A nurse is caring for a client who has pneumonia. Which of the following assessments is the priority?

Correct Answer: A

Rationale: The correct answer is A: Breath sounds. In pneumonia, assessing breath sounds is the priority to monitor for respiratory distress and adequacy of oxygenation. Abnormal breath sounds can indicate worsening pneumonia and the need for immediate intervention. Peripheral edema (B), urinary output (C), and skin turgor (D) are important assessments but are secondary to monitoring respiratory status in a client with pneumonia. It is crucial to prioritize respiratory assessments to ensure timely intervention and prevent respiratory compromise.

Correct Answer: B

Rationale: The correct answer is B: Positioning the client sitting upright and leaning forward. This position helps to expose the area for the thoracentesis and prevents puncturing of the underlying structures. It also maximizes lung expansion, making the procedure safer and more effective. Administering analgesics (choice A) is important but not the priority. Ensuring informed consent (choice C) is important but can be done after positioning. Teaching deep breathing exercises (choice D) is also important but not the priority pre-procedure intervention.

Correct Answer: D

Rationale: The correct answer is D. Positioning the client to promote lung expansion is the priority intervention for a client experiencing respiratory acidosis as it helps improve ventilation and oxygenation. This intervention helps optimize lung function and can aid in correcting the acidosis by increasing the efficiency of gas exchange. Administering a bronchodilator (A) may help with bronchoconstriction but is not the priority in this situation. Initiating deep breathing exercises (B) may be helpful in some cases but may not be appropriate for a client in respiratory distress. Providing supplemental oxygen (C) may help improve oxygenation, but without addressing the underlying cause of the acidosis, it may not fully resolve the issue.

Correct Answer: C

Rationale: The correct answer is C: Oxygen saturation of 87%. In pulmonary embolism, decreased oxygen saturation indicates impaired gas exchange due to reduced blood flow to the lungs. This is concerning as it can lead to hypoxemia and tissue damage. Respiratory rate (choice B) and heart rate (choice D) can be elevated in response to hypoxemia but are not as direct indicators of impaired gas exchange. Chest pain and hemoptysis (choice A) are common symptoms of pulmonary embolism but do not directly reflect the severity of oxygenation impairment.

Correct Answer: A

Rationale: The correct answer is A: Administering prescribed bronchodilators. The priority intervention for a client with chronic bronchitis experiencing worsening shortness of breath is to address the underlying cause, which is airway obstruction due to inflammation and mucus production. Bronchodilators help to open up the airways and improve airflow, providing immediate relief for shortness of breath. This intervention directly targets the client's respiratory distress and is essential for managing exacerbations of chronic bronchitis. Choice B: Encouraging pursed-lip breathing may be beneficial for some clients with chronic bronchitis but is not the priority intervention in this case. It is more of a supportive measure to help manage symptoms. Choice C: Positioning the client in high Fowler's position can help improve breathing by maximizing lung expansion, but it is not the priority intervention when the client is experiencing worsening shortness of breath. Choice D: Monitoring oxygen saturation levels is important in assessing the client's respiratory status