Nokea
A client diagnosed with acquired immunodeficiency syndrome (AIDS) is being admitted to the hospital for treatment of a Pneumocystis jiroveci respiratory infection. Which intervention should the nurse include in the plan of care to assist in maintaining the comfort of this client?
- A. Monitoring for bloody sputum
- B. Evaluating arterial blood gas results
- C. Keeping the head of the bed elevated
- D. Assessing respiratory rate, rhythm, depth, and breath sounds
Correct Answer: C
Rationale: Clients with respiratory difficulties are often more comfortable with the head of the bed elevated. Options 1, 2, and 4 are appropriate measures to evaluate respiratory function and avoid complications. Option 3 is the only choice that addresses planning for client comfort.
You may also like to solve these questions
What is the smallest gauge catheter that the nurse can use to administer blood?
- A. 12 gauge
- B. 20 gauge
- C. 22 gauge
- D. 24 gauge
Correct Answer: B
Rationale: An intravenous catheter used to infuse blood should be at least 20 gauge or larger to help prevent additional hemolysis of red blood cells and to allow infusion of the blood without occluding the IV catheter.
After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. When asked, how would the nurse describe this finding to the client?
- A. Waves of loud gurgles auscultated in all four quadrants
- B. Soft gurgling or clicking sounds auscultated in all four quadrants
- C. Low-pitched swishing sounds auscultated in one or two quadrants
- D. Very high-pitched loud rushes auscultated, especially in one or two quadrants
Correct Answer: B
Rationale: Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute. Loud gurgles (borborygmi) indicate hyperperistalsis. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. No aortic bruits should be heard. Bowel sounds will be higher pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction.
A 2-year-old toddler has just returned from surgery where a hip spica cast was applied. Which nursing action will best maintain the child's skin integrity?
- A. Changing the toddler's diapers every 2 hours.
- B. Keeping the toddler's genital area open to the air.
- C. Implementing a 3-hour turning schedule for the toddler.
- D. Assessing the toddler's perineal area for redness regularly.
Correct Answer: A
Rationale: The spica cast is often needed to treat developmental hip dysplasia (DDH) or after hip/pelvis surgery. The cast encases the child's trunk and one or both legs while leaving access to the genital. Considering the age of the child, diapers will be in use and will need to be changed at least every 2 hours during the day and 3 to 4 hours during the night to help minimize the effect of urine and feces on the child's diaper area. Exposing the genital and perineal area to the air is an intervention that is implemented to assist in healing damaged skin tissue. Turning the child regularly is appropriate care but has no impact on the major issue of incontinence. Assessment of the skin is necessary but identifies skin breakdown once it has begun.
A client has been prescribed procainamide. The nurse implements which intervention before administering the medication to minimize the client's risk for injury?
- A. Obtaining a chest x-ray
- B. Assessing blood pressure and pulse
- C. Obtaining a complete blood cell count and liver function studies
- D. Scheduling a drug level to be drawn 1 hour after the dose is administered
Correct Answer: B
Rationale: Procainamide is an antidysrhythmic medication. Before the medication is administered, the client's blood pressure and pulse are checked. This medication can cause toxic effects, and serum blood levels would be checked before administering the medication (therapeutic serum level is 4 to 10 mcg/mL [17.00 to 42.50 mcmol/L]). A chest x-ray and obtaining a complete blood cell count and liver function studies are unnecessary.
A client has fallen and sustained a leg injury. Which question should the nurse ask to help determine if the client sustained a fracture?
- A. Is the pain a dull ache?
- B. Is the pain sharp and continuous?
- C. Does the discomfort feel like a cramp?
- D. Does the pain feel like the muscle was stretched?
Correct Answer: B
Rationale: Fracture pain is generally described as sharp, continuous, and increasing in frequency. Bone pain is often described as a dull, deep ache. Muscle injury is often described as an aching or cramping pain, or soreness. Strains result from trauma to a muscle body or the attachment of a tendon from overstretching or overextension.