A nurse is performing initial planning for a client who has been admitted with pneumonia. Which of the following actions should the nurse take first?

Assess the client's vital signs, oxygen saturation, and respiratory status.

Educate the client about the disease process and preventive measures.

Collaborate with the physician to prescribe antibiotics and bronchodilators.

Set goals and outcomes for the client's recovery and discharge.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Assessing the client's vital signs, oxygen saturation, and respiratory status is the first action the nurse should take because it provides baseline data on the client's condition and helps to identify any urgent needs or complications. This is consistent with the principle of prioritizing assessment before intervention and following the ABCs (airway, breathing, circulation) of emergency care.

Choice B reason:

Educating the client about the disease process and preventive measures is an important action, but not the first one. The nurse should assess the client's learning needs, readiness, and preferences before providing education. Education is also a lower priority than addressing any immediate threats to the client's health or safety.

Choice C reason:

Collaborating with the physician to prescribe antibiotics and bronchodilators is an appropriate action for a client with pneumonia, but not the first one. The nurse should assess the client's condition and obtain relevant laboratory and diagnostic tests before initiating pharmacological interventions. The nurse should also follow the physician's orders and the facility's policies and protocols when administering medications.

Choice D reason:

Setting goals and outcomes for the client's recovery and discharge is a necessary step in the nursing process, but not the first one. The nurse should assess the client's current status, needs, preferences, and resources before planning care. The nurse should also involve the client and family in setting realistic and measurable goals and outcomes.

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Correct Answer is A

Explanation

Choice A reason:

Checking the pain level and location before and after giving the medication is an example of an independent intervention because it is within the nurse's scope of practice and does not require a provider's order. It is also part of the nursing process to assess the patient's pain and evaluate the effectiveness of the intervention.

Choice B reason:

Flushing the IV line with normal saline before and after giving the medication is not an independent intervention because it is a dependent intervention that requires a provider's order. It is also a standard procedure for administering IV medications to prevent occlusion and contamination of the IV line.

Choice C reason:

Monitoring the vital signs and level of consciousness every 15 minutes after giving the medication is not an independent intervention because it is a dependent intervention that requires a provider's order. It is also a safety measure to detect any adverse effects of the medication, such as respiratory depression, hypotension, or sedation.

Choice D reason:

Asking the physician to order naloxone in case of an adverse reaction to the medication is not an independent intervention because it is a collaborative intervention that involves consultation with another health care professional. It is also a precautionary measure to have an opioid antagonist available in case of overdose or severe respiratory depression.

A. Review the client's medications and dosage instructions with them. B. Evaluate the client's blood glucose levels and insulin administration technique. C. Refer the client to a home health nurse or a diabetes educator as needed. D. All of the above.

Correct Answer is D

Explanation

Choice A reason:

Review the client’s medications and dosage instructions with them. This step is crucial to prevent medication errors and ensure the client understands their regimen. It helps in maintaining proper glycemic control and avoiding complications.

Choice B reason:

Evaluate the client’s blood glucose levels and insulin administration technique. This ensures the client can manage their diabetes effectively at home. Proper technique and understanding of blood glucose monitoring are essential for maintaining target glucose levels.

Choice C reason:

Refer the client to a home health nurse or a diabetes educator as needed. Ongoing support and education from healthcare professionals are vital for managing diabetes. This referral provides the client with resources and guidance to manage their condition effectively.

Choice D reason:

All of the above. Combining all these actions ensures a holistic approach to discharge planning, addressing medication management, self-monitoring, and continuous support, which are all critical for effective diabetes management.

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