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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Correct Answer is C
Explanation
Choice A rationale
Advising the client that it is too late to receive an influenza vaccination once symptoms occur is correct, but it does not address the client’s question about oseltamivir.
Choice B rationale
Explaining that antibiotics are not useful in treating viral infections is correct, but it does not address the client’s question about oseltamivir.
Choice C rationale
Referring the client to the healthcare provider to obtain a medication prescription is the most appropriate response. Oseltamivir is an antiviral medication that can be effective if started within 48 hours of symptom onset.
Choice D rationale
Instructing the client that over-the-counter medications are sufficient to manage influenza symptoms is not appropriate, as oseltamivir can help reduce the severity and duration of the illness if taken early.
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.