A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia.
Which of the following actions should the nurse take?
Obtain a sputum culture.
Position head of bed at 10 degrees.
Cough and deep breathe every 8 hr.
Encourage fluid intake of 1500 mL/day.
The Correct Answer is A
Choice A rationale:
Obtaining a sputum culture helps identify the causative organism and guide treatment.
Choice B rationale:
Positioning the head of bed at 10 degrees is not beneficial for pneumonia patients.
Choice C rationale:
Coughing and deep breathing every 8 hours is not frequent enough for pneumonia patients.
Choice D rationale:
Encouraging fluid intake of 1500 mL/day is not sufficient for pneumonia patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C: "I will make a list of my favorite beverages."
Choice A rationale: Stating that they will put beverages in large containers to give the appearance of drinking a lot demonstrates a lack of understanding of fluid restriction guidelines. It focuses on the appearance rather than the actual fluid intake limitation. This statement does not reflect an understanding of the need to limit fluids in acute kidney disease.
Choice B rationale: Consuming most fluids during the evening is not recommended for clients with acute kidney disease as it may lead to discomfort, nighttime urination, and fluid overload. This statement does not demonstrate an understanding of the importance of spreading fluid intake throughout the day.
Choice C rationale: Making a list of favorite beverages indicates the client's understanding of fluid restrictions. This approach can help the client prioritize their preferred beverages while staying within their prescribed fluid allowance. It shows that the client is aware of the need to be selective in their fluid intake.
Choice D rationale: Although avoiding ice cream is an appropriate action due to its contribution to fluid intake, this statement alone does not necessarily indicate a comprehensive understanding of fluid restrictions. The client must also be aware of the importance of monitoring all sources of fluid intake, including other foods and beverages.
Correct Answer is D
Explanation
Choice A rationale:
Aspirin is not typically recommended for gout due to its potential to elevate uric acid levels.
Choice B rationale:
A high-purine diet can exacerbate gout symptoms, so this statement is incorrect.
Choice C rationale:
Limiting fluid intake can lead to dehydration, which can trigger a gout attack.
Choice D rationale:
Alcohol, especially beer, can increase uric acid levels and trigger gout attacks, so limiting alcohol intake is recommended.
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