When caring for an older adult client with a pulmonary infection, what action should the nurse take first?

Correct Answer: B

Rationale: The correct answer is B: Assess the client's level of consciousness. This is the priority because changes in consciousness can indicate deteriorating respiratory status or potential respiratory distress. Next steps would depend on the assessment findings. A: Encouraging fluid intake is important but not the first priority. C: Raising the head of the bed helps with breathing but doesn't address potential immediate respiratory distress. D: Providing humidified oxygen may be necessary but assessing consciousness comes first to determine the urgency of oxygen therapy.

Correct Answer: B

Rationale: The correct answer is B: Do you have any chronic breathing problems? This question is relevant because equal AP and lateral chest diameters can indicate a barrel chest, which is often associated with chronic breathing problems like chronic obstructive pulmonary disease (COPD). Chronic breathing problems can lead to this specific chest shape due to increased lung volume. Choice A is incorrect as it does not directly relate to the physical assessment findings. Choice C is incorrect as it focuses on exercise habits rather than the client's current health status. Choice D is incorrect as it does not address the potential underlying health issue indicated by the chest measurements.

Correct Answer: B

Rationale: The correct answer is B: Absent breath sounds. This finding requires immediate action because it could indicate a pneumothorax, which is a potentially life-threatening complication following a lung biopsy. Absent breath sounds suggest air trapped in the pleural space, leading to lung collapse. Immediate intervention is necessary to prevent respiratory distress. A: Increased temperature is concerning but may indicate infection, which would require monitoring and possibly treatment, but it is not as urgent as addressing a potential pneumothorax. C: Productive cough is common post-lung biopsy and may be managed symptomatically. It does not typically require immediate action. D: Incisional discomfort is expected after a biopsy and can be managed with pain medication. It does not indicate a critical issue requiring immediate intervention.

Correct Answer: D

Rationale: The correct answer is D because ensuring informed consent is crucial before any invasive procedure to protect the client's autonomy and rights. This involves confirming the client's understanding of the procedure, risks, benefits, and alternatives. Option B is correct as it directly relates to the ethical and legal aspect of the procedure. Option A is incorrect as it focuses solely on monitoring oxygen saturation, which is important but not the priority before thoracentesis. Option C is incorrect as simply explaining the procedure does not ensure the client's understanding or consent.

Correct Answer: D

Rationale: The correct answer is D: Place the client in a high Fowler's position. Placing the client in a high Fowler's position helps improve lung expansion and oxygenation by maximizing chest expansion. This position facilitates better breathing mechanics and can alleviate respiratory distress. Choice A is incorrect because administering oxygen via nasal cannula should be done after positioning the client properly. Choice B is important but assessing vital signs alone may not provide immediate relief to the client's breathing difficulty. Choice C, notifying the Rapid Response Team, is not the best immediate action as positioning the client correctly should be the priority before seeking additional help.