A patient with right lower-lobe pneumonia has been treated with intravenous antibiotics for 3 days.Which assessment data obtained by the nurse indicates that the treatment is effective?

Choice C rationale

Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.

Choice A rationale

Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.

Choice B rationale

Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.

Choice D rationale

Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.

Choice A rationale

Measuring blood pressure manually is important in assessing the patient's hemodynamic status, but it is not the priority intervention in diabetic ketoacidosis (DKA). The priority is to address dehydration and electrolyte imbalances.

Choice B rationale

Administering intravenous fluids is the priority intervention for a client with DKA. Rapid, deep respirations (Kussmaul breathing) indicate severe metabolic acidosis and dehydration. IV fluids help to correct fluid deficit, improve perfusion, and decrease blood glucose levels.

Choice C rationale

Oxygen therapy may be beneficial if the client is hypoxic, but it is not the priority intervention for DKA. The primary issue is fluid deficit and metabolic acidosis.

Choice D rationale

Administering subcutaneous insulin is essential for managing hyperglycemia in DKA, but it should be done after initiating IV fluids to avoid rapid shifts in electrolyte balance.