A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?
Obtain arterial blood gases.
Administer a prescribed antipyretic.
Offer a prescribed PRN analgesic.
Suction to clear secretions from airway.
The Correct Answer is D
A. Obtaining arterial blood gases is important for assessing respiratory status but is not the immediate priority.
B. Administering an antipyretic can help reduce fever but does not address the immediate respiratory distress the client is experiencing.
C. Offering an analgesic can improve comfort but is not the priority intervention in this scenario.
D. Suctioning to clear secretions from the airway is the most critical intervention to improve the client’s respiratory status, especially given the weak cough effort and use of accessory muscles, indicating possible airway obstruction or ineffective clearance of secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","F","G"]
Explanation
A. Enalapril can potentially cause hyperkalemia and hypotension, which could be detrimental to a client with pneumonia. The prescription should be questioned due to these risks.
B. A chest X-ray may be necessary to assess the extent of pneumonia; thus, it is appropriate and should not be questioned.
C. Admission to the medical floor is necessary for monitoring the client's condition due to pneumonia, so this prescription is appropriate.
D. Monitoring vital signs every 4 hours is essential for assessing the client's condition, making this prescription appropriate.
E. Sending blood for a complete blood count and electrolytes is important to evaluate the patient's infection status and metabolic balance, so this is appropriate.
F. Changing the supplemental oxygen from a face mask to a nasal cannula may compromise oxygenation and should be questioned.
G. Administering ibuprofen could mask fever and may not be advisable in the presence of pneumonia, so this prescription should be questioned.
H. Continuous pulse oximetry is crucial for monitoring the patient's oxygen saturation, especially given the pneumonia diagnosis, making this prescription appropriate.
Correct Answer is B
Explanation
A. It is accurate that vaccination is most effective before symptoms appear, but this statement does not address the client's immediate need for treatment.
B. Oseltamivir (Tamiflu) is an antiviral medication that can be prescribed for influenza symptoms if taken within the first 48 hours of symptom onset, making it appropriate to refer the client for a prescription.
C. While over-the-counter medications may help alleviate some symptoms, they do not treat the underlying viral infection, and antiviral medications can be more effective.
D. This statement is true but does not directly answer the client's question about the treatment of influenza with oseltamivir.
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