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?
Suction to clear secretions from the airway.
Offer a prescribed PRN analgesic.
Obtain arterial blood gases.
Administer a prescribed antipyretic.
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 A
Explanation
Choice A rationale
The severity of nausea and vomiting and serum amylase results are crucial in diagnosing and managing pancreatitis. Elevated serum amylase levels are a key indicator of pancreatitis, and the severity of nausea and vomiting can help assess the patient’s condition and response to treatment.
Choice B rationale
Reports of chronic constipation and serum gastrin levels are not directly related to the acute management of pancreatitis. Chronic constipation is more associated with gastrointestinal motility disorders, and serum gastrin levels are typically measured in conditions like Zollinger-Ellison syndrome.
Choice C rationale
Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts are not directly relevant to the acute management of pancreatitis. H. pylori is associated with peptic ulcer disease, and urine output is more relevant in assessing renal function.
Choice D rationale
The presence of bowel sounds and the degree of abdominal pain are important but not as specific as serum amylase levels in diagnosing pancreatitis. Bowel sounds can be affected by various conditions, and abdominal pain is a common symptom in many gastrointestinal disorders.
Correct Answer is B
Explanation
Choice A rationale
An increase in B-lymphocytes and IgM is not how HIV suppresses the immune system. B-lymphocytes are responsible for producing antibodies, and IgM is a type of antibody. HIV primarily affects T-lymphocytes, specifically helper T-cells (CD4 cells), rather than B-lymphocytes.
Choice B rationale
The destruction of helper T-cells and CD4 cells is the primary mechanism by which HIV suppresses the immune system. HIV targets and infects these cells, leading to their depletion. Helper T-cells play a crucial role in coordinating the immune response, and their loss results in a weakened immune system, making the body more susceptible to infections and diseases.
Choice C rationale
A deficiency of cytotoxic T cells is not the primary mechanism by which HIV suppresses the immune system. Cytotoxic T cells (CD8 cells) are involved in directly killing infected cells, but the main impact of HIV is on helper T-cells (CD4 cells), which are essential for orchestrating the immune response.
Choice D rationale
The proliferation of suppressor T-cells is not how HIV suppresses the immune system. Suppressor T-cells (regulatory T cells) help regulate and control the immune response, but HIV primarily affects helper T-cells (CD4 cells), leading to their destruction and a weakened immune system.