An adult client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?
Administer a prescribed antipyretic.
Offer a prescribed PRN analgesic.
Suction to clear secretions from airway.
Obtain arterial blood gases.
The Correct Answer is C
C. The client's weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise. Suctioning to clear secretions from the airway can help improve air exchange and alleviate respiratory distress.
A. The client's primary issue appears to be respiratory distress rather than fever.
B. Offering pain relief is important for overall comfort but it is not be the most immediate intervention needed to address the client's respiratory distress.
D. Arterial blood gases may provide valuable information but they may not be the most immediate intervention needed to address the client's respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. After eye surgery, especially when there's been trauma like glass removal, it's crucial to protect the eye from further injury, particularly during sleep when movements may be involuntary and less controlled. An eye shield helps prevent inadvertent rubbing or trauma to the eye, promoting healing and reducing the risk of complications.
A. While deep breathing and coughing exercises are important for preventing respiratory complications after surgery, they are not the immediate intervention required following surgical removal of glass from the eye.
B. Monitoring vital signs is essential for assessing the client's overall health status and detecting any signs of complications. However, it is not a priority
D. While administering eye drops may be a part of postoperative care, it's not the immediate intervention required right after the surgical removal of glass from the eye.
Correct Answer is A
Explanation
A. Tiotropium is commonly delivered via a handihaler device for inhalation. Using the medication every day is consistent with the recommended dosing regimen for managing chronic obstructive pulmonary disease (COPD) symptoms.
B. While it's important for clients with COPD to have access to a rescue inhaler for sudden shortness of breath, it's also crucial for them to understand the specific instructions for using each medication.
C. Tiotropium is a long-acting bronchodilator that helps relax the airway muscles. It does not have direct effect on the thickness of mucus secretions.
D. While tiotropium can help prevent exacerbations and reduce the frequency of sudden shortness of breath, it is not typically used as a rescue inhaler for acute symptom relief.
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