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:
Candidiasis, also known as thrush, is a fungal infection caused by Candida albicans. It commonly affects the mouth, causing white patches on the tongue, inner cheeks, gums, or tonsils.
Individuals with AIDS often have weakened immune systems due to a decreased CD4 T-cell count. This makes them more susceptible to opportunistic infections like candidiasis.
The fungal infection can spread to the esophagus, causing difficulty swallowing, or even to the bloodstream, leading to more serious complications.
Choice B rationale:
Xerostomia refers to dry mouth. It can be caused by various factors, including medications, salivary gland dysfunction, or radiation therapy. While it can occur in individuals with AIDS, it's not directly linked to a decreased CD4 T-cell count.
Choice C rationale:
Halitosis, or bad breath, can have multiple causes, including poor oral hygiene, gum disease, or digestive issues. It's not specifically associated with AIDS or a decreased CD4 T-cell count.
Choice D rationale:
Gingivitis is inflammation of the gums, often caused by plaque buildup. It's a common condition, but it's not directly linked to AIDS or a decreased CD4 T-cell count.

A. Develops an acute retroviral syndrome B. Has a CD4+ T lymphocyte level of less than 200 cells/mm C. Is capable of transmitting the virus to others D. Contracts HIV-specific antibodies A nurse is caring for a client who has been diagnosed as HIV positive.

Correct Answer is B

Explanation

Choice A rationale:
Acute retroviral syndrome (ARS) is an early stage of HIV infection that often presents with flu-like symptoms. It does not determine AIDS diagnosis.

Choice B rationale:
A CD4+ T lymphocyte level of less than 200 cells/mm is a defining criterion for AIDS diagnosis. This low count indicates a severely weakened immune system, leading to susceptibility to opportunistic infections and other AIDS-defining illnesses.

Choice C rationale:
A person with HIV can transmit the virus to others regardless of their CD4+ T cell count. Transmission risk is not a diagnostic criterion for AIDS.

Choice D rationale:
HIV-specific antibodies are produced by the immune system in response to HIV infection but their presence does not signify AIDS progression.

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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 in a clinic is assessing a client who has AIDS and a significantly decreased CD4 T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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