A nurse is collecting data from a client who has pneumonia and reports shortness of breath. The nurse notes the client has crackles auscultated in the lower lobes and an SaO2 of 88% on room air. Which of the following actions should the nurse take first?
Assist the client to cough and deep breathe.
Administer scheduled antibiotic medication.
Discuss the pneumococcal vaccine with the provider.
Position the client in high-Fowler's position.
The Correct Answer is D
A. Assist the client to cough and deep breathe: Encouraging coughing and deep breathing helps mobilize secretions and improve alveolar ventilation. While this is an important intervention for pneumonia, it does not immediately address the client’s current hypoxemia, which requires rapid intervention to improve oxygenation.
B. Administer scheduled antibiotic medication: Antibiotics are essential to treat the underlying infection, but their effect is not immediate. They do not correct acute hypoxemia or respiratory distress, so administering the antibiotic is not the first priority in this situation.
C. Discuss the pneumococcal vaccine with the provider: Vaccination is a preventive measure to reduce the risk of future infections. It does not address the acute hypoxemia or impaired gas exchange the client is experiencing during the current episode of pneumonia.
D. Position the client in high-Fowler's position: Elevating the client to a high-Fowler’s position promotes maximal lung expansion and improves ventilation-perfusion matching. This immediate intervention helps increase oxygen saturation and ease shortness of breath, making it the priority action in a client with SaO2 of 88% on room air.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["360"]
Explanation
- Convert ounces to milliliters
Ice cream: 4 oz × 30 mL/oz = 120 mL
Coffee: 8 oz × 30 mL/oz = 240 mL
- Calculate total fluid intake
Total intake = 120 + 240
Total intake = 360 mL
Correct Answer is B
Explanation
A. "You can resume a regular diet 3 days after your procedure.": Most adolescents can resume their regular diet shortly after a cardiac catheterization once vital signs are stable and there are no complications. Delaying diet for 3 days is unnecessary unless the provider specifies restrictions due to other medical conditions.
B. "You can take a shower 1 day after your procedure.": Showering is generally allowed 24 hours after cardiac catheterization, provided the dressing over the insertion site remains dry and intact. This instruction promotes hygiene while minimizing the risk of infection at the puncture site.
C. "You can begin exercising 2 days after your procedure.": Physical activity is typically restricted for several days to a week after catheterization to allow the vascular access site to heal and reduce the risk of bleeding or hematoma formation. Exercising too soon could compromise site integrity.
D. "You can return to school 1 week after your procedure.": Returning to school may depend on the adolescent’s overall recovery and provider instructions. While many can resume school within a few days, the primary focus immediately after the procedure is ensuring safe hygiene and access site healing rather than full activity, making showering the first priority instruction.
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