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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Evaluating chest expansion assesses breathing, the second priority in the ABCDE approach. Trauma from a motor vehicle crash may cause rib fractures, pneumothorax, or hemothorax, impairing ventilation. Unequal or absent expansion indicates a life-threatening issue, requiring immediate intervention like chest tube placement to restore adequate respiration.

Choice B reason: Assessing capillary refill evaluates peripheral perfusion, a circulation parameter in the ABCDE approach. While important, it is secondary to airway and breathing. Trauma patients may have shock, but chest injuries affecting ventilation (e.g., pneumothorax) are more immediate threats, making chest expansion the first assessment to ensure respiratory function.

Choice C reason: Checking pupillary response assesses neurological status (disability in ABCDE), relevant for head trauma. However, breathing takes precedence over neurological assessment in trauma patients. Chest injuries can cause rapid respiratory failure, making chest expansion evaluation critical to identify life-threatening conditions like flail chest or pneumothorax before neurological checks.

Choice D reason: Checking orientation to place and time assesses neurological function, part of the disability component in ABCDE. While important in trauma, it is secondary to airway and breathing. Chest injuries from a crash can compromise ventilation, making chest expansion the priority to detect and address immediate respiratory threats before neurological evaluation.

A. Report of discomfort during dialysate inflow B. Slight pressure in the abdomen C. Yellow dialysate outflow D. Purulent dialysate outflow

Correct Answer is D

Explanation

Choice A reason: Discomfort during dialysate inflow is common in peritoneal dialysis due to the rapid introduction of fluid into the peritoneal cavity, stretching the peritoneum. It is usually transient and not a sign of serious complications like infection. Immediate reporting is unnecessary unless severe or persistent, as it does not indicate an acute emergency.

Choice B reason: Slight abdominal pressure during peritoneal dialysis is normal due to the presence of dialysate in the peritoneal cavity. It does not indicate a serious complication like infection or peritonitis. This sensation typically resolves and does not require immediate reporting unless accompanied by severe pain or other alarming symptoms.

Choice C reason: Yellow dialysate outflow is typically normal, as dialysate may appear slightly yellow due to the presence of fibrin or minor hemolysis. It does not indicate infection or a life-threatening issue. Clear or slightly yellow outflow is expected, unlike purulent outflow, which signals infection and requires urgent attention.

Choice D reason: Purulent dialysate outflow indicates peritonitis, a serious complication of peritoneal dialysis caused by bacterial infection in the peritoneal cavity. This presents with cloudy, pus-filled effluent, often with fever or abdominal pain. Immediate reporting is critical to initiate antibiotics and prevent sepsis, making this the most urgent finding to address.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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