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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
The vial contains 0.3 mg of medication, which has been reconstituted with 2 mL of sterile water. Therefore, each milliliter of solution contains 0.15 mg of medication.
The prescribed dose is 0.125 mg, so the nurse should administer \( \frac{0.125\ mg}{0.15\ mg/mL} = 0.8333 \) mL of the solution.
After rounding to the nearest tenth, the nurse should administer 0.8 mL of the reconstituted solution to the client every other day.
Correct Answer is A
Explanation
A. According to the usage guidelines for ipratropium inhalers, priming the inhaler typically requires only two sprays into the air, away from the face, before the first use to ensure proper medication dosage.
B. Rinsing the mouth after each use is a recommended practice to prevent irritation and infection.
C. Storing the medication at room temperature is correct, as extreme temperatures can affect the medication's efficacy.
D. Attaching a spacer device to the inhaler is also a recommended practice to improve medication delivery and reduce the risk of side effects.
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