What intervention should the nurse identify as a priority for a client with a nursing diagnosis of ineffective airway clearance related to HIV related pneumonia?

Coughing and deep breathing and hydration maintenance

Keep the head of the bed elevated

Preparation for insertion of a tracheostomy tube

Provide supplemental oxygen

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Coughing and deep breathing are essential for mobilizing and removing secretions from the airways, which is crucial for improving airway clearance in patients with pneumonia. These techniques help to loosen mucus and bring it up from the lungs, allowing it to be expelled through coughing.
Hydration maintenance is also critical because it helps to thin secretions, making them easier to cough up. Adequate hydration helps to keep mucus moist and less sticky, which promotes easier expectoration.
Choice B rationale:
Keeping the head of the bed elevated can help to improve oxygenation and reduce the work of breathing, but it does not directly address the issue of airway clearance. It may be a helpful adjunct intervention, but it's not the priority for this specific nursing diagnosis.
Choice C rationale:
Preparation for insertion of a tracheostomy tube is a more invasive intervention that may be necessary in severe cases of airway obstruction, but it is not the first-line intervention for ineffective airway clearance related to pneumonia. It would be considered if other measures fail to maintain adequate ventilation.

Choice D rationale:
Providing supplemental oxygen can help to improve oxygenation in patients with pneumonia, but it does not directly address the issue of airway clearance. It's important to support oxygenation, but it's not the primary intervention to clear secretions.

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Correct Answer is A

Explanation

Choice A rationale:
Lymph nodes are small, bean-shaped structures that play a crucial role in the immune system. They filter lymph fluid, which carries white blood cells and other immune cells throughout the body.
When the body is fighting an infection or other immune challenge, lymph nodes often swell and become tender. This is because they are actively working to filter out pathogens and activate immune cells.
Palpation of the lymph nodes can provide valuable information about the patient's immune function. The nurse can assess for enlargement, tenderness, and mobility of the lymph nodes.
Lymph node assessment is a non-invasive, painless procedure that can be performed quickly and easily.
Choice B rationale:
Auscultation of the apical heart rate is important for assessing cardiovascular function, but it does not directly assess immune function.
While heart rate can be indirectly affected by certain immune conditions (e.g., fever), it is not a primary indicator of immune system activity.
Choice C rationale:
Palpation of the liver can provide information about liver size and consistency, but it does not directly assess immune function.
The liver plays a role in immune function by producing proteins that help fight infection, but its size and consistency do not necessarily reflect its immune activity.
Choice D rationale:
Percussion of the abdomen can be used to assess the size and location of abdominal organs, but it does not directly assess immune function.
While certain immune conditions may involve abdominal organs (e.g., splenomegaly), percussion is not a primary method for assessing immune function.

A. Delivering meal trays to clients in their rooms B. Helping observe postoperative clients who are confused C. Assisting ambulatory clients with meals D. Delivering mail

Correct Answer is B

Explanation

Choice A rationale:
Delivering meal trays to clients in their rooms is a simple task that does not require any specialized skills or knowledge. Volunteers can be safely assigned this task, as it does not involve any direct patient care or decision-making.

Choice B rationale:
Observing postoperative clients who are confused requires a higher level of skill and knowledge than delivering meal trays. Volunteers are not typically trained to assess and monitor patients for changes in their condition, and they may not be able to recognize and respond to potential emergencies. This task is best assigned to a licensed nurse or other qualified healthcare professional.

Choice C rationale:
Assisting ambulatory clients with meals is another task that can be safely assigned to volunteers. This task involves helping patients with simple activities such as opening food containers and cutting food. Volunteers can be trained to perform these tasks safely and effectively.

Choice D rationale:
Delivering mail is a simple task that does not require any specialized skills or knowledge. Volunteers can be safely assigned this task, as it does not involve any direct patient care or decision-making.

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What intervention should the nurse identify as a priority for a client with a nursing diagnosis of ineffective airway clearance related to HIV related pneumonia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?

Correct Answer is A

Explanation

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer?

Correct Answer is B

Explanation

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