A client with pneumonia develops pleuritic chest pain. What is the nurse's priority intervention?

Correct Answer: A

Rationale: The correct answer is A: Administering prescribed analgesics. The priority intervention is to manage the client's pain to promote comfort and encourage deep breathing and coughing. This helps prevent complications such as atelectasis. Positioning for comfort is important but not the priority when the client is experiencing pleuritic chest pain. Assessing for pleural effusion is relevant but not the immediate priority over addressing the client's pain.

Correct Answer: C

Rationale: The correct answer is C: Airborne precautions. Tuberculosis is an airborne disease spread through respiratory droplets. Airborne precautions include wearing an N95 mask, isolating the patient in a negative pressure room, and ensuring proper ventilation. This type of precaution is necessary to prevent the transmission of TB to others. Droplet precautions (choice A) are used for diseases transmitted through larger respiratory droplets. Contact precautions (choice B) are for diseases spread through direct contact with the patient or contaminated surfaces. Standard precautions (choice D) are used for all patients to prevent the spread of infection, but they are not sufficient for TB due to its airborne nature.

Correct Answer: A

Rationale: The correct answer is A: Encouraging fluid intake of at least 3 liters per day. Increasing fluid intake helps to thin the mucus, making it easier to clear from the airways. Adequate hydration also helps to keep the mucus membranes moist, facilitating mucus clearance. This intervention promotes effective coughing and expectoration, ultimately aiding in clearing the excess mucus associated with bronchitis. Choice B: Administering prescribed antitussive medication would not be effective in promoting mucus clearance as antitussives suppress coughing, which is needed to clear mucus. Choice C: Positioning the client in a high Fowler's position may improve breathing but does not directly address mucus clearance. Choice D: Limiting activity to conserve energy does not promote mucus clearance. In fact, some degree of activity can help mobilize mucus and facilitate its clearance.

Correct Answer: A

Rationale: The correct answer is A: Administering antibiotics on schedule. Administering antibiotics on time is crucial to maintain therapeutic levels in the bloodstream, effectively treating the infection. Delay or missing doses can lead to treatment failure. Monitoring for allergic reactions (C) is important but secondary to ensuring timely administration of antibiotics. Encouraging fluid intake (B) is beneficial but not as critical as antibiotic administration. Assessing sputum production (D) is important for evaluating treatment response but should not take precedence over administering antibiotics.

Correct Answer: B

Rationale: The correct answer is B: Teach pursed-lip breathing to use when feeling anxious. This intervention helps the client manage anxiety-induced shortness of breath by promoting relaxation and improving oxygen exchange. Pursed-lip breathing slows down the client's breathing rate, reduces respiratory rate, and decreases the work of breathing. It also helps to prevent air trapping in the lungs. Administering anti-anxiety medication (Option A) should not be the first-line intervention for managing anxiety-induced shortness of breath. Discouraging visitors (Option C) may isolate the client and not address the underlying issue of anxiety. Teaching proper use of inhalers (Option D) is important for managing COPD symptoms, but it does not directly address anxiety-related shortness of breath.