Question

A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?

A. Encourage the client to cough and deep breathe. Rationale- when using the airway, breathing, circulation approach to client care, the nurse should place the priority on the client's airway. Therefore the nurse should encourage the client to cough and deep breath to clear secretions.
B. Obtain the client's temperature. Rationale: The nurse should monitor the temperature of a client who has pneumonia to alert the nurse to the development of a secondary bacterial infection but there is another action the nurse should take first.
C. Encourage the client to increase oral fluids. Rationale: The nurse should instruct the client to increase oral fluids to thin the secretions, but there is another action the nurse should take first.
D. Provide chest percussion on the client. Rationale: The nurse can provide chest percussion on the client if other methods are not successful to clear the client's secretions, but there is another action the nurse should take first.

Answer 1

The nurse's first action should be to encourage the client with pneumonia to cough and deep breathe to clear secretions and maintain airway patency.

Step-by-step explanation:

If a nurse is caring for a client who has pneumonia and is coughing up secretions, the first action they should take is to encourage the client to cough and deep breathe. This is because using the airway, breathing, circulation approach to client care, the priority is to maintain the client's airway, and by encouraging them to cough and deep breathe, it helps clear secretions and preserve airway patency. While it might also be important to obtain the client's temperature, encourage them to increase oral fluids, and provide chest percussion, these actions follow after ensuring that the airway is clear.