With a diagnosis of pneumonia, which assessment finding warrants immediate intervention by the nurse

Ineffective airway clearance.

There are adventitious breath sounds present, tachypnea, changes in depth of respirations, fever, and cough, which support this as a priority diagnosis. Additional priority diagnoses are impaired gas exchange and ineffective breathing patterns. Impaired gas exchange is reflected in the client's hypercapnia and hypoxia. The diagnosis of ineffective breathing pattern is supported by his tachypnea, use of accessory muscles, and changes in the depth of respiration.