During change-of-shift report on a medical unit, a client admitted with aspiration pneumonia and respiratory distress has become increasingly agitated. Which action should the nurse take first?
Notify the health care provider about the client's status
Give the prescribed PRN sedative drug
Use pulse oximetry to check the oxygen saturation
Offer reassurance and reorient the client
The Correct Answer is C
Choice A reason: Notifying the provider is important but not the first action. Agitation in aspiration pneumonia may stem from hypoxemia, a life-threatening issue. The ABCDE approach prioritizes assessing breathing (oxygen saturation) to identify and correct hypoxemia before escalating to the provider, ensuring immediate intervention for a potentially reversible cause.
Choice B reason: Administering a PRN sedative may reduce agitation but risks masking underlying causes like hypoxemia, common in aspiration pneumonia. Sedatives can depress respiration, worsening hypoxia. The ABCDE approach prioritizes assessing oxygen status first to address life-threatening causes of agitation, making sedation a secondary consideration after evaluation.
Choice C reason: Agitation in aspiration pneumonia often results from hypoxemia due to alveolar inflammation and impaired gas exchange. Using pulse oximetry to check oxygen saturation is the first action in the ABCDE approach, as it assesses breathing and identifies hypoxia, a life-threatening condition requiring immediate oxygen therapy or ventilatory support to stabilize the client.
Choice D reason: Offering reassurance and reorientation addresses agitation’s psychological aspects but does not treat underlying physiological causes like hypoxemia. In aspiration pneumonia, agitation is likely due to low oxygen levels, which must be assessed first via pulse oximetry. The ABCDE approach prioritizes breathing over non-physiological interventions in acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: IV corticosteroids reduce inflammation in conditions like autoimmune pancreatitis, but they do not address acute hypoxemia. Sudden dyspnea and low oxygen saturation (85%) in acute pancreatitis suggest complications like ARDS or pleural effusion, requiring immediate oxygenation. Corticosteroids act slowly and are not the priority for correcting life-threatening hypoxia in this scenario.
Choice B reason: Sudden dyspnea and oxygen saturation of 85% indicate acute hypoxemia, potentially from ARDS or pulmonary complications in pancreatitis. High-flow oxygen therapy increases alveolar oxygen, improving arterial PaO2 and preventing tissue hypoxia. The ABCDE approach prioritizes breathing, making this the first intervention to stabilize the client before addressing underlying causes.
Choice C reason: ERCP diagnoses or treats pancreatic duct obstructions, a potential cause of pancreatitis, but it does not address immediate hypoxemia. Dyspnea and low saturation require urgent oxygen delivery to prevent organ damage. ERCP is a diagnostic or therapeutic procedure, not an acute intervention for respiratory distress in this critical scenario.
Choice D reason: Increasing IV fluid rate supports hydration and perfusion in pancreatitis, preventing hypovolemia. However, it does not correct acute hypoxemia causing dyspnea and low saturation. The ABCDE approach prioritizes breathing, and high-flow oxygen is needed to address the immediate threat of hypoxia, making fluid adjustment a secondary intervention.
Correct Answer is C
Explanation
Choice A reason: A respiratory rate of 28/min and temperature of 101°F suggest tachypnea and fever, possibly due to infection or inflammation. While concerning, these do not indicate immediate life-threatening issues like acute coronary syndrome. The ABCDE approach prioritizes circulation (chest pain) over respiratory rate, making this a lower priority.
Choice B reason: Difficulty swallowing and nausea may indicate an esophageal issue or infection but are not immediately life-threatening. These symptoms do not compromise airway, breathing, or circulation acutely in the ABCDE framework. Chest pain with diaphoresis suggests a cardiac emergency, which takes precedence due to potential for rapid deterioration.
Choice C reason: Chest pain with diaphoresis is highly suggestive of acute coronary syndrome, such as myocardial infarction, a life-threatening emergency. The ABCDE approach prioritizes circulation, and these symptoms indicate potential cardiac ischemia, requiring immediate assessment, ECG, and intervention to prevent cardiac arrest, making this the highest priority client.
Choice D reason: Blood pressure of 100/60 mm Hg with a painful, swollen wrist suggests a musculoskeletal injury with mild hypotension. While concerning, it is not immediately life-threatening compared to chest pain with diaphoresis, which may indicate acute coronary syndrome. The ABCDE approach prioritizes circulation issues like cardiac events over stable injuries.
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