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 ["033"]
Explanation
Step 1 is to calculate the number of milliliters (mL) that contain the ordered dose of 300 mg of clindamycin.
Step 2 is to divide the total milliliters (mL) from Step 1 by the infusion time in minutes to get the flow rate in mL/hour. Here are the calculations:
Step 1:
900 mg of clindamycin is in 50 mL.
To find the mL that contain 300 mg, set up a proportion:
(300 mg / 900 mg) = (x mL / 50 mL) Cross-multiply and solve for x:
x = (300 mg * 50 mL) / 900 mg x = 16.67 mL
Step 2:
The infusion time is 30 minutes.
Divide the total mL (16.67 mL) by the infusion time in hours to get the flow rate in mL/hour: Flow rate = 16.67 mL / (30 minutes / 60 minutes/hour)
Flow rate = 33.33 mL/hour
Round to the nearest whole number, using a leading zero if it applies, and no trailing zero: Flow rate = 033 mL/hour
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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