A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

Initiate humidification therapy.

Encourage the client to cough and deep breathe.

Increase the client's oral fluid intake.

Raise the head of the bed.

Answer and Explanation

The Correct Answer is D

Choice A reason: Initiating humidification therapy can be beneficial for a client with pneumonia. Humidified air can help loosen respiratory secretions, making them easier to expectorate. However, while this intervention is helpful, it is not typically the first action a nurse should take. The priority is to address the client's immediate need for adequate oxygenation and ventilation.

Choice B reason: Encouraging the client to cough and perform deep breathing exercises is an essential part of care for patients with pneumonia. These actions help to clear mucus from the lungs and improve ventilation. Deep breathing helps to fully expand the alveoli, which can be compromised in pneumonia, and coughing helps to expel secretions that may be blocking the airways. However, this is not the most immediate action when the oxygen saturation is borderline normal.

Choice C reason: Increasing the client's oral fluid intake is important in the management of pneumonia. Adequate hydration thins respiratory secretions, making them easier to clear. It also supports overall bodily functions, which can be taxed during illness. Nonetheless, this intervention is not the most critical initial step in managing a client's immediate respiratory needs.

Choice D reason: Raising the head of the bed is the correct and immediate action to take for a client with pneumonia and an oxygen saturation of 88%. This position helps to improve chest expansion, promotes better lung aeration, and facilitates easier breathing. It also reduces the risk of aspiration, which is particularly important in clients with pneumonia. Elevating the head of the bed is a simple yet effective way to enhance oxygenation and should be the first step taken.

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Correct Answer is A

Explanation

Choice A reason: The first step after a needlestick injury is to wash the wound with soap and water to reduce the risk of infection. This helps to remove any pathogens that may have been introduced into the puncture site.

Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.

Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.

Choice D reason: Postexposure prophylaxis (PEP) should be started as soon as possible, ideally within hours and no later than 72 hours after potential exposure to HIV. Waiting until the following day could decrease the effectiveness of PEP.

A. Severity of the condition B. Vital signs C. Nonverbal behavior D. Self-report of pain

Correct Answer is D

Explanation

Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.

Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.

Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.

Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.

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A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

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