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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale:
Antinuclear antibody (ANA) titer is a blood test that detects the presence of antinuclear antibodies, which are autoantibodies that target the body's own tissues. These antibodies are often present in people with autoimmune diseases, including rheumatoid arthritis.
While a positive ANA test does not definitively diagnose rheumatoid arthritis, it can support a diagnosis when considered alongside other clinical findings and laboratory tests.
Choice B rationale:
Blood urea nitrogen (BUN) is a blood test that measures the amount of urea nitrogen in the blood. Urea nitrogen is a waste product that is produced when the body breaks down proteins.
BUN levels can be elevated in people with kidney disease, dehydration, or certain other medical conditions. However, BUN is not specifically used to diagnose rheumatoid arthritis.
Choice C rationale:
Urinalysis is a test that examines the urine for various substances, including cells, bacteria, and chemicals.
It can be used to diagnose a variety of conditions, including urinary tract infections, kidney disease, and diabetes. However, urinalysis is not typically used to diagnose rheumatoid arthritis.
Choice D rationale:
Erythrocyte sedimentation rate (ESR) is a blood test that measures how quickly red blood cells settle at the bottom of a test tube.
A high ESR can indicate inflammation in the body.
ESR is often elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
Choice E rationale:
White blood cell count (WBC) is a blood test that measures the number of white blood cells in the blood. White blood cells are part of the immune system and help fight infection.
A high WBC count can indicate an infection or inflammation.
WBC count can be elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
Correct Answer is A
Explanation
Rationale for Choice A:
Tachypnea and restlessness are common signs of respiratory distress, which is a potential complication of pneumonia. These signs indicate that the client's oxygenation may be compromised and require immediate attention.
Rationale for Choice B:
Weight loss of 1 pound since yesterday is a non-specific finding and could be due to a variety of factors, including poor appetite, dehydration, or muscle wasting. While weight loss can be a symptom of HIV infection, it is not an acute sign that requires immediate prioritization in this case.
Rationale for Choice C:
Frequent loose stools can be a symptom of HIV infection or a side effect of certain medications. However, it is not an acute sign that requires immediate prioritization in this case, especially in the context of the client's respiratory distress.
Rationale for Choice D:
An oral temperature of 100°F is a low-grade fever and is not a specific indicator of any serious condition. While fever can be a symptom of pneumonia, it is not the most concerning finding in this case.
Therefore, based on the client's presenting symptoms, tachypnea and restlessness are the most concerning findings and should be prioritized by the nurse.
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