The practical nurse (PN) is caring for a hospice client who requests a priest for the "Last Rites." Which should be the next response by the PN?

The child’s symptoms—drowsiness, thick yellow secretions, low respiratory rate, and fever—along with the chest x-ray showing consolidation consistent with pneumonia, indicate that he is experiencing respiratory insufficiency. Respiratory insufficiency occurs when the respiratory system fails to meet the body's oxygen needs or remove carbon dioxide effectively.

Actions to Take:

1. Perform oropharyngeal suctioning
Suctioning is necessary to clear the thick yellow secretions that can obstruct the airway and contribute to respiratory insufficiency. It helps maintain a patent airway and improves the child's ability to breathe.

2. Provide humidified supplemental oxygen
Humidified oxygen helps to maintain airway moisture and improve oxygenation, which is critical for managing respiratory insufficiency. It can also help loosen secretions and alleviate symptoms related to pneumonia.

Parameters to Monitor:

1. Oxygen Saturation
Monitoring oxygen saturation is essential to assess the effectiveness of supplemental oxygen and interventions for respiratory insufficiency. Low oxygen saturation indicates that the respiratory system is not meeting the oxygen demands of the body.

2. Temperature
Temperature monitoring is important to assess the effectiveness of fever management and to monitor for potential worsening of the infection. Elevated temperature can exacerbate respiratory insufficiency and indicate ongoing infection.

A. Administering acetaminophen can help reduce fever and discomfort but does not directly address the respiratory distress indicated by tachypnea and stridor.
B. Monitoring the child's oxygen saturation level via pulse oximeter is essential to assess the severity of the respiratory distress. It provides critical information on the child's oxygenation status and helps guide further interventions.
C. Encouraging the child to drink adequate amounts of cool, clear liquids is beneficial for hydration but does not directly address the acute respiratory symptoms of irritability, tachypnea, and stridor.
D. Instructing the mother to play with the child for stimulation and distraction may help alleviate irritability but does not address the underlying respiratory distress, which requires immediate attention.