After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.
Which action should the nurse take next?

Choice A rationale:

Ask the wife to stop and assess the client's swallowing reflex. Rationale: While assessing the client's swallowing reflex is important, the immediate priority is to provide hydration and comfort to the client, especially if the client is tearful and attempting to drink water. The nurse should assist the wife in providing small sips of water while being cautious and observing the client's ability to swallow safely.

Choice B rationale:

Give the wife a straw to help facilitate the client's drinking. Rationale: Giving the wife a straw may be helpful, but it does not address the client's immediate need for hydration and assistance with drinking. The nurse should actively assist in providing water to the client while assessing the client's ability to swallow safely.

Choice C rationale:

Assist the wife and carefully give the client small sips of water. Rationale: This is the correct answer. The nurse's immediate priority should be to assist the client with hydration. Providing small sips of water while being cautious and observing the client's ability to swallow safely is an appropriate action. This can help address the client's immediate needs for comfort and hydration.

Choice D rationale:

Obtain thickening powder before providing any more fluids. Rationale: While thickening powder may be necessary for clients with swallowing difficulties, it may cause unnecessary delay in providing hydration to the client in distress. The nurse should first provide water and assess the client's swallowing abilities. If thickened liquids are indicated, they can be administered later as per the healthcare provider's orders.

Choice A rationale:

Supplemental oxygen is given to the patient to prevent hypoxia and tissue damage due to pneumonia. Pneumonia is an infection that inflames the air sacs in one or both lungs, which may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing. Hypoxia occurs when the body or a region of the body is deprived of adequate oxygen supply at the tissue level. It can cause serious damage to your heart, brain, and other organs. Hence, supplemental oxygen is administered to ensure that the patient’s tissues receive adequate oxygen.

Choice B rationale:

While supplemental oxygen can indirectly help lower blood pressure by improving oxygen supply and reducing strain on the heart, it is not primarily used for this purpose. Enalapril, which the patient is already taking, is an angiotensin-converting enzyme (ACE) inhibitor that is commonly used to lower blood pressure and reduce the workload of the heart.

Choice C rationale:

Supplemental oxygen does increase the oxygen saturation and improve respiratory function. However, this is a more general rationale for providing supplemental oxygen and not specific to this patient’s condition of pneumonia.

Choice D rationale:

Supplemental oxygen does not directly dilate the bronchioles or decrease inflammation in the lungs. Medications such as bronchodilators and corticosteroids are typically used for these purposes. In this case, supplemental oxygen is being used to prevent hypoxia and tissue damage due to pneumonia.