Patient Data
Increase IV fluids to 150 mL/hr
Monitor for adverse reaction to antibiotics
Repeat CD4+ T-cell count STAT
Initiate airborne isolation
Administer antiemetic
Correct Answer : A,B,E
A. This intervention is likely to be ordered due to the patient's fever and elevated heart rate, which may suggest dehydration or the need for increased fluid intake to support hemodynamic stability and mitigate the effects of fever and potential dehydration from fever and nausea.
B. Given the diagnosis of Pneumocystis pneumonia, the patient will likely be on or start antibiotics specific to this infection, such as trimethoprim-sulfamethoxazole. Monitoring for adverse reactions is crucial, especially in a newly diagnosed HIV-positive patient who might be starting multiple new medications.
C. While it is important to monitor CD4 counts in HIV-positive patients to guide treatment decisions, repeating the CD4 count immediately might not be prioritized unless there are specific clinical changes that suggest a rapid decline in immune function. Given the recent test results showing a CD4 count of 443 cells/mm^3, immediate retesting might not be clinically justified unless guided by other symptoms or considerations not detailed here.
D. Pneumocystis pneumonia does not require airborne isolation as it is not typically contagious between people under normal circumstances. Instead, it arises as an opportunistic infection in individuals with weakened immune systems. Hence, this order would not be appropriate unless there were other infections suspected that require such precautions.
E. The patient reports severe nausea, which not only is distressing but can also prevent the patient from taking oral medications and maintain necessary nutrition. Administering an antiemetic can help manage this symptom effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Social interaction can help, but it is not the most effective immediate strategy for managing anxiety.
B. Reflecting on the reasons for anxiety is useful for long-term management but not for immediate relief.
C. Muscle relaxation techniques are an effective and immediate method for reducing anxiety symptoms.
D. Listening to music can help but is less effective than targeted relaxation techniques.
Correct Answer is A
Explanation
A. Diarrhea can lead to significant fluid and electrolyte imbalances, especially in older adults. Prioritizing hydration and electrolyte management is essential to prevent severe complications like renal failure or shock.
B. While caregiver stress is significant and must be addressed, it is not as immediately life-threatening as a fluid volume deficit.
C. This is an ongoing management issue but does not pose an immediate threat to the client's life compared to fluid and electrolyte imbalances.
D. Although important for overall care and prevention of complications such as pressure ulcers, it is not as critical as managing fluid volume deficit in this scenario.
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