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 C
Explanation
Choice A rationale
Attaching humidification to oxygen delivery can help with comfort but is not the immediate priority in assessing the client’s respiratory status.
Choice B rationale
Coaching through using huff coughing is a useful technique for clearing secretions but should follow the assessment of the client’s oxygenation status.
Choice C rationale
Obtaining a pulse oximetry reading is the next immediate action after positioning the client upright. It provides essential information about the client’s oxygen saturation and helps guide further interventions.
Choice D rationale
Providing a nebulizer breathing treatment can help relieve symptoms but should be based on the assessment of the client’s oxygenation status.