After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.
Which action should the nurse take next?

Choice A rationale:

Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.

Choice B rationale:

Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.

Choice C rationale:

Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.

Choice D rationale:

Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.

The correct answer is D. Notify your healthcare provider if you start having abdominal pain.

Choice A rationale:

Exenatide does not act in the same way as insulin. Insulin directly lowers blood glucose levels by facilitating the uptake of glucose into cells, while exenatide is an incretin mimetic that enhances glucose-dependent insulin secretion and slows gastric emptying.

Choice B rationale:

Exenatide should be injected within 30 minutes before or after a meal, but this is not the most critical information for discharge instructions.

Choice C rationale:

There are precautions about taking exenatide with other medications, especially those that affect kidney function or interact with exenatide.

Choice D rationale:

Notifying the healthcare provider if abdominal pain starts is crucial because exenatide can cause side effects such as pancreatitis, which presents with severe abdominal pain. Early detection and intervention are essential for patient safety.