An adult client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?
Administer a prescribed antipyretic.
Offer a prescribed PRN analgesic.
Suction to clear secretions from airway.
Obtain arterial blood gases.
The Correct Answer is C
C. The client's weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise. Suctioning to clear secretions from the airway can help improve air exchange and alleviate respiratory distress.
A. The client's primary issue appears to be respiratory distress rather than fever.
B. Offering pain relief is important for overall comfort but it is not be the most immediate intervention needed to address the client's respiratory distress.
D. Arterial blood gases may provide valuable information but they may not be the most immediate intervention needed to address the client's respiratory distress.
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Related Questions
Correct Answer is D
Explanation
D. The correct instruction to include in a discharge teaching plan for an adult client with hypernatremia is to review food labels for sodium content. Hypernatremia is a condition characterized by high levels of sodium in the blood, and it is often due to fluid loss rather than excessive sodium intake.
A. Hypernatremia is characterized by elevated levels of sodium in the blood, and reducing sodium intake is typically part of the treatment plan. Instructing the client to use salt tablets would exacerbate the hypernatremia and could lead to further complications.
B. This instruction is not directly related to managing hypernatremia. While monitoring urine output is important for assessing hydration status and kidney function, it may not specifically address the underlying cause of hypernatremia.
C. Hypernatremia is often caused by dehydration or inadequate water intake, leading to elevated sodium levels in the blood. Therefore, hydrating is an important instruction but not the most important.
Correct Answer is A
Explanation
A. Increasing oral fluid intake can help thin respiratory secretions, making them easier to expectorate. This can be particularly beneficial for a client experiencing thickened, tenacious mucous associated with asthma and bronchitis.
B. Avoiding crowded enclosed areas can reduce the risk of exposure to respiratory pathogens but it may not directly address the client's current symptoms of shortness of breath and productive cough.
C. Monitoring medication side effects does not directly address the client's current symptoms of shortness of breath and productive cough.
D. Addressing anxiety is important for overall well-being but it may not directly address the underlying respiratory symptoms or promote effective airway clearance.
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