Question

A nurse is caring for a client who has bilateral pneumonia and an SpO2 of 88%. The client is dyspneic, has a productive cough, and is using accessory muscles to breathe. Which of the following actions should the nurse take first?

A) Administer a bronchodilator.
B) Initiate oxygen therapy.
C) Encourage deep breathing exercises.
D) Administer an antibiotic.

Answer 1

The first action the nurse should take is to initiate oxygen therapy to address low SpO2 and improve respiratory function in a client with bilateral pneumonia who is displaying symptoms of severe respiratory distress.

Step-by-step explanation:

A client with bilateral pneumonia and an SpO2 of 88% is displaying serious symptoms such as dyspnea, productive cough, and usage of accessory muscles to breathe. The primary concern in this scenario is to address the low blood oxygen levels and difficulty in breathing. Therefore, initiate oxygen therapy is the first action that the nurse should take. Following the administration of oxygen, the nurse can then assess the need for further interventions such as bronchodilators, antibiotics, or breathing exercises. However, stabilizing the client's oxygen saturation takes precedence to prevent hypoxemia and its complications. As the condition described relates to a severe infection that compromises gas exchange in the alveoli, immediate oxygen supplementation will help in improving the client's respiratory function and preventing further deterioration.