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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:
The length of time the mother has been caring for the baby is not directly relevant to the risk of HIV transmission through breastfeeding. While a longer duration of breastfeeding may increase overall exposure, the primary concern is whether breastfeeding is occurring at all, as it presents a significant transmission route.

Choice B rationale:
Kissing does not typically transmit HIV, as the virus does not survive well outside the body. While there is a very low theoretical risk of transmission if both individuals have open sores or bleeding gums, it's not a primary concern in this scenario.

Choice C rationale:
The timing of the baby's last antibiotic treatment is not directly relevant to the risk of HIV transmission from breastfeeding. Antibiotics do not prevent or treat HIV infection, and their use would not impact the assessment of breastfeeding-related risks.

Choice D rationale:
Breastfeeding is a significant route of HIV transmission from mother to child. If the baby is breastfeeding, it's crucial for the nurse to determine the mother's viral load and CD4 count, assess the baby's HIV status, and provide appropriate counseling and interventions to reduce the risk of transmission. This information is essential for guiding decisions about infant feeding and potential prophylactic measures to protect the baby's health.

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.

View Question and Answer

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

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 mother with a diagnosis of AIDS states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine?

Correct Answer is D

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 on a medical-surgical unit is providing care for a group of clients. Which of the following specimens should the nurse delegate collection of to the assistive personnel (AP)?

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer?

The nurse is caring for a group of patients on a medical surgical unit. Which of the following patients is at most risk for developing gout?

A nurse is caring for a patient with rheumatoid arthritis. The patient is prescribed hydroxychloroquine to slow the progression of the disease. Which of the following laboratory results should the nurse monitor for this patient?

A nurse is assessing a 28-year-old client with HIV who has been admitted with pneumonia. Which of the following observations should the nurse prioritize?

Which of the following is the most reliable early indicator of infection in a client with low WBC?

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

A nurse is discussing gout with a patient who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? Select all that applies.