Question

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 C (100F), respirations 30/min, BP 130/76, HR 100/min, and SaO2 91% on RA. Prioritize the following nursing interventions.

A. Administer antibiotics.
B. Administer O2 therapy
C. Perform a sputum culture.
D. Instruct the client to obtain a yearly influenza vaccination.

Answer 1

To prioritize nursing interventions for a pneumonia patient, first administer O2 therapy to improve oxygen saturation, then perform a sputum culture, followed by administering antibiotics, and finally instruct on yearly influenza vaccinations.

When prioritizing nursing interventions for a client with pneumonia, the following order is recommended based on the assessment findings of temperature 37.8°C, respirations 30/min, BP 130/76, HR 100/min, and SaO2 91% on room air:

1. Administer O2 therapy to address the immediate need for improved oxygen saturation.
2. Perform a sputum culture before starting antibiotic therapy to ensure appropriate treatment and avoid development of antibiotic resistance.
3. Administer antibiotics as soon as the sputum sample has been obtained to combat the infection.
4. Instruct the client to obtain a yearly influenza vaccination, which is a long-term preventive measure and the lowest priority in the acute care setting.

So, addressing hypoxemia with oxygen therapy should be the first intervention, followed by the collection of a sputum sample and administration of antibiotics. The recommendation for an annual flu vaccine is important for future prevention but is not a priority during the acute phase of illness.