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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?

A.

Obtain a sputum culture.

B.

Position head of bed at 10 degrees.

C.

Cough and deep breathe every 8 hr.

D.

Encourage fluid intake of 1500 mL/day.

Answer and Explanation

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.
 


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

  • Vision (Blurred)

    • Interpretation: Potential worsening condition
    • Rationale: Blurred vision can be a sign of lithium toxicity. Despite the lithium level improving, this symptom indicates that neurotoxicity may still be present.

  • Lithium Level (1.2 mEq/L)

    • Interpretation: Potential improvement
    • Rationale: The lithium level has decreased from 1.8 mEq/L (toxic) to 1.2 mEq/L, which is within the therapeutic range (0.6-1.2 mEq/L). This indicates that treatment to lower lithium toxicity is effective.

  • Urine Output (40 mL/hr)

    • Interpretation: Potential improvement
    • Rationale: A urine output of 40 mL/hr is within the acceptable range (normal is greater than 30 mL/hr), suggesting that kidney function is adequate and not compromised by lithium toxicity.

  • Mucous Membranes (Pale, Dry)

    • Interpretation: Potential worsening condition
    • Rationale: Pale, dry mucous membranes suggest dehydration, which can increase the risk of lithium toxicity and negatively affect overall health.

  • Vital Signs (BP 88/50 mm Hg, Pulse 96/min)

    • Interpretation: Potential worsening condition
    • Rationale: The drop in blood pressure from 130/84 mm Hg to 88/50 mm Hg indicates hypotension. This could be related to dehydration or lithium toxicity, and it requires follow-up as the condition is deteriorating.

Correct Answer is A

Explanation

Choice A rationale:
An increased WBC count with increased bands (immature neutrophils) indicates an acute infectious process. Normal range for WBC is 4,500-11,000/mm².
Choice B rationale:
A resolving inflammatory process would typically show a decreasing WBC count.
Choice C rationale:
An allergic reaction would typically show an increase in eosinophils, not neutrophils.
Choice D rationale:
Neutropenia is a decrease in neutrophils, not an increase.

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