A. Night sweats can occur with infections such as tuberculosis and occasionally with severe bacterial infections, but they are not the most specific or early sign of pneumonia or hypoxia in an older adult. In elderly clients, more subtle or atypical signs such as mental status changes are often more indicative of underlying respiratory compromise.
B. Normothermia, or having a normal body temperature, is common in older adults even during infections. Older adults may present with a blunted febrile response to infection, meaning they might not have a high fever. However, normothermia alone does not directly signal pneumonia or hypoxia and could lead to underrecognition of infection severity if relied on solely.
C. Narrowed pulse pressure, defined as a small difference between systolic and diastolic blood pressures, can indicate cardiac issues such as heart failure or shock but is not a hallmark of pneumonia or hypoxia. While hypoxia can eventually impair cardiac function, narrowed pulse pressure is not the most reliable or early respiratory indicator.
D. Confusion is a common and often early sign of pneumonia and hypoxia in older adults. Due to decreased cerebral oxygenation and the blunted inflammatory response of aging, older adults frequently present with delirium or acute confusion when seriously ill, even before respiratory symptoms become prominent.

A. Low urine output is expected in heat stroke due to significant dehydration and reduced renal perfusion. The body conserves fluids by decreasing urinary output, and acute kidney injury can develop if hypoperfusion persists, further exacerbating the risk of complications.
B. Temperature lower than 97°F would not be expected; in fact, heat stroke is characterized by hyperthermia, often with core body temperatures exceeding 104°F. A low body temperature would suggest hypothermia, not heat stroke, and thus does not align with the anticipated clinical presentation.
C. No perspiration is common in classic (non-exertional) heat stroke because the body's thermoregulatory mechanisms fail, and sweating ceases. The lack of perspiration despite extreme heat is a critical diagnostic clue that distinguishes heat stroke from milder heat-related illnesses like heat exhaustion.
D. Diaphoresis, or excessive sweating, is more typical of heat exhaustion rather than heat stroke. In heat stroke, the skin often becomes hot and dry due to the collapse of the body's cooling mechanisms, and active sweating typically stops by the time the patient becomes unresponsive.
E. Alert and oriented is unlikely in a client experiencing heat stroke severe enough to cause unresponsiveness. Heat stroke often leads to neurological dysfunction such as confusion, delirium, seizures, or coma due to direct thermal injury to brain tissues and widespread systemic effects.

A. Airway protection is the immediate priority because maintaining a patent airway is essential for oxygen delivery to all vital organs. Without airway management, hypoxia can rapidly lead to cardiac arrest, brain injury, and death. In trauma patients, airway compromise is a frequent and life-threatening concern that must be addressed first according to the ABC (Airway, Breathing, Circulation) principles.
B. Preventing musculoskeletal disability is important but is a secondary priority after stabilizing life-threatening conditions. While fractures and spinal injuries require careful management to prevent long-term disability, they do not take precedence over ensuring adequate oxygenation and ventilation in the acute trauma setting.
C. Stabilizing cardiac arrhythmias is necessary if present, but airway obstruction or compromise is more immediately fatal. Unless the arrhythmia is causing life-threatening hemodynamic instability, it will be addressed after securing the airway and ensuring adequate breathing and circulation.
D. Decreasing intracranial pressure is critical in clients with head trauma, but it is prioritized after the airway is secured. Without a functional airway, the brain and other organs will become hypoxic, worsening intracranial hypertension and leading to irreversible damage. Thus, airway management must come first.

Thoracentesis is non-essential for a client with pneumothorax because it is primarily used to drain fluid accumulation, not air. Unless there is a suspicion of a hemothorax or fluid build-up, thoracentesis would not address the cause of the client's respiratory distress and would not be the initial intervention.

Prepare for insertion of a chest tube is anticipated because it is the standard treatment for pneumothorax. A chest tube allows continuous evacuation of air from the pleural space, promoting lung re-expansion and stabilizing breathing, which is urgently needed for clients who report severe dyspnea and shallow respirations.

Pulmonary Function Tests (PFTs) are contraindicated because they involve deep inhalation and forceful exhalation maneuvers, which could cause further lung collapse or exacerbate the pneumothorax. These tests are inappropriate during acute respiratory distress and must be deferred until the pneumothorax resolves.

Obtaining intravenous access is anticipated because having a reliable IV line ensures immediate access for emergency medications, fluids, sedation, and possible analgesia, particularly when preparing for procedures such as chest tube insertion or stabilizing hemodynamic status in case of deterioration.

Obtain ABGs is anticipated because arterial blood gases provide critical information about the client's respiratory efficiency, including oxygenation, ventilation, and acid-base balance. These results help guide the need for supplemental oxygen therapy, ventilatory support, or further interventions.

A. Administering rescue breathing is important in providing oxygen to the client, but without circulation provided by chest compressions, oxygen will not effectively reach vital organs. In adult cardiac arrest, immediate chest compressions are the first priority to maintain blood flow to the brain and heart.
B. Opening the client's airway is an essential component of basic life support but comes after initiating chest compressions in the current guidelines. Prioritizing airway over circulation delays the delivery of critical perfusion necessary to preserve organ function during cardiac arrest.
C. Beginning chest compressions is the first action because effective compressions circulate oxygenated blood to vital organs, improving the chance of survival. The American Heart Association emphasizes "CAB" (Circulation, Airway, Breathing) for adults, starting with compressions to minimize delays in restoring circulation.
D. Activating code blue is critical to summon additional help, but it should be done simultaneously if possible or immediately after starting chest compressions. Delaying compressions to call for help compromises perfusion and decreases the client’s chances of successful resuscitation.

