A client with pneumonia is receiving antibiotics. Which action should the nurse prioritize?

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: D

Rationale: The correct answer is D. The most important result to report immediately is a pH of 7.31, which indicates acidosis, a potentially life-threatening condition. A low pH can lead to organ dysfunction and requires prompt intervention. The other choices have pH levels within normal limits. PaO2, PaCO2, and O2 saturation are also important, but in this case, the critical value is the pH. Choices A, B, and C have pH values closer to normal range and, although abnormalities in PaO2, PaCO2, or O2 saturation should be monitored, they are not as urgent as a pH indicating acidosis.

Correct Answer: C

Rationale: The correct answer is C because the high-pressure alarm on the ventilator sounding indicates that the patient is experiencing increased airway pressure, which can lead to barotrauma and compromise ventilation. Immediate intervention is required to prevent lung injury. Choice A (respiratory rate of 22 breaths/min) is within the normal range and does not indicate an urgent need for intervention. Choice B (arterial oxygen saturation of 89%) is low but may not require immediate intervention as long as it is not rapidly declining and other factors are stable. Choice D (patient attempting to remove the endotracheal tube) is concerning but may not require immediate intervention as long as the airway is still secured, and other parameters are stable.

Correct Answer: B

Rationale: The correct answer is B because changing the tracheostomy ties before cleaning the stoma can lead to contamination of the stoma site. The correct sequence should be to first clean the stoma with saline solution, then change the tracheostomy ties, and finally apply a new sterile dressing. This helps prevent infection and ensures proper hygiene. Choices A, C, and D are incorrect because using sterile technique for suctioning, applying a new sterile dressing, and cleaning the stoma with saline solution are all appropriate actions in tracheostomy care.

Correct Answer: D

Rationale: The correct answer is D: Ensuring the patient is sitting upright during the treatment. This is important because being in an upright position optimizes lung expansion and airflow, promoting better drug delivery to the lungs. Sitting upright also helps prevent potential aspiration of the medication. Choice A is incorrect because the breathing technique (in through nose, out through mouth) is not the most critical aspect of nebulizer administration. Choice B is incorrect because while monitoring for tachycardia is important, it is not the most crucial action during bronchodilator administration. Choice C is incorrect because diluting the medication with normal saline may be necessary for certain medications, but it is not the most important action when administering a bronchodilator via nebulizer.