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 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.

A. Remove ties to secure a disposable, soft foam collar with hook and loop fastener B. Secure tracheostomy ties by making knots close to the tube C. Leave the old ties in place until the new ones are secure D. Place knots of the ties lateral to prevent irritation and pressure

Correct Answer is C

Explanation

Choice A reason: Using a soft foam collar may reduce skin irritation but risks dislodging the tracheostomy tube if not secured properly. Leaving old ties in place until new ones are secure ensures tube stability, preventing accidental decannulation, which is critical in early tracheostomy care.

Choice B reason: Knots close to the tracheostomy tube increase pressure on the skin, risking irritation or necrosis. This is incorrect, as ties should allow slight movement. Maintaining old ties until new ones are secure prevents tube displacement, prioritizing airway safety during the procedure.

Choice C reason: Leaving old ties in place until new ones are secure prevents tracheostomy tube dislodgement, a life-threatening risk. This ensures continuous airway patency during tie changes, especially in fresh tracheostomies, making it the safest and most critical action to maintain tube stability.

Choice D reason: Placing knots laterally reduces irritation but does not address the risk of tube dislodgement during tie changes. Keeping old ties in place until new ones are secure is the priority, as it ensures the tube remains stable, preventing airway compromise.

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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

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is securing a tracheostomy tube for a client post-procedure. Which action should the nurse take to ensure proper tracheostomy care?

Correct Answer is C

Explanation

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