A. Small serosanguineous drainage from the puncture site is generally expected after a thoracentesis and is not typically alarming unless the drainage becomes heavy, purulent, or continuous. Minimal drainage indicates a healing puncture site without significant complications like infection or major bleeding.
B. Decreased temperature from baseline is not commonly associated with immediate thoracentesis complications. While hypothermia can occur in critically ill patients, a slight drop in temperature is not a key warning sign for pneumothorax, hemorrhage, or respiratory distress, which are more urgent concerns after thoracentesis.
C. Mild discomfort at the puncture site is a normal finding after a thoracentesis procedure. Some soreness or aching is expected due to the needle insertion but should not be severe or worsening. Monitoring is important, but mild discomfort alone does not suggest an emergency situation.
D. Increased heart rate and respirations from baseline can indicate the development of a pneumothorax, hemothorax, or respiratory distress, all of which are serious complications of thoracentesis. Tachycardia and tachypnea reflect the body’s attempt to compensate for impaired gas exchange and should prompt immediate provider notification.

A. Respiratory acidosis is characterized by a low pH (below 7.35) and an elevated PaCO₂ (above 45 mm Hg), both of which are present in the client's ABG results. A respiratory rate of 7/min indicates hypoventilation, causing CO₂ retention and leading directly to respiratory acidosis. The normal bicarbonate level further confirms that the primary problem is respiratory, not metabolic.
B. Metabolic alkalosis is marked by a high pH and elevated bicarbonate levels, neither of which is present here. The client's pH is low, and the bicarbonate is within the normal range, ruling out a metabolic origin for the acid-base imbalance.
C. Respiratory alkalosis would present with a high pH and a low PaCO₂, usually caused by hyperventilation. In this case, the client is hypoventilating, with high CO₂ and low pH values, which is the opposite pattern seen in respiratory alkalosis.
D. Metabolic acidosis involves a low pH accompanied by a decreased bicarbonate level, typically less than 22 mEq/L. Since the client's bicarbonate is normal at 26 mEq/L and the PaCO₂ is elevated, the acid-base disturbance is respiratory rather than metabolic.

A. Metabolic acidosis, uncompensated is indicated by a low pH (below 7.35) and a low bicarbonate level (HCO₃ less than 21). In this case, the bicarbonate is 16 mEq/L, confirming metabolic acidosis. Since the PaCO₂ is within the normal range and not yet decreased to compensate, this indicates the acidosis is uncompensated.
B. Metabolic alkalosis, partially compensated would show an elevated pH and an elevated HCO₃ level, typically with some respiratory compensation. However, the client has a low pH and low bicarbonate, which directly contradicts metabolic alkalosis patterns.
C. Respiratory alkalosis, partially compensated would involve a high pH and a low PaCO₂, often due to hyperventilation. This client's pH is low, not high, and the PaCO₂ remains normal, ruling out respiratory alkalosis.
D. Respiratory acidosis, uncompensated would present with a low pH and an elevated PaCO₂, reflecting inadequate ventilation. In this case, the PaCO₂ is normal, and the bicarbonate is low, confirming the problem is metabolic rather than respiratory.

A. "This test will measure different parts of the way I breathe" accurately reflects the purpose of pulmonary function tests (PFTs). These tests evaluate lung volumes, capacities, flow rates, and gas exchange efficiency, helping to diagnose and monitor respiratory conditions like asthma, COPD, and restrictive lung diseases.
B. "This test will help in finding out why I have been short of breath lately" is correct because PFTs are used to investigate symptoms such as dyspnea. The results provide critical information about the underlying cause of breathing difficulties by assessing pulmonary function objectively.
C. "I will make sure not to smoke at least 8 hours before my appointment" is appropriate because smoking can affect airway reactivity and baseline pulmonary function measurements. Abstaining from smoking helps ensure more accurate and reliable test results by preventing artificially worsened readings.
D. "I will make sure to use my inhaler immediately before my appointment" requires further teaching because using a bronchodilator before PFTs can alter the results, masking the severity of airway obstruction. Unless specifically instructed for a post-bronchodilator test, patients should generally withhold bronchodilators for several hours before testing.

A. Lowering the sedation dose on the intravenous pump is inappropriate because reducing sedation may cause the client to become more awake and agitated, leading to increased coughing, movement, and fighting against the ventilator, which can worsen high pressure alarms rather than resolve them.
B. Turning off the alarm's volume to promote a therapeutic environment is dangerous and should never be done. Alarm systems are critical safety features that alert nurses to life-threatening problems such as airway obstruction, ventilator disconnection, or high pressures, and silencing them risks patient harm.
C. Tightening connections from endotracheal tube to the ventilator is typically a response for low-pressure alarms indicating disconnection or leak, not high pressure alarms. High pressure alarms signal increased airway resistance or decreased lung compliance rather than loose connections.
D. Suctioning the client's endotracheal airway is appropriate because high pressure alarms often result from secretions blocking the airway. Suctioning removes these obstructions, improves airflow, and decreases resistance within the endotracheal tube, effectively addressing one of the most common causes of high pressure alarms.