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A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94%, a weak cough effort, and is using accessory muscles to breathe. Which intervention should the nurse implement first?

A.

Suction to clear secretions from the airway.

B.

Offer a prescribed PRN analgesic.

C.

Obtain arterial blood gases.

D.

Administer a prescribed antipyretic.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

Suctioning to clear secretions from the airway is the first intervention to implement. 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.

 

Choice B rationale

 

Offering a prescribed PRN analgesic is important for overall comfort but is not the most immediate intervention needed to address the client’s respiratory distress.

 

Choice C rationale

 

Obtaining arterial blood gases may provide valuable information but is not the most immediate intervention needed to address the client’s respiratory distress.

 

Choice D rationale

 

Administering a prescribed antipyretic is not the most immediate intervention needed to address the client’s respiratory distress.

 


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Ipratropium is a bronchodilator used to treat respiratory conditions such as chronic obstructive pulmonary disease (COPD) and asthma. It does not have significant interactions with the medications prescribed for H. pylori treatment, so it is not a priority to review in this context.

Choice B rationale

Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding and ulcers, especially when combined with other medications that affect the stomach lining, such as bismuth subsalicylate and tetracycline. Reviewing the client’s use of aspirin is important to prevent potential adverse effects and complications.

Choice C rationale

Famotidine is an H2 receptor antagonist used to reduce stomach acid production. While it is relevant to gastrointestinal health, it does not have significant interactions with the H. pylori treatment regimen. Therefore, it is not a priority to review in this context.

Choice D rationale

Loperamide is an antidiarrheal medication used to manage diarrhea. It does not have significant interactions with the medications prescribed for H. pylori treatment, so it is not a priority to review in this context.

Correct Answer is ["B","D","F"]

No explanation

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