Question

a nurse is caring for a client who has pneumonia. assessment findings include temperature 37.8°c (100°f), respirations 30/min, blood pressure 130/76, heart rate 100/min, and spo₂ 91% on room air. prioritize the following nursing interventions.
administer antibiotics.
administer oxygen therapy.
perform a sputum culture.
instruct the client to obtain a yearly influenza vaccination.

Explanation:

• Administer oxygen therapy: The client's SpO₂ is 91% on room air (normal is ≥95%). Hypoxemia is a life - threatening condition in pneumonia as it affects tissue oxygenation. This is the most immediate intervention.
• Perform a sputum culture: To identify the causative organism (bacterial, viral, or fungal). This helps in guiding the appropriate antibiotic therapy (if bacterial). Antibiotics should be based on culture results when possible to avoid unnecessary use and resistance.
• Administer antibiotics: After obtaining the sputum culture (to ensure proper antibiotic selection if bacterial pneumonia), antibiotics can be started. They target the underlying infection but are secondary to addressing the immediate oxygenation issue.
• Instruct the client to obtain a yearly influenza vaccination: This is a preventive measure for future respiratory infections. It is an important long - term measure but is the least urgent among the given interventions as it does not address the current acute condition of pneumonia.

Answer:

1. Administer oxygen therapy
2. Perform a sputum culture
3. Administer antibiotics
4. Instruct the client to obtain a yearly influenza vaccination