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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale for Choice A:
Phenytoin is an anticonvulsant medication used to control seizures. It is typically a long-term medication, and abruptly stopping it can lead to breakthrough seizures or worsen existing seizures.
This statement indicates that the client may not understand the importance of taking phenytoin consistently and the potential consequences of discontinuing it without consulting their doctor.

Rationale for Choice B:
Making an appointment with a dentist is important for all individuals, including those with seizure disorders. There is no specific concern related to phenytoin and dental care that would necessitate further teaching in this context.

Rationale for Choice C:
It is important for clients to understand that switching brands of phenytoin might affect its effectiveness due to slight variations in formulation. However, simply stating awareness of this fact does not necessarily indicate a need for further teaching, as the nurse can assess the client's understanding through further questioning.

Rationale for Choice D:
Notifying a doctor before taking any new medications is crucial for individuals with seizures, as some medications can interact with phenytoin and increase the risk of seizures. This statement demonstrates the client's understanding of an important safety precaution.
Therefore, Choice A is the only statement that suggests a potential lack of understanding about the long-term nature of phenytoin treatment and the dangers of discontinuing it without medical supervision. This highlights the need for further education to ensure the client's safety and adherence to the prescribed medication regimen.

A. I will closely follow a high-purine diet B. I will take one aspirin every day C. I will limit my alcohol intake D. I will limit my fluid intake to 1 liter per day

Correct Answer is C

Explanation

Choice A rationale:
A high-purine diet is not recommended for clients with gout. Purines are substances found in certain foods, such as red meat, organ meats, seafood, and beer. When the body breaks down purines, it produces uric acid. Uric acid is a waste product that can build up in the blood and cause gout attacks.
Choice B rationale:
Aspirin is not typically recommended for clients with gout. In fact, aspirin can sometimes worsen gout symptoms by increasing uric acid levels in the blood.
Choice C rationale:
Limiting alcohol intake is a key part of the treatment regimen for gout. Alcohol can increase uric acid levels in the blood and trigger gout attacks.
Choice D rationale:
Limiting fluid intake is not recommended for clients with gout. In fact, it is important for clients with gout to stay well- hydrated to help flush uric acid out of the body.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

Correct Answer is C

Explanation

A nurse is teaching a client who has a new prescription for colchicine to treat gout. Which of the following instructions should the nurse include?

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A client has a prescription for seizure precaution. Which intervention should the nurse include in the plan of care?

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

The nurse is planning education for a patient diagnosed with fibromyalgia. Which risk factors should the nurse include in the teaching plan? (Select all that apply)

The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)