A nurse is caring for a client with a history of advanced HIV who was admitted with a diagnosis of Pneumocystis jirovecci pneumonia. The nurse should prioritize which nursing care goal?
Assist with passive range of motion exercises.
Monitor the pulse oximetry every two hours.
Encourage 1 liter of fluid intake in 24 hours.
Encourage the client to focus efforts on discharge.
The Correct Answer is B
A. Assist with passive range of motion exercises: While promoting mobility is important for overall well-being, it may not be the priority in a client with Pneumocystis jirovecii pneumonia, which requires respiratory support and oxygenation.
B. Monitor the pulse oximetry every two hours: Monitoring oxygen saturation is crucial in clients with Pneumocystis jirovecii pneumonia to assess respiratory status and the effectiveness of treatment. Hypoxemia is a common complication and requires prompt intervention.
C. Encourage 1 liter of fluid intake in 24 hours: Encouraging adequate fluid intake is important for hydration, but it may not be the priority over monitoring respiratory status in a client with pneumonia.
D. Encourage the client to focus efforts on discharge: Discharge planning is important but should not take precedence over immediate nursing care priorities such as respiratory assessment and monitoring.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Respond to ventilator alarms: Responding to ventilator alarms is important but may not be the priority if the client is not spontaneously breathing.
B. Report the absence of spontaneous respirations: This is the priority action because the absence of spontaneous respirations may indicate inadequate ventilation or respiratory arrest, requiring immediate intervention.
C. Encourage the client to take spontaneous breaths: While encouraging spontaneous breaths is beneficial, it is not appropriate if the client is paralyzed due to neuromuscular blockade.
D. Place the call bell within reach: Ensuring the call bell is within reach is important for communication but may not be the priority if the client is not breathing spontaneously.
Correct Answer is D
Explanation
A. Freshly squeezed orange juice: Orange juice is generally not considered a trigger for gout attacks. However, it is high in fructose, which may contribute to gout if consumed excessively.
B. Milk: Milk is not typically associated with triggering gout attacks and is often recommended as part of a healthy diet for gout.
C. Black Coffee: Coffee, especially black coffee, is generally considered safe for individuals with gout and may even have some protective effects against gout attacks.
D. Sweetened iced tea: Sweetened iced tea is often made with high-fructose corn syrup, which can increase uric acid levels and potentially trigger gout attacks. Therefore, it is important for individuals with gout to limit their intake of sweetened beverages like iced tea.
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