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","B","E"]

Explanation

Choice A rationale:
Loosening the patient's clothing around the neck and chest promotes easier breathing during the seizure. It also prevents potential injury from constrictive clothing that could restrict movement or circulation.
Choice B rationale:
Easing the patient to the floor if they are standing helps to prevent falls and injuries that could occur due to loss of consciousness and muscle control during the seizure. It's crucial to guide the patient gently to the floor to avoid abrupt movements that could trigger or worsen the seizure.
Choice C rationale:
Restraining the patient during a seizure is not recommended as it can cause harm. Attempting to restrain a patient's movements during a seizure can lead to muscle strains, joint injuries, or even fractures. It can also increase anxiety and agitation, potentially prolonging the seizure.
Choice D rationale:
Protecting the patient's mouth with a padded tongue blade is not necessary and can even be dangerous. It was once a common practice, but it's now discouraged as it can cause oral injuries, obstruct the airway, or induce vomiting.

Choice E rationale:
Providing privacy helps to protect the patient's dignity and reduce any potential embarrassment during the seizure. It also creates a calmer and less stimulating environment, which can be beneficial in managing the seizure.

Correct Answer is ["1370"]

Explanation

To calculate the total output for the client, we need to add up all the individual outputs:

The client voided 400 mL at 1100.
The client voided 350 mL at 1430.
The closed chest drainage system increased from 155 mL to 175 mL, which is an increase of 20 mL.
The NG tube has 575 mL in the drainage container.
The Jackson-Pratt drainage tube has 25 mL.

Adding all these amounts together, the total output that the nurse should record in the medical record is 1370 mL.

Here’s the calculation:

400 mL + 350 mL + (175 mL - 155 mL) + 575 mL + 25 mL = 1370 mL400mL+350mL+(175mL−155mL)+575mL+25mL=1370mL

So, the nurse should record a total output of 1370 mL in the medical record for the client.

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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

The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

Correct Answer is ["1370"]

Explanation

The nurse is planning education for a patient diagnosed with fibromyalgia. Which risk factors should the nurse include in the teaching plan? (Select all that apply)

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