A client presents with a temperature of 100°F (37.8°C) and reports difficulty breathing. Which intervention should the nurse implement first?

Obtain arterial blood gases

Suction to clear secretions from airway

Offer a prescribed PRN analgesia

Administer a prescribed antipyretic

Answer and Explanation

The Correct Answer is B

Choice A reason: Arterial blood gases assess oxygenation and acid-base balance, critical for diagnosing respiratory distress severity. However, this diagnostic measure does not immediately relieve airway obstruction. Clearing secretions is prioritized to restore ventilation, as hypoxia can rapidly cause tissue damage or cardiac arrest in acute respiratory distress.

Choice B reason: Suctioning removes airway secretions, directly addressing breathing difficulty. Secretions obstruct airways, reducing oxygen delivery to alveoli and impairing gas exchange. Immediate suctioning restores patency, enhances ventilation, and prevents hypoxia, making it the priority intervention to stabilize the client’s respiratory function in acute distress.

Choice C reason: PRN analgesia addresses pain, which is not indicated as the primary issue. Pain relief does not resolve airway obstruction or improve breathing. Administering analgesia prematurely could mask respiratory symptoms, delaying critical airway management and potentially worsening hypoxia by neglecting the underlying obstruction.

Choice D reason: An antipyretic reduces fever, improving comfort but not addressing breathing difficulty. Fever is secondary, and treating it does not restore airway patency or oxygenation. Airway management is prioritized in respiratory distress to prevent hypoxia and ensure effective gas exchange before managing fever symptoms.

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Correct Answer is C

Explanation

Choice A reason: Throat irritation is a common albuterol side effect due to its deposition in the oropharynx during inhalation. It is not life-threatening and can be managed with rinsing or spacer use. This does not require immediate intervention compared to cardiovascular effects, as it does not compromise vital organ function.

Choice B reason: Uncontrollable shaking (tremors) is a frequent albuterol side effect, resulting from beta-2 receptor stimulation in skeletal muscles. It is usually transient and benign, not requiring immediate intervention. Monitoring is sufficient unless severe, as it does not pose an acute threat compared to cardiac irregularities.

Choice C reason: An irregular rapid heart rate (tachycardia or arrhythmia) is a serious albuterol side effect, as beta-2 agonists can stimulate beta-1 receptors in the heart, causing cardiovascular instability. This warrants immediate intervention, as it risks cardiac compromise, especially in emphysema patients with compromised respiratory and cardiac reserves.

Choice D reason: Increased anxiety is a possible albuterol side effect due to its stimulatory effects on the central nervous system. While distressing, it is not immediately life-threatening. It requires monitoring but is secondary to cardiovascular complications, which pose a greater acute risk in emphysema patients with wheezing.

A. Age over 40 years B. Daily walking 2 to 3 miles C. Low-fat diet D. Male gender

Correct Answer is A

Explanation

Choice A reason: Age over 40 increases cholelithiasis risk due to reduced gallbladder motility and increased bile cholesterol saturation, promoting gallstone formation. Aging alters bile composition, with higher lithogenic potential, making older adults more susceptible to cholesterol gallstones, a primary type in Western populations.

Choice B reason: Daily walking of 2 to 3 miles reduces cholelithiasis risk by promoting physical activity, which enhances gallbladder motility and reduces bile stasis. Exercise lowers cholesterol levels in bile, decreasing stone formation, making this a protective factor rather than a risk.

Choice C reason: A low-fat diet decreases cholelithiasis risk by reducing dietary cholesterol intake, which lowers bile cholesterol saturation. This promotes healthier bile composition, reducing the likelihood of cholesterol gallstone formation, making it a protective dietary habit rather than a risk factor.

Choice D reason: Male gender is associated with a lower risk of cholelithiasis compared to females, who have higher estrogen levels that increase bile cholesterol. Men have less lithogenic bile, making gender a protective factor, not a significant risk, unlike age-related changes.

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A client presents with a temperature of 100°F (37.8°C) and reports difficulty breathing. Which intervention should the nurse implement first?

Nursing Test Bank

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Correct Answer is C

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