A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take?

Choice A Reason

Determine the time the last dose of pain medication was administered. While it is important to know when the last dose of pain medication was given, assessing the client’s current pain level is a priority. This helps in understanding the severity and nature of the pain, which guides further interventions.

Choice B Reason

Reposition the client to assist with reduction of pain. Repositioning can help alleviate pain, but it should be done after assessing the pain. Without understanding the pain’s characteristics, repositioning might not address the underlying issue effectively.

Choice C Reason

Ask the client to describe the pain and rate it on a scale of 0 to 10. This is the correct first action. Pain assessment is crucial in determining the appropriate intervention. By asking the client to describe and rate their pain, the nurse can tailor the pain management plan to the client’s specific needs.

Choice D Reason

Check the client’s medical record for type of PRN pain medication. Reviewing the medical record for PRN pain medication is important, but it should follow the initial pain assessment. Knowing the pain’s intensity and characteristics will help in deciding whether PRN medication is needed.

Choice A Reason

Request a prescription for an antibiotic. This intervention is not typically included in the standard care plan for all COPD patients. Antibiotics are generally reserved for cases of acute exacerbations of COPD (AECOPD) with signs of bacterial infection, such as increased dyspnea, increased sputum purulence, and increased sputum volume. Routine use of antibiotics without these signs is not recommended.

Choice B Reason

Educate the client on pursed-lip breathing. This is the correct intervention. Pursed-lip breathing is a technique that helps improve ventilation, release trapped air in the lungs, and reduce the work of breathing. It is particularly beneficial for patients with COPD as it helps them manage shortness of breath and improve their breathing efficiency.

Choice C Reason

Place the client on airborne precautions. This intervention is incorrect. COPD is not an infectious disease that requires airborne precautions. Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis. COPD management focuses on improving lung function and preventing exacerbations.

Choice D Reason

Initiate oxygen therapy for SpO₂ of 92%. This intervention is partially correct but needs clarification. Oxygen therapy is typically initiated for COPD patients with chronic hypoxemia, usually when SpO₂ is less than 88-90%. An SpO₂ of 92% may not necessarily require oxygen therapy unless the patient is experiencing significant symptoms or has other comorbid conditions.