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 A
Explanation
Choice A rationale:
Diabetes insipidus is characterized by excessive thirst and excretion of large amounts of severely dilute urine, leading to dehydration.
Choice B rationale:
Bradycardia is not a typical finding in diabetes insipidus.
Choice C rationale:
Polyphagia (excessive hunger) is more commonly associated with diabetes mellitus, not diabetes insipidus.
Choice D rationale:
Hyperglycemia is a symptom of diabetes mellitus, not diabetes insipidus.
Correct Answer is A
Explanation
Choice A rationale:
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
Choice B rationale:
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
Choice C rationale:
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
Choice D rationale:
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
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