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 C
Explanation
Choice A rationale:
Holding the client's arms and legs from moving during a seizure can actually cause injury to the client or the nurse. The forceful muscle contractions that occur during a seizure can cause bones to break or joints to dislocate. Additionally, trying to restrain the client can increase their agitation and make the seizure worse.
Choice B rationale:
Placing the client back in bed during a seizure is not safe. The client could fall out of bed and injure themselves. It is also important to allow the client to have space to move freely during the seizure to prevent injury.
Choice C rationale:
Placing the client on their side is the safest position for a client who is having a seizure. This position helps to protect the airway and prevent aspiration. It also allows any fluids or secretions to drain out of the mouth, which can help prevent choking.
Choice D rationale:
Inserting a tongue blade into the client's mouth during a seizure is not recommended. It is a common misconception that people can swallow their tongue during a seizure. This is not possible. Inserting a tongue blade can actually cause more harm than good. It can break teeth, damage the mouth, or even block the airway.
Correct Answer is A
Explanation
Choice A rationale:
Magnet activation: Placing a magnet over the implantable device activates an on-demand feature of the VNS, delivering extra stimulation to the vagus nerve. This can potentially disrupt or shorten a seizure, especially when used at the onset of an aura (a warning sign that a seizure may be imminent).
Patient empowerment: Teaching the patient how to use the magnet provides them with a sense of control and a way to actively manage their seizures. It can reduce anxiety and improve quality of life.
Choice B rationale:
Microwave safety: While there's no definitive evidence that microwaves directly interfere with VNS devices, manufacturers generally recommend avoiding close or prolonged exposure to microwaves as a precaution. Specific guidelines may vary, but they often suggest keeping a distance of at least 15-20 inches from microwaves. The statement in Choice B about 12,000 watts or less is inaccurate and misleading.
Choice C rationale:
CT scans with contrast: There's no contraindication for patients with VNS to undergo CT scans with contrast. The device is designed to withstand common imaging procedures.
Choice D rationale:
Pain management: Burst catheters are typically used for pain management after surgery or during childbirth. They have no direct relevance to VNS therapy or seizure management.
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