The nurse is assessing a client experiencing acute pain.
What assessments should validate the client with acute pain? Select all that apply.

The nurse should obtain a sputum culture specimen before administering any antibiotics to the client with bacterial pneumonia.

This is because the sputum culture can help identify the causative organism and the appropriate antibiotic therapy.

Administering antibiotics before obtaining the sputum culture can alter the results and lead to ineffective treatment.

Choice B is wrong because azithromycin is an antibiotic that should be given after obtaining the sputum culture.

Choice C is wrong because coughing and deep breathing are important interventions to promote airway clearance and gas exchange, but they are not the priority actions for this client.

Choice D is wrong because offering clear liquids can help prevent dehydration and thin secretions, but they are not the most urgent action for this client.

Normal ranges for blood urea nitrogen (BUN) are 7 to 20 mg/dL and for creatinine are 0.6 to

1.2 mg/dL.

Elevated levels of these substances can indicate renal impairment, which can be a complication of bacterial pneumonia.

The nurse should monitor these levels and report any abnormalities to the health care provider.

A client who has been NPO for four days is most at risk to develop skin breakdown. This is because being NPO (nothing by mouth) can lead

to malnutrition and dehydration, which are both risk factors for bedsores. Malnutrition can impair the skin’s ability to heal and resist infection, while dehydration can make the skin dry and fragile.

Choice A is wrong because applying powder after drying the skin can help prevent moisture and friction, which are also risk factors for bedsores.

Choice C is wrong because bathing twice a week may not be frequent enough to keep the skin clean and free of irritants, which can also contribute to bedsores.

Choice D is wrong because hypertension (high blood pressure) does not directly cause bedsores, although it may be associated with other conditions that affect blood circulation and tissue oxygenation.