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 B
Explanation
Choice A reason: Open-angle glaucoma involves chronic optic nerve damage due to impaired aqueous humor drainage, not a reversible “angle” change. Medications reduce intraocular pressure but cannot restore anatomical angles. This response is inaccurate, as the condition requires lifelong management to prevent further nerve damage and vision loss.
Choice B reason: Open-angle glaucoma requires lifelong medication to maintain normal intraocular pressure, preventing optic nerve damage. Medications like prostaglandin analogs or beta-blockers enhance aqueous humor outflow or reduce production, controlling pressure long-term. This is the accurate response, as sustained pressure management is essential to preserve vision in chronic glaucoma.
Choice C reason: Reducing excess pressure is a goal of glaucoma treatment, but open-angle glaucoma is chronic, requiring ongoing medication even after pressure is lowered. This response is incomplete, as it suggests a temporary treatment, whereas lifelong therapy is needed to prevent pressure spikes and progressive optic nerve damage.
Choice D reason: Open-angle glaucoma is typically painless and not associated with swelling. Medications target intraocular pressure, not pain or inflammation. This response is inaccurate, as it misaligns with the pathophysiology of glaucoma, which involves optic nerve damage from pressure, not inflammatory or painful symptoms.
Correct Answer is B
Explanation
Choice A reason: Delegating oral care to UAP is appropriate for routine hygiene in AIDS patients with candidiasis. Leaving oral care solely to the nurse is unnecessary unless complex treatments are required. A soft-bristled toothbrush ensures safe, effective cleaning, supporting UAP involvement in standard oral hygiene.
Choice B reason: A soft-bristled toothbrush is ideal for oral care in candidiasis, as it gently cleans without traumatizing painful ulcers. In AIDS, oral hygiene reduces fungal load and discomfort. This instruction ensures safe, effective care by UAP, aligning with standard hygiene practices for mucosal infections.
Choice C reason: Sterile gloves are unnecessary for routine oral care, as candidiasis is not highly contagious in this context. Standard precautions, including clean gloves, suffice for UAP performing hygiene. Requiring sterile gloves is excessive, complicating care without added benefit compared to using a soft toothbrush.
Choice D reason: Mouthwash may irritate candidiasis ulcers, especially if alcohol-based, and is not the priority. Brushing with a soft-bristled toothbrush effectively cleans the mouth without causing trauma. Mouthwash is secondary and requires nurse oversight to ensure compatibility with the client’s condition, unlike brushing.
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