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 A
Explanation
A. The symptoms of persistent upper abdominal pain radiating to the back, elevated serum amylase and lipase levels, vomiting, and fever suggest acute pancreatitis, which can occur after cholecystectomy due to potential injury to the pancreas or bile duct obstruction.
B. While biliary duct obstruction can occur postoperatively, the significantly elevated amylase and lipase levels, along with the described symptoms, more strongly indicate pancreatitis.
C. Surgical site infection typically presents with localized symptoms rather than systemic symptoms like elevated amylase and lipase.
D. Hepatorenal failure is unlikely to present with these specific gastrointestinal symptoms and enzyme elevations.
Correct Answer is D
Explanation
A. While H. pylori can be related to gastrointestinal issues, it is not the primary focus in pancreatitis management, and urine output is less critical than pancreatic enzyme levels.
B. Assessing bowel sounds and abdominal pain is important, but specific laboratory results provide more concrete information regarding the condition.
C. Chronic constipation and serum gastrin levels are not directly relevant to acute pancreatitis.
D. The severity of nausea and vomiting, along with serum amylase results, directly indicates the status of pancreatitis, as elevated amylase levels are typically associated with this condition. This information is vital for guiding treatment decisions.
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