A client is being treated for bacterial pharyngitis. Which of the following should a nurse recommend when promoting the client's nutrition during treatment?

A. Auscultate lungs for the presence of breath sounds: This is the priority action following endotracheal intubation, as it directly assesses the effectiveness of the intubation. Auscultating the lungs allows the nurse to confirm that the endotracheal tube is properly positioned in the trachea and that air is reaching the lungs. Abnormal breath sounds, such as decreased or absent sounds on one side, may indicate improper placement or complications like a pneumothorax, making this assessment critical for patient safety.
B. Assess baseline level of consciousness: While assessing the client's level of consciousness is important for evaluating their overall neurological status, it is not the immediate priority following intubation. Changes in consciousness can be influenced by various factors, including sedation or hypoxia, but ensuring proper airway placement and ventilation is more urgent to prevent respiratory compromise.
C. Assess for the presence of circumoral cyanosis: Circumoral cyanosis can indicate inadequate oxygenation, but it may not be immediately apparent after intubation. This assessment is important, but it is secondary to confirming that breath sounds are present and that the airway is secure. Identifying airway placement issues is more crucial before evaluating for signs of hypoxia.
D. Determine that the pulse oximetry is greater than 95%: Monitoring pulse oximetry is essential for assessing oxygen saturation and identifying potential hypoxia. However, if the endotracheal tube is not properly placed, the pulse oximetry may not accurately reflect the client’s respiratory status. Therefore, ensuring proper ventilation through auscultation of breath sounds takes precedence over solely relying on pulse oximetry readings.

A. Clubbing of the fingers: This finding is often associated with chronic respiratory conditions, including emphysema, due to prolonged hypoxia. The chronic low oxygen levels can lead to changes in the nail beds, resulting in clubbing as the body attempts to compensate for the decreased oxygenation. Therefore, clubbing is a common assessment finding in clients with emphysema.
B. Bradycardia: Emphysema typically does not cause bradycardia; instead, clients may experience tachycardia due to increased respiratory effort and oxygen demand. While individual variations can occur, bradycardia is not a standard finding in clients with emphysema, making this option less likely to be present.
C. Barrel chest: This is a common physical assessment finding in clients with emphysema. The chronic overinflation of the lungs leads to a characteristic increase in the anteroposterior diameter of the chest, resulting in a barrel-shaped appearance. This occurs as the diaphragm becomes flattened and the rib cage is expanded from prolonged air trapping.
D. Dyspnea: Shortness of breath, or dyspnea, is a hallmark symptom of emphysema. As the disease progresses, clients may experience increased difficulty in breathing, especially during exertion, due to the destruction of alveoli and reduced lung elasticity. This finding is expected and significant in the assessment of a client with emphysema.
E. Deep respirations: In emphysema, clients often exhibit shallow, rapid breathing patterns rather than deep respirations. The loss of elasticity in the lungs leads to difficulty in full lung expansion, which can result in a more shallow and increased respiratory rate. Therefore, deep respirations are not a typical finding in clients with emphysema.