to keep mucus moist and less sticky, which promotes easier expectoration.
Choice B rationale:
Keeping the head of the bed elevated can help to improve oxygenation and reduce the work of breathing, but it does not directly address the issue of airway clearance. It may be a helpful adjunct intervention, but it's not the priority for this specific nursing diagnosis.
Choice C rationale:
Preparation for insertion of a tracheostomy tube is a more invasive intervention that may be necessary in severe cases of airway obstruction, but it is not the first-line intervention for ineffective airway clearance related to pneumonia. It would be considered if other measures fail to maintain adequate ventilation.
Choice D rationale:
Providing supplemental oxygen can help to improve oxygenation in patients with pneumonia, but it does not directly address the issue of airway clearance. It's important to support oxygenation, but it's not the primary intervention to clear secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Step 1: Determine the desired dose in mL.
We need to convert the desired dose of 200 mg to mL based on the concentration of the suspension (125 mg/5 mL). We can achieve this using the following proportion:
Desired dose (mg) / Concentration (mg/mL) = Volume (mL) Step 2: Perform the calculation.
Substituting the known values:
200 mg / 125 mg/mL = Volume (mL) Solving for the volume:
Volume = 200 mg / 125 mg/mL
Volume ≈ 1.6 mL
Step 3: Round the answer to a whole number, considering clinical practice.
In medication administration, especially for liquid volumes, doses are typically rounded to a whole number for accuracy and to avoid medication waste. Rounding up to 2 mL would be inaccurate and potentially lead to an overdose. Therefore, we round down to the nearest whole number, which is 1 mL.
Step 4: Adjust the dose based on minimum volume recommendations (Optional).
Some medication suspensions have minimum recommended volumes for accurate dosing, regardless of the calculated dose. Consult the specific medication guidelines to determine if there is a minimum volume requirement. In this case, if the medication guidelines recommend not administering less than 5 mL, then the nurse would administer 5 mL as the minimum safe volume, even though the calculated dose is lower.
Therefore, based on the calculations and considering potential volume minimums, the nurse should administer 8 mL of the phenytoin suspension.
Correct Answer is A
Explanation
Rationale for Choice A:
Tachypnea and restlessness are common signs of respiratory distress, which is a potential complication of pneumonia. These signs indicate that the client's oxygenation may be compromised and require immediate attention.
Rationale for Choice B:
Weight loss of 1 pound since yesterday is a non-specific finding and could be due to a variety of factors, including poor appetite, dehydration, or muscle wasting. While weight loss can be a symptom of HIV infection, it is not an acute sign that requires immediate prioritization in this case.
Rationale for Choice C:
Frequent loose stools can be a symptom of HIV infection or a side effect of certain medications. However, it is not an acute sign that requires immediate prioritization in this case, especially in the context of the client's respiratory distress.
Rationale for Choice D:
An oral temperature of 100°F is a low-grade fever and is not a specific indicator of any serious condition. While fever can be a symptom of pneumonia, it is not the most concerning finding in this case.
Therefore, based on the client's presenting symptoms, tachypnea and restlessness are the most concerning findings and should be prioritized by the nurse.
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