A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?
a. Encourage the client to increase fluid intake.
b. Assess the client's level of consciousness.
c. Raise the head of the bed to at least 45 degrees.
d. Provide the client with humidified oxygen.
ANS: B
Assessing the client's level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.
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