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 D
Explanation
Choice A rationale
A chest X-ray or computed tomography (CT) scan can show abnormalities in the lungs that are suggestive of tuberculosis (TB), but they cannot definitively diagnose TB. These imaging tests can reveal changes in the lungs, such as nodules, inflammation, or fluid buildup, which can be caused by TB or other conditions. Therefore, a chest X-ray or CT scan alone is not sufficient to diagnose TB.
Choice B rationale
A hemoccult test on sputum collected from hemoptysis is not a diagnostic test for TB. It is a test for blood in the stool, which can be a symptom of TB but is not specific to TB. Hemoptysis, or coughing up blood, can occur in various conditions, including bronchitis, pneumonia, lung cancer, and TB. The hemoccult test cannot differentiate between these causes, making it an unreliable test for diagnosing TB.
Choice C rationale
A positive purified protein derivative (PPD) skin test indicates exposure to TB but does not confirm active infection. The PPD skin test involves injecting a small amount of tuberculin, a protein derived from Mycobacterium tuberculosis, into the skin. If a person has been exposed to TB, their immune system will react to the tuberculin, causing a raised red bump to appear at the injection site. However, a positive PPD skin test does not necessarily mean that a person has active TB infection. It could also mean that they have been exposed to TB in the past but have successfully fought off the infection. Further testing, such as a sputum culture, is needed to confirm the diagnosis of TB.
Choice D rationale
A sputum culture positive for Mycobacterium tuberculosis is the definitive diagnostic test for TB. It involves collecting a sample of sputum, which is the mucus coughed up from the lungs, and culturing it in a laboratory to see if Mycobacterium tuberculosis, the bacteria that causes TB, grows. This test is highly specific for TB, meaning that a positive result is almost always indicative of TB infection. It is also sensitive, meaning that it can detect TB infection even when there are few bacteria present.
Correct Answer is C
Explanation
Choice A rationale
Auscultating bowel sounds is important for assessing gastrointestinal function, but it is not directly related to the administration of vancomycin for Clostridium difficile infection.
Choice B rationale
Measuring oxygen saturation is important for assessing respiratory function, but it is not directly related to the administration of vancomycin for Clostridium difficile infection.
Choice C rationale
Checking serum creatinine is crucial before administering vancomycin because this medication can be nephrotoxic. Monitoring kidney function helps prevent potential renal damage.
Choice D rationale
Assessing body temperature is important for monitoring infection, but it is not directly related to the administration of vancomycin for Clostridium difficile infection.