A client who has been diagnosed with acquired immunodeficiency syndrome (AIDS) presents with the following signs/symptoms; vital signs are: temperature, 102.8°F; pulse, 88 beats per minute; respirations 26 breaths per minute; blood pressure, 144/76; and oxygen saturation of 85%. The client complains of difficulty breathing, shortness of breath, and a productive cough. The nurse notes crackles bilaterally. The client denies nausea, vomiting, and diarrhea. Based on these findings, the nurse would anticipate which of the following orders? Select all that apply.
prepare the client for chest x-ray
obtain a sputum culture
antibiotic therapy as prescribed
insert a Foley catheter
nasogastric tube to suction for decompression
apply O2 at 2L per nasal cannula as needed
Correct Answer : A,B,C,F
A. The client's signs and symptoms, including crackles on auscultation and difficulty breathing, warrant a chest x-ray to assess for possible pneumonia or other respiratory conditions.
B. Obtaining a sputum culture can help identify the causative organism and guide antibiotic therapy for respiratory infection.
C. Antibiotic therapy is indicated for the treatment of respiratory infection, especially if the sputum culture indicates bacterial involvement.
D. There is no indication for inserting a Foley catheter based on the client's signs and symptoms.
E. Nasogastric tube insertion for decompression is not indicated based on the client's respiratory symptoms.
F. Oxygen therapy is indicated for the client's low oxygen saturation level and respiratory distress. Applying oxygen at 2L per nasal cannula can help improve oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Chemotherapy can cause side effects such as stomatitis and alopecia but is not typically prescribed solely to treat these side effects.
B. While chemotherapy aims to kill cancer cells, complete eradication of all tumor cells in the body is often not achievable.
C. Chemotherapy-induced bone marrow suppression is a potential side effect of treatment and is managed with supportive care measures, but preventing these symptoms is not the primary goal of palliative chemotherapy.
D. Palliative chemotherapy is aimed at providing relief from symptoms caused by cancer, such as pain, fatigue, and other symptoms associated with advanced disease, rather than focusing on cure or tumor eradication.
Correct Answer is C
Explanation
A. While pain is a common symptom associated with inflammation, providing a feedback mechanism for pain identification is not the ultimate purpose of the inflammatory process.
B. The inflammatory process is not primarily aimed at increasing fatty deposits in affected tissue.
C. The ultimate purpose of the inflammatory process is to localize, destroy, and remove injurious agents such as pathogens and damaged cells, thereby preparing the wound for healing.
D. Releasing antigens into the general circulation is not the primary purpose of the inflammatory process.
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