An older client is admitted to an acute care facility with the diagnosis of left lower lobe pneumonia. How should the practical nurse (PN) position the client for auscultation of posterior lung fields?

Choice A rationale:

The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.

Choice B rationale:

Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.

Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.

Choice C rationale:

Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.

Choice D rationale:

Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.

The correct answer is choice B. Notify the charge nurse of the client's concerns about surgery. Choice A rationale:

Reminding the client that the consent has already been obtained does not address the client's current fears and uncertainty about undergoing the surgery. It may come across as dismissive and unsupportive of the client's emotional needs.

Choice B rationale:

This is the correct answer because notifying the charge nurse of the client's concerns about surgery allows the nursing team to provide the necessary support and address the client's emotional needs appropriately. The charge nurse can assess the client's anxiety level, discuss the procedure, and involve the healthcare provider if needed to ensure the client is well-

informed and comfortable with their decision. Choice C rationale:

Documenting the client's expressed concerns about the surgery is essential for accurate documentation but does not provide the immediate support and intervention the client may require.

Choice D rationale:

Encouraging the client to continue with the scheduled surgery without addressing their fears and uncertainty may not be appropriate. The client's emotional well-being should be a priority, and they should feel supported in their decision-making process.