A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?

Monitors the patient's temperature, heart rate, respiratory rate and blood pressure.

Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums.

C Encourages the patient to perform cough, deep breathing, postural drainage every 2 to 4 hours.

Provides nutritional support if patient is unable to take sufficient amounts by mouth.

Answer and Explanation

The Correct Answer is C

A. Monitors the patient's temperature, heart rate, respiratory rate, and blood pressure:
Monitoring vital signs is crucial for assessing the patient's overall condition, including respiratory status. However, while changes in vital signs may indicate respiratory distress, they do not directly address the need to ensure clear breath sounds. This intervention alone does not actively promote airway clearance or improve breath sounds.

B. Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums:
This intervention focuses on reducing the risk of exposure to potential pathogens that could worsen the patient's respiratory condition. While important for infection control, it does not directly address the need to ensure clear breath sounds. Environmental precautions, although necessary, do not actively promote airway clearance or improve breath sounds.

C. Encourages the patient to perform cough, deep breathing, and postural drainage every 2 to 4 hours:
This intervention directly targets promoting airway clearance and improving breath sounds in a patient with pneumonia. Coughing helps mobilize secretions, deep breathing promotes lung expansion and ventilation, and postural drainage assists in the drainage of secretions from different lung segments. Regular performance of these interventions prevents secretion accumulation, thereby improving breath sounds and respiratory function.

D. Provides nutritional support if the patient is unable to take sufficient amounts by mouth:
While nutritional support is important for overall patient care, especially during illness or compromised nutritional intake, it does not directly address the need to ensure clear breath sounds in a patient with pneumonia. Although adequate nutrition supports immune function and overall recovery, it does not directly impact respiratory clearance or breath sounds.

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Correct Answer is B

Explanation

A. Loss of hair over toes:
Loss of hair over the toes is not typically associated with deep vein thrombosis (DVT). Instead, it may be indicative of peripheral arterial disease (PAD) or poor peripheral circulation. In DVT, symptoms are more related to venous congestion and inflammation rather than hair loss.

B. Tenderness in the thigh:
Tenderness in the thigh is a common clinical manifestation of deep vein thrombosis (DVT). It occurs due to the presence of a thrombus within the deep veins of the thigh, causing local inflammation and irritation of the vessel wall. This tenderness may be elicited by palpation along the course of the affected vein.

C. Rest pain:
Rest pain is not typically associated with deep vein thrombosis (DVT). Rest pain is more commonly seen in conditions such as peripheral arterial disease (PAD), where inadequate blood supply to the extremities leads to ischemic pain at rest, especially during periods of reduced blood flow.

D. Auscultation of bruit over pedal pulse:
Auscultation of a bruit over the pedal pulse is not typically associated with deep vein thrombosis (DVT). A bruit is an abnormal sound caused by turbulent blood flow through a narrowed or obstructed vessel, commonly heard in arterial conditions such as atherosclerosis. In DVT, venous obstruction does not typically produce bruits.

A. Diarrhea B. Insomnia C. Urinary retention D. Gum changes

Correct Answer is B

Explanation

A. Diarrhea: Diarrhea is not a common side effect of metoprolol, a beta-blocker medication commonly used to treat hypertension. While gastrointestinal side effects such as nausea or constipation may occur, diarrhea is not typically associated with metoprolol use.

B. Insomnia: Insomnia, or difficulty falling or staying asleep, is a potential side effect of metoprolol. Beta-blockers like metoprolol may interfere with sleep patterns in some individuals, leading to insomnia. It is important for the nurse to assess the patient for changes in sleep patterns while taking metoprolol.

C. Urinary retention: Urinary retention, or the inability to completely empty the bladder, is not a common side effect of metoprolol. In fact, beta-blockers like metoprolol are more likely to cause urinary frequency or urgency rather than retention.

D. Gum changes: Gum changes, such as gingival hyperplasia, are not typically associated with metoprolol use. This side effect is more commonly associated with certain other medications, such as calcium channel blockers or anticonvulsants.

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A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?