A client with pneumonia has a pulse oximetry reading of 88%. What intervention should the nurse perform first?

Correct Answer: B

Rationale: The correct answer is B: Raise the head of the bed. Elevating the client's head helps improve ventilation and oxygenation by facilitating better lung expansion. This intervention can help enhance oxygen exchange, which is crucial for a client with pneumonia and low oxygen saturation. Increasing the oxygen flow rate (choice A) may be necessary but should not be the first intervention. Notifying the healthcare provider (choice C) is important but not the immediate priority. Encouraging deep breathing exercises (choice D) can be beneficial but may not address the immediate need for improved oxygenation.

Correct Answer: B

Rationale: The correct answer is B: Placing the client in high Fowler's position. This is the priority intervention for a client with acute respiratory failure as it helps improve lung expansion and oxygenation by maximizing chest expansion. Administering a bronchodilator (Choice A) may help with airway patency but placing the client in an upright position takes precedence. Preparing the client for intubation (Choice C) is a more invasive intervention and should be considered after optimizing non-invasive measures. Administering IV antibiotics (Choice D) may be necessary but addressing the immediate respiratory distress by positioning the client correctly is the priority.

Correct Answer: C

Rationale: The correct answer is C: Using an N95 respirator while providing care. This is because TB is an airborne disease that can spread through respiratory droplets. The N95 respirator provides the highest level of protection against inhaling these droplets. A: Wearing a surgical mask is not sufficient to protect against TB transmission as it does not filter out small infectious particles. B: Hand hygiene is important for infection control but does not specifically address airborne transmission of TB. D: Gowning and gloving may be necessary for contact precautions but do not provide adequate protection against airborne transmission of TB.

Correct Answer: A

Rationale: The correct answer is A: Monitoring for decreased breath sounds on the affected side. This is the priority assessment because pneumothorax involves the accumulation of air in the pleural space, leading to lung collapse and decreased breath sounds on the affected side. This assessment is crucial to promptly detect worsening respiratory status and the need for immediate intervention. Choice B is incorrect because while assessing for bilateral chest rise and fall is important in general respiratory assessment, it is not the priority in pneumothorax where the focus is on the affected side. Choice C is incorrect as cyanosis and tachycardia may occur later as a result of respiratory distress, but monitoring breath sounds is more direct for detecting pneumothorax. Choice D is incorrect because measuring oxygen saturation levels may not accurately reflect the severity of pneumothorax and should not be the priority assessment in this case.

Correct Answer: B

Rationale: The correct answer is B: Performing chest physiotherapy regularly. Chest physiotherapy helps mobilize and clear mucus from the airways in cystic fibrosis patients, improving airway clearance. This intervention is essential in preventing respiratory complications. Administering bronchodilators before meals (A) may help with bronchodilation but does not directly address airway clearance. Providing a high-calorie, high-protein diet (C) is important for nutrition but does not specifically target airway clearance. Encouraging the use of a spacer with inhalers (D) may help with medication delivery but does not directly improve airway clearance like chest physiotherapy.