A client has a PRN prescription for a nasal cannula at 2 to 3 L/minute. The client is wearing a nasal cannula at 2 L/minute and asks the practical nurse (PN) if it can be removed. Which client data is most important for the PN to obtain before responding to the client?

Choice A reason: Sputum is the most appropriate specimen to collect prior to the initiation of antibiotic therapy in a client with suspected pneumonia. Sputum cultures can help identify the specific bacteria or other pathogens causing the infection, allowing for targeted antibiotic therapy. Collecting the sputum sample before starting antibiotics ensures that the culture results are not influenced by the medication, leading to more accurate identification of the causative agent and more effective treatment.
Choice B reason: Urine is not the appropriate specimen to collect for diagnosing pneumonia. While urine cultures can be useful for diagnosing urinary tract infections or detecting certain pathogens through urine antigen tests, they are not relevant to identifying the etiology of a respiratory infection like pneumonia. The focus should be on obtaining samples directly from the respiratory system.
Choice C reason: A throat smear can be useful for diagnosing upper respiratory tract infections, such as strep throat, caused by Group A Streptococcus. However, it is not the most relevant test for diagnosing pneumonia, which affects the lower respiratory tract. A sputum sample is more appropriate for identifying the pathogens responsible for pneumonia.
Choice D reason: Blood cultures can be useful for detecting bacteremia or septicemia, especially in severe cases of pneumonia where the infection has spread to the bloodstream. However, they are not the primary method for identifying the specific cause of pneumonia. Blood cultures are typically used in conjunction with other tests, such as sputum cultures, to provide a comprehensive diagnosis.

Choice A reason: Demonstrating the use of an incentive spirometer is a valuable intervention for encouraging deep breathing and preventing atelectasis. However, in the context of a client with absent breath sounds on one side, the priority is to monitor for signs of respiratory distress or complications such as a pneumothorax. While using an incentive spirometer may be beneficial in other scenarios, it is not the immediate priority in this case.
Choice B reason: Monitoring the client for increasing respiratory distress is the most critical action to take. The absence of breath sounds on the left side could indicate a serious complication such as a pneumothorax, hemothorax, or other issues that can compromise respiratory function. By closely monitoring the client, the practical nurse can detect signs of worsening condition, such as increased work of breathing, cyanosis, or changes in vital signs, and provide timely intervention or support while awaiting the healthcare provider's arrival.
Choice C reason: Administering a PRN dose of a diuretic medication is not appropriate in this context. Diuretics are used to manage fluid balance and treat conditions such as heart failure or hypertension but are not relevant for addressing the immediate concern of absent breath sounds and potential respiratory distress. The focus should remain on monitoring the client's respiratory status and ensuring appropriate interventions are available if needed.
Choice D reason: Encouraging the client to use pursed-lip breathing can be beneficial for clients experiencing shortness of breath or for managing chronic obstructive pulmonary disease (COPD). However, in the case of absent breath sounds on one side, it is more important to monitor for signs of respiratory compromise and ensure the client receives prompt medical evaluation and intervention. Pursed-lip breathing is not the immediate priority in this scenario.