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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hepatorenal failure involves liver and kidney dysfunction, typically from chronic liver disease or shock. Elevated amylase and lipase, with pain and vomiting, point to pancreatic inflammation, not hepatorenal issues. Pancreatitis is more consistent with the client’s post-cholecystectomy presentation and lab findings.
Choice B reason: Biliary duct obstruction causes jaundice and elevated bilirubin, not amylase or lipase. Pain may radiate, but vomiting and fever with high pancreatic enzymes suggest pancreatitis, a known post-cholecystectomy complication, rather than a blocked bile duct, which lacks pancreatic enzyme elevation.
Choice C reason: Surgical site infection causes localized pain, erythema, and fever but not elevated amylase or lipase. Radiating pain and vomiting align with pancreatitis, not wound infection. Pancreatic enzyme elevation is specific to pancreatic inflammation, making infection less likely than pancreatitis in this scenario.
Choice D reason: Acute pancreatitis is characterized by elevated amylase and lipase, epigastric pain radiating to the back, vomiting, and fever. Post-cholecystectomy, bile duct manipulation or gallstone migration can trigger pancreatitis. These findings align perfectly with the client’s symptoms and lab results, making it the correct condition.
Correct Answer is A
Explanation
Choice A reason: Neutropenia, a low neutrophil count, is a common chemotherapy side effect due to bone marrow suppression, increasing infection risk. Monitoring neutrophil counts is critical, as infections in breast cancer patients can be life-threatening, making it the priority side effect to assess.
Choice B reason: Hypertension is not a typical chemotherapy side effect, though some agents cause cardiovascular effects. Neutropenia is more common, compromising immunity, making it the priority to monitor, as infections pose an immediate threat in breast cancer patients on chemotherapy.
Choice C reason: Hyperkalemia is rare with chemotherapy, except in tumor lysis syndrome. Neutropenia is a frequent side effect, increasing infection risk due to marrow suppression, making it the priority to monitor, as it directly impacts patient safety during breast cancer treatment.
Choice D reason: Weight gain is not a primary chemotherapy side effect; weight loss is more common due to nausea. Neutropenia is critical to monitor, as low neutrophils increase infection risk, requiring urgent intervention in breast cancer patients undergoing chemotherapy.
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