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 B
Explanation
Choice A rationale:
Placing the client back in bed during a seizure could lead to injury.
Choice B rationale:
Placing the client on his side, specifically the left side, allows for the tongue to fall forward, preventing aspiration.
Choice C rationale:
Holding the client’s arms and legs from moving could cause harm to the client or nurse.
Choice D rationale:
Inserting a tongue blade in the client’s mouth could cause injury to the client’s oral cavity.
Correct Answer is D
Explanation
Choice A rationale:
Cardiac enzymes do not identify the location of the MI, they are biomarkers that indicate heart muscle injury.
Choice B rationale:
Cardiac enzyme tests do not provide information about the heart’s structure or the mobility of the heart valves. That’s typically assessed using imaging studies like an echocardiogram.
Choice C rationale:
Cardiac enzymes do not assist in diagnosing the presence of pulmonary congestion. They are specific to heart muscle damage.
Choice D rationale:
Cardiac enzymes, such as troponin and creatine kinase, rise when there is damage to the heart muscle, such as in an MI. Therefore, these tests help determine the degree of damage to the heart tissues.
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