A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?
Call another nurse for help
Give pain medication as ordered
Call the admitting healthcare provider
Tell client to remain calm
Apply oxygen via nasal cannula as ordered
The Correct Answer is E
A. Calling another nurse for help is unnecessary unless additional assistance is required after initial interventions.
B. Giving pain medication as ordered may address the chest pain but does not address the immediate need for oxygenation.
C. Calling the admitting healthcare provider can be done later if symptoms do not improve, but the immediate priority is to improve oxygenation.
D. Telling the client to remain calm may help reduce anxiety but does not address the low oxygen saturation.
E. Applying oxygen via nasal cannula as ordered is the priority action to improve the client’s oxygen saturation and alleviate hypoxemia, which could be contributing to their chest pain.
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Correct Answer is E
Explanation
A. Providing care based on predetermined criteria may not be responsive to the unique cultural needs of each client.
B. Focusing solely on hospital unit workflow prioritizes efficiency over individualized patient care, which may not respect cultural differences.
C. This approach fails to acknowledge the diverse values and beliefs of clients, which can lead to miscommunication and unmet needs.
D. This implies a top-down approach to care, which may disregard the client’s preferences and cultural context.
E. Honoring the client's differences and perspectives demonstrates the nurse's commitment to culturally responsive care, ensuring that care is tailored to meet the unique needs of each client.
Correct Answer is D
Explanation
A. Hyperresonance is often heard in cases of pneumothorax or emphysema, not pneumonia.
B. Bubbling is not a percussed sound but rather a description of breath sounds or fluid.
C. Tympany is typically heard over hollow organs like the stomach and is not expected in lung assessment.
D. Dullness over lung tissue indicates fluid or consolidation, as seen in pneumonia.
E. Resonance is normal over healthy lung tissue but would not be expected over areas of consolidation.