A nurse is caring for a client diagnosed with pneumonia and assesses labored breathing and copious tracheobronchial secretions. What priority action should the nurse encourage with the client?

Pulmonary Function Tests assess chronic respiratory conditions like COPD and asthma. In an acute pneumothorax, these tests are unnecessary as the priority is stabilizing the airway and restoring lung expansion. The client is in respiratory distress, making PFTs impractical and irrelevant at this stage.

Obtain Intravenous Access: IV access is necessary to administer fluids, medications, and potential emergency interventions. Given the client's signs of respiratory distress and hemodynamic instability (tachycardia, hypotension), IV access ensures rapid treatment in case of deterioration.

Thoracentesis: Thoracentesis is used to remove pleural fluid in conditions like pleural effusion but is not appropriate for a pneumothorax. Inserting a needle into the pleural space could worsen the lung collapse and lead to further respiratory compromise. The correct intervention is a chest tube insertion.

Obtain ABGs: ABGs provide critical information on oxygenation, ventilation, and acid-base balance. The client has tachypnea, cyanosis, and low O₂ saturation, indicating possible respiratory acidosis or hypoxemia. ABGs will guide oxygen therapy and further management.

Prepare for Insertion of a Chest Tube: A chest tube is the definitive treatment for a pneumothorax. It removes air from the pleural space, allowing lung re-expansion. Given the client's absent breath sounds, tachypnea, and hypoxia, immediate chest tube insertion is necessary to prevent further deterioration.

Computed Tomography (CT) of the Chest: While a CT scan provides detailed lung imaging, it is not the first-line diagnostic tool for pneumothorax. A chest X-ray is usually sufficient to confirm the diagnosis. In an emergency setting, immediate intervention (such as chest tube placement) takes priority over advanced imaging.

A. Respond to ventilator alarms: While it is crucial to respond to ventilator alarms promptly to ensure the client’s safety and adequate ventilation, this action is not the highest priority in relation to the use of neuromuscular blockers. The use of neuromuscular blockade requires a broader focus on the patient's overall care and safety.
B. Report the absence of spontaneous respirations: Reporting the absence of spontaneous respirations is important, as neuromuscular blockers can cause paralysis of the respiratory muscles. However, the focus should be on maintaining the client's safety and comfort while they are on mechanical ventilation, rather than just reporting findings.
C. Provide passive range-of-motion exercises: This is the priority action when caring for a client receiving neuromuscular blockers. Since the client cannot move voluntarily due to the effects of the neuromuscular blockade, passive range-of-motion exercises are essential to prevent complications such as contractures and muscle atrophy. This intervention helps maintain joint mobility and circulation, which is critical in patients who are mechanically ventilated for an extended period.
D. Encourage the client to attempt to breathe on their own: Encouraging the client to breathe on their own is not appropriate when they are receiving neuromuscular blockade, as their respiratory muscles are paralyzed. Instead, the focus should be on ensuring that the mechanical ventilation settings are adequate to provide proper oxygenation and ventilation while the client cannot initiate breaths independently. This action could lead to respiratory distress if attempted while under neuromuscular blockade.