A client presents with a temperature of 100°F (37.8°C) and reports difficulty breathing. Which intervention should the nurse implement first?
Obtain arterial blood gases
Suction to clear secretions from airway
Offer a prescribed PRN analgesia
Administer a prescribed antipyretic
The Correct Answer is B
Choice A reason: Arterial blood gases assess oxygenation and acid-base balance, critical for diagnosing respiratory distress severity. However, this diagnostic measure does not immediately relieve airway obstruction. Clearing secretions is prioritized to restore ventilation, as hypoxia can rapidly cause tissue damage or cardiac arrest in acute respiratory distress.
Choice B reason: Suctioning removes airway secretions, directly addressing breathing difficulty. Secretions obstruct airways, reducing oxygen delivery to alveoli and impairing gas exchange. Immediate suctioning restores patency, enhances ventilation, and prevents hypoxia, making it the priority intervention to stabilize the client’s respiratory function in acute distress.
Choice C reason: PRN analgesia addresses pain, which is not indicated as the primary issue. Pain relief does not resolve airway obstruction or improve breathing. Administering analgesia prematurely could mask respiratory symptoms, delaying critical airway management and potentially worsening hypoxia by neglecting the underlying obstruction.
Choice D reason: An antipyretic reduces fever, improving comfort but not addressing breathing difficulty. Fever is secondary, and treating it does not restore airway patency or oxygenation. Airway management is prioritized in respiratory distress to prevent hypoxia and ensure effective gas exchange before managing fever symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Assisting with mobility and fall prevention is critical in Parkinson’s disease, as bradykinesia and rigidity increase fall risk. Physical therapy and assistive devices enhance safety, reducing injury risk, making this the priority intervention to maintain functional independence and prevent fractures.
Choice B reason: High-protein meals may interfere with levodopa absorption in Parkinson’s, worsening symptoms. Mobility assistance is the priority, as falls are a leading cause of injury, requiring immediate intervention to ensure safety, making dietary protein secondary to physical support.
Choice C reason: Restricting fluid intake is inappropriate, as hydration prevents constipation in Parkinson’s. Mobility and fall prevention are critical, as motor symptoms increase injury risk. Assisting with mobility addresses the primary functional challenge, making fluid restriction irrelevant to priority care.
Choice D reason: Promoting social isolation worsens depression in Parkinson’s, a common comorbidity. Mobility assistance is the priority, as falls due to motor impairment are a significant risk, requiring immediate intervention to ensure safety, making social isolation counterproductive to care.
Correct Answer is A
Explanation
Choice A reason: Diclofenac, an NSAID, can cause gastrointestinal bleeding, leading to anemia. Pale appearance and fatigue suggest blood loss. Reviewing hemoglobin levels is critical to confirm anemia, as low hemoglobin impairs oxygen delivery, exacerbating fatigue and requiring immediate intervention to address potential bleeding.
Choice B reason: Glucose levels are unrelated to diclofenac’s common side effects. Fatigue may occur in hypoglycemia, but diclofenac does not typically affect glucose metabolism. Pale appearance and fatigue are more indicative of anemia from NSAID-related bleeding, making hemoglobin a more urgent lab value to review.
Choice C reason: Total protein levels reflect nutritional status or liver function but are not directly linked to diclofenac’s side effects. Fatigue and pallor suggest anemia from gastrointestinal bleeding, a known NSAID risk. Hemoglobin is more critical to assess, as it directly correlates with the client’s symptoms.
Choice D reason: Sodium levels influence fluid balance but are not typically altered by diclofenac. Fatigue and pallor point to anemia from potential bleeding, not electrolyte imbalance. Hemoglobin review is prioritized, as diclofenac’s gastrointestinal side effects are more likely to cause blood loss than sodium disturbances.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.