A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?
Obtain arterial blood gases.
Administer a prescribed antipyretic.
Offer a prescribed PRN analgesic.
Suction to clear secretions from airway.
The Correct Answer is D
A. Obtaining arterial blood gases is important for assessing respiratory status but is not the immediate priority.
B. Administering an antipyretic can help reduce fever but does not address the immediate respiratory distress the client is experiencing.
C. Offering an analgesic can improve comfort but is not the priority intervention in this scenario.
D. Suctioning to clear secretions from the airway is the most critical intervention to improve the client’s respiratory status, especially given the weak cough effort and use of accessory muscles, indicating possible airway obstruction or ineffective clearance of secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Eye drops for glaucoma are not used for pain and swelling control but to manage intraocular pressure.
B. Open-angle glaucoma is not about restoring a smaller angle; it is managed primarily by controlling intraocular pressure.
C. Long-term use of eye drops is necessary for maintaining normal eye pressure and preventing optic nerve damage in clients with open-angle glaucoma.
D. While the drops may reduce excess pressure initially, lifelong treatment is generally required to maintain safe pressure levels and prevent further damage.
Correct Answer is A
Explanation
A. Culturing for sensitive organisms is essential in identifying the causative agent of the infection indicated by the purulent drainage, guiding appropriate antibiotic therapy.
B. Blood pH level is not directly relevant to assessing wound drainage or infection status.
C. C-reactive protein (CRP) can indicate inflammation but is not specific enough to provide immediate information regarding the infection at the wound site.
D. Serum blood glucose level is more relevant for assessing the client's overall metabolic status and risk for infections rather than directly correlating with the purulent drainage observed.
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