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.

Answer and Explanation

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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Correct Answer is D

Explanation

D. Since the client has reported only minimal reduction in symptoms after taking lansoprazole (a proton pump inhibitor used to treat GERD) for one full week, it suggests that the current dosage may not be sufficient for adequate symptom relief. Therefore, the nurse should notify the healthcare provider.

A. Auscultating the client's bowel sounds and measure the abdominal girth. This action is not directly related to the client's reported lack of symptom improvement with lansoprazole.

B. Lansoprazole is typically taken before meals to maximize its effectiveness in reducing gastric acid production.

C.While it is true that healing of erosive esophagitis may take several weeks with treatment, the client's report of minimal symptom reduction suggests that further evaluation and potentially a change in treatment approach are warranted.

A. "I should use this medication in its handihaler every day." B. "I will use my other inhaler in between uses." C. "When I cough up sputum, the secretions should be less thick." D. "If I have sudden shortness of breath, I will use this inhaler."

Correct Answer is A

Explanation

A. Tiotropium is commonly delivered via a handihaler device for inhalation. Using the medication every day is consistent with the recommended dosing regimen for managing chronic obstructive pulmonary disease (COPD) symptoms.

B. While it's important for clients with COPD to have access to a rescue inhaler for sudden shortness of breath, it's also crucial for them to understand the specific instructions for using each medication.

C. Tiotropium is a long-acting bronchodilator that helps relax the airway muscles. It does not have direct effect on the thickness of mucus secretions.

D. While tiotropium can help prevent exacerbations and reduce the frequency of sudden shortness of breath, it is not typically used as a rescue inhaler for acute symptom relief.

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Naxlex Comprehensive Predictor Exams

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

Correct Answer is D

Explanation

A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

Correct Answer is A

Explanation

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