Question

A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first?

a. Administer bronchodilators as prescribed.

b. Initiate oxygen therapy using a nasal cannula.

c. Encourage the client to deep breathe and cough.

d. Prepare for endotracheal intubation.

Answer 1

The nurse should first initiate oxygen therapy using a nasal cannula to address the patient's hypoxemia, which is the most urgent need. After ensuring proper oxygenation, further treatment can be considered based on the patient's response and continuous pulse oximeter readings.

Step-by-step explanation:

The nurse should prioritize interventions that address the patient's immediate need for oxygen. A client displaying hypoxemia with an SaO2 of 85%, dyspnea, productive cough, and use of accessory muscles to breathe requires prompt attention to their oxygenation status. The first action the nurse should take is to initiate oxygen therapy using a nasal cannula (Option b). This intervention aims to increase the oxygen saturation to an acceptable level and reduce the work of breathing.

Administering bronchodilators (Option a), encouraging deep breathing and coughing (Option c), and preparing for endotracheal intubation (Option d) may be appropriate subsequent steps after oxygen therapy has been initiated and the patient's immediate oxygenation needs have been addressed. However, establishing oxygen therapy is the most critical and urgent intervention to prevent further hypoxemic damage.

Utilizing a pulse oximeter can continuously monitor the blood oxygen levels to ensure that interventions are effective and to guide further treatment decisions. In situations of significant respiratory distress, such as in this client with bilateral pneumonia, close observation and additional supportive measures are crucial.