A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?

A. Excessive pulmonary secretions can be a sign of airway irritation or infection rather than a direct adverse effect of oxygen therapy. It may warrant further assessment and intervention, but it is not typically attributed to oxygen therapy itself.
B. Dryness and cracking of oral mucous membranes can occur as a result of oxygen therapy. Oxygen delivered at higher concentrations or for prolonged periods can dry out mucous membranes, leading to discomfort and potential cracking.
C. Tachycardia (an elevated heart rate) can occur as a compensatory response to hypoxia or increased metabolic demands rather than as a direct adverse effect of oxygen therapy. However, if oxygen therapy leads to an overcorrection of hypoxemia, it could potentially contribute to changes in heart rate.
D. Poor skin turgor is typically a sign of dehydration or fluid imbalance, not directly related to oxygen therapy. It may be important to assess fluid status in clients receiving oxygen therapy, but poor skin turgor itself is not an adverse effect of oxygen administration.

A. The tragus is a small projection of cartilage in front of the ear canal. Applying gentle pressure to the tragus after instilling ear drops helps to facilitate the passage of the drops into the ear canal. This action should not be avoided; rather, it is recommended to enhance the delivery of the medication.
B. Sterile gloves are not typically necessary for instilling ear drops unless the client has an open or infected ear canal. Using clean, non-sterile gloves or practicing proper hand hygiene is sufficient to maintain cleanliness during the procedure.
C. For an adult client, pulling the pinna (outer ear) upward and backward helps to straighten the ear canal. This allows the drops to flow easily into the ear canal rather than pooling in the outer ear or leaking out. This technique ensures that the medication reaches the target area effectively.
D. Chilling otic (ear) solutions is not recommended unless specifically instructed by the healthcare provider for therapeutic reasons (e.g., to soothe ear pain or inflammation). Cold solutions can cause discomfort or dizziness when instilled into the ear. Therefore, otic solutions are typically administered at room temperature to avoid these adverse effects.