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. Set ground rules: This step involves establishing guidelines for the discussion to ensure that all participants feel respected and heard. By inviting each staff member to speak in turn and asking them to listen respectfully without making personal or professional remarks, the nurse manager is creating a safe and structured environment for open communication. Setting ground rules is crucial for facilitating a productive dialogue and minimizing conflict during negotiations.
B. Perform an opening move: This refers to the initial statement or action taken to start the negotiation process. While the nurse manager is initiating the meeting, the emphasis on respectful communication and turn-taking indicates that the focus is more on establishing an effective communication framework rather than simply making an opening statement.
C. Continue the negotiation: This step implies that the negotiation is already underway and is focused on maintaining momentum in the discussion. However, the scenario describes the nurse manager taking proactive steps to set the stage for the negotiation rather than continuing an existing conversation.
D. Clarify the problem: While it is important to identify and clarify the staffing issues and tardiness, the nurse manager's actions are more about creating an environment for discussion rather than explicitly defining the problem at this stage. Setting ground rules is a foundational step that supports problem clarification by fostering respectful dialogue among participants.