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 A

Explanation

A. Check an apical pulse: Digoxin is known to cause toxicity, which can manifest as nausea, weakness, and anorexia. Bradycardia is a common sign of digoxin toxicity. Therefore, the nurse's first action should be to assess the client's apical pulse rate to determine if there are any signs of bradycardia, which could indicate digoxin toxicity.

B. Request a dietitian consult: While nutrition is important, the client's symptoms of nausea and weakness need immediate attention to rule out digoxin toxicity before considering dietary interventions.

C. Request an order for an antiemetic: Administering an antiemetic may be indicated if the client is experiencing nausea, but it's crucial to assess for digoxin toxicity first, as antiemetics may mask symptoms of toxicity.

D. Suggest that the client rests before eating the meal: Rest may be beneficial for the client, but addressing the potential cause of the symptoms, such as digoxin toxicity, takes priority

A. Give the client a low sodium diet. B. Monitor for serum electrolyte imbalances. C. Obtain daily weights. D. Educate the client on techniques to cope with thirst. E. Increase IV fluids.

Correct Answer is ["A","B","C","D"]

Explanation

A. Give the client a low sodium diet: SIADH causes retention of water and dilutional hyponatremia. Therefore, restricting sodium intake can help prevent further fluid retention and worsening of hyponatremia.

B. Monitor for serum electrolyte imbalances: SIADH can lead to electrolyte imbalances, particularly hyponatremia. Monitoring electrolyte levels, especially sodium, is essential for early detection and intervention.

C. Obtain daily weights: Monitoring daily weights is crucial for assessing fluid balance and detecting changes in hydration status, which is essential in clients with SIADH.

D. Educate the client on techniques to cope with thirst: Clients with SIADH often experience excessive thirst due to the body's inability to excrete excess water. Educating the client on strategies to manage thirst, such as chewing gum or sucking on ice chips, can help improve comfort.

E. Increase IV fluids: This option is incorrect because SIADH is characterized by water retention, so increasing IV fluids would exacerbate the condition and worsen hyponatremia.

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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 congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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