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.

Answer and Explanation

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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Correct Answer is ["B","D","E"]

Explanation

A. Elevated temperature: Elevated temperature is not typically associated with advanced COPD unless there is an underlying infection. Infections such as pneumonia may exacerbate COPD symptoms but are not universal findings in advanced COPD.

B. Pursed-lip breathing: Pursed-lip breathing is a common compensatory mechanism seen in clients with COPD. It helps to slow down the rate of expiration and prevents alveolar collapse, improving gas exchange.

C. Clubbing of the fingers: Clubbing of the fingers is not typically associated with COPD. It is more commonly seen in conditions such as chronic hypoxemia, congenital heart disease, and certain lung diseases like bronchiectasis.

D. Concave chest: In advanced COPD, the chest may appear hyperinflated with a barrel-shaped chest due to air trapping. The presence of a concave chest is not characteristic of COPD.

E. Dyspnea at rest: Dyspnea, or difficulty breathing, is a hallmark symptom of COPD. In advanced stages, clients may experience dyspnea even at rest due to severe airflow limitation and impaired gas exchange.

A. Assess the insertion site. B. Keep the client NPO for 4 hr. C. Keep the affected leg slightly flexed. D. Elevate the head of the bed 45°.

Correct Answer is A

Explanation

A. Assess the insertion site: Assessing the insertion site for bleeding, hematoma, or signs of infection is the priority action because complications at the insertion site can occur post- procedure and require immediate attention.

B. Keep the client NPO for 4 hr: Keeping the client NPO is not typically necessary after a cardiac catheterization unless there are specific orders or complications.

C. Keep the affected leg slightly flexed: The affected leg should actually be kept straight to prevent bleeding from the insertion site.

D. Elevate the head of the bed 45°: The head of the bed should usually be kept flat or only slightly elevated to reduce the risk of bleeding from the femoral site.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with advanced COPD. The nurse should anticipate which assessment findings when caring for clients with advanced COPD? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is caring for a client arriving to the unit following a cardiac catheterization with a right femoral insertion site. Which of the following is the nurse's priority action?

Correct Answer is A

Explanation

A clinic nurse is caring for a large number of clients diagnosed with the common cold. The nurse should recognize that which factor contributes to the high communicability of the common cold?

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