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?

Tachypnea and restlessness

Weight loss of 1 pound since yesterday

Frequent loose stools

Oral temperature of 100°F

Answer and Explanation

The Correct Answer is A

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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Correct Answer is ["033"]

Explanation

Step 1 is to calculate the number of milliliters (mL) that contain the ordered dose of 300 mg of clindamycin.

Step 2 is to divide the total milliliters (mL) from Step 1 by the infusion time in minutes to get the flow rate in mL/hour. Here are the calculations:

Step 1:

900 mg of clindamycin is in 50 mL.

To find the mL that contain 300 mg, set up a proportion:

(300 mg / 900 mg) = (x mL / 50 mL) Cross-multiply and solve for x:

x = (300 mg * 50 mL) / 900 mg x = 16.67 mL

Step 2:

The infusion time is 30 minutes.

Divide the total mL (16.67 mL) by the infusion time in hours to get the flow rate in mL/hour: Flow rate = 16.67 mL / (30 minutes / 60 minutes/hour)

Flow rate = 33.33 mL/hour

Round to the nearest whole number, using a leading zero if it applies, and no trailing zero: Flow rate = 033 mL/hour

A. Serum creatinine B. Serum sodium C. Blood urea nitrogen (BUN) D. Urine-specific gravity

Correct Answer is A

Explanation

Choice A rationale:
Serum creatinine is a waste product that is produced by muscle metabolism and is normally excreted by the kidneys.
When kidney function is impaired, creatinine levels in the blood increase, making it a sensitive and specific indicator of renal function.
It is considered one of the most reliable markers for assessing kidney function and is routinely used to screen for and monitor kidney disease.

Choice B rationale:
Serum sodium is an electrolyte that is regulated by the kidneys, but it is not a direct measure of renal function. Sodium levels can be affected by various factors, including fluid intake, medications, and hormonal imbalances.
While abnormal sodium levels can sometimes be a sign of kidney dysfunction, they can also occur due to other conditions, making it less specific as an indicator of renal function.
Choice C rationale:

Blood urea nitrogen (BUN) is another waste product that is produced by the breakdown of proteins and is normally excreted by the kidneys.
However, BUN levels can be influenced by factors other than kidney function, such as dietary protein intake, dehydration, and gastrointestinal bleeding.
This makes BUN less specific than serum creatinine as a marker of renal function.

Choice D rationale:
Urine-specific gravity measures the concentration of solutes in urine, which can provide some information about kidney function.
However, it is not as sensitive or specific as serum creatinine.
Urine-specific gravity can be affected by factors such as fluid intake and hydration status, which can make it less reliable as an indicator of renal function.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["033"]

Explanation

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