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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Prolonged P-R interval: A prolonged P-R interval may indicate an atrioventricular (AV) block or conduction delay, but it is not specifically associated with hyperkalemia.
B. Peaked T waves: Peaked T waves are a classic EKG finding in hyperkalemia. Hyperkalemia can affect cardiac repolarization, leading to tall, peaked T waves on the EKG.
C. Elevated ST segment: An elevated ST segment may indicate myocardial injury or ischemia but is not typically associated with hyperkalemia.
D. Inverted P wave: An inverted P wave may indicate atrial enlargement or conduction abnormalities but is not specifically associated with hyperkalemia.
Correct Answer is A
Explanation
A. "High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis." Chronic renal disease often develops as a complication of long-standing
hypertension. Persistent high blood pressure can damage the small blood vessels in the kidneys, reducing blood flow and causing kidney tissue damage over time.
B. "Thickening of the kidney structures and gradual death of nephrons has caused this diagnosis." This statement describes changes seen in conditions like diabetic nephropathy but is not specific to the development of renal disease in hypertension.
C. "Cysts compress renal tissue, which destroys the kidneys, causing this diagnosis." This statement describes the pathogenesis of polycystic kidney disease, not chronic renal disease due to hypertension.
D. "Immune complexes form in the kidney tissue and produce inflammation, causing this diagnosis." This statement describes the pathogenesis of glomerulonephritis, not chronic renal disease due to hypertension.
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