A nurse is caring for a client who has Alzheimer's disease and is confused. Which of the following actions should the nurse take?

Choice A reason: The correct answer is a because auscultating the lung fields allows the nurse to determine the areas of congestion and plan the most effective positioning and techniques for chest percussion, vibration, and postural drainage.

Choice B reason: Providing mouth care is important for client comfort but is not the first step in preparing for chest physiotherapy.

Choice C reason: Cupping hands and tapping on the client’s chest repeatedly is part of the chest percussion technique but should be done after assessing the lung fields to target the appropriate areas.

Choice D reason: Positioning the client so that the lung area to be drained is above the trachea is part of postural drainage but should be planned based on the findings from auscultation.

Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.

Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.

Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.

Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.