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
Respiratory acidosis is characterized by elevated levels of carbon dioxide (CO2) in the blood due to impaired ventilation. This accumulation of CO2 leads to a decrease in blood pH, making it more acidic.
Choice B rationale
Hyperventilation leads to a rapid elimination of CO2, which would result in respiratory alkalosis, not acidosis. Therefore, this choice does not support the pathophysiological process of respiratory acidosis.
Choice C rationale
Blood oxygen levels stimulating the respiratory rate is a compensatory mechanism for hypoxemia but does not directly cause respiratory acidosis. This process is more related to respiratory alkalosis.
Choice D rationale
The kidneys do play a role in acid-base balance, but they primarily eliminate acids other than CO2. They do not significantly convert CO2 for elimination, making this choice incorrect.
Correct Answer is B
Explanation
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.