The nurse is caring for a patient with a blood pressure of 88/50 and symptomatic. The nurse recognizes which nursing action is a priority?

Choice A reason: Administering an extra dose of albuterol before bedtime is not appropriate. The correct approach is to manage bronchial secretions through other means, such as hydration.

Choice B reason: Using a dehumidifier is not recommended for clients with respiratory issues. A humidifier, not a dehumidifier, helps keep the air moist and can help with secretions.

Choice C reason: Increasing the amount of fluids consumed helps to thin bronchial secretions, making them easier to cough up. Hydration is an effective method to manage secretions and improve respiratory function.

Choice D reason: Increasing daily exercise can be beneficial for overall health but is not the primary method to clear bronchial secretions. Hydration is more directly effective in this situation.

Rationale

• B. Sudden pain relief: The intense pain associated with otitis media is caused by the accumulation of fluid and pressure against the tympanic membrane. When the membrane ruptures, that pressure is instantaneously released, resulting in a sudden and dramatic decrease in pain. This is often followed by purulent (pus-filled) or serosanguineous (bloody) drainage in the external ear canal.

Why the others are incorrect

• A. Increased temperature: While a fever is a common sign of an acute infection (Acute Otitis Media), it is not a specific indicator that the eardrum has ruptured. In fact, systemic symptoms like fever may actually decrease once the pressure and infection are vented through a rupture.

• C. Popping sensation when swallowing: This sensation is typically associated with the opening and closing of the Eustachian tube as it attempts to equalize pressure in the middle ear. It is a common symptom of Eustachian tube dysfunction or fluid in the ear, but it indicates an intact eardrum rather than a ruptured one.

• D. Green-blue discharge in the ear canal: While drainage (otorrhea) occurs after a rupture, the color is typically clear, bloody, or yellowish-white (purulent). Green-blue discharge is more characteristic of Pseudomonas infections, often seen in otitis externa (swimmer's ear), rather than a standard tympanic membrane rupture from middle ear effusion.