A nurse is caring for a 51-year-old male client with pneumonia in the hospital. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4 and surgical repair of a fractured tibia at age 20.
History and Physical
The client is a 51-year-old male with pneumonia. He has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4 and surgical repair of a fractured tibia at age 20.
Nurses’ Notes
The client is alert and oriented but appears fatigued. He reports shortness of breath and a productive cough with greenish sputum. The client has been receiving oxygen therapy via nasal cannula at 2 L/min. He has been compliant with his medication regimen and reports no recent changes in his health status. The client denies any chest pain but mentions occasional wheezing.
Diagnostic Results
Chest X-ray: Consolidation noted in the right middle and lower lobe consistent with pneumonia.
Vital Signs
- Temperature: 38.5°C (101.3°F)
- Heart Rate: 98 bpm
- Respiratory Rate: 24 breaths per minute
- Blood Pressure: 145/90 mmHg
- Oxygen Saturation: 92% on 2 L/min of oxygen via nasal cannula
Physical Examination Results
The client appears fatigued and is using accessory muscles to breathe. Lung auscultation reveals crackles in the right middle and lower lobes. There is no peripheral edema, and the client’s skin is warm and dry. The client has a productive cough with greenish sputum. He is alert and oriented but appears anxious.
Provider’s Prescriptions
- Continue enalapril 10 mg daily
- Acetaminophen 500 mg every 6 hours as needed for fever
- Increase oxygen to 3 L/min via nasal cannula if oxygen saturation drops below 90%
- Administer albuterol nebulizer treatment every 4 hours as needed for wheezing
- Encourage deep breathing and coughing exercises every hour
Question: Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.
Avoid treating fever with antipyretics
Assist the client in ambulating safely
Providing suctioning so the client does not have to cough
Positioning the client with the head of the bed elevated
Encourage the client to take breaks from the oxygen mask every few hours
Teaching the client to cough at least once an hour
Asking the client to do quick, shallow breaths
Correct Answer : B,D,F
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Correct Answer is B
Explanation
Choice A rationale
Ipratropium is a bronchodilator used to treat respiratory conditions such as chronic obstructive pulmonary disease (COPD) and asthma. It does not have significant interactions with the medications prescribed for H. pylori treatment, so it is not a priority to review in this context.
Choice B rationale
Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding and ulcers, especially when combined with other medications that affect the stomach lining, such as bismuth subsalicylate and tetracycline. Reviewing the client’s use of aspirin is important to prevent potential adverse effects and complications.
Choice C rationale
Famotidine is an H2 receptor antagonist used to reduce stomach acid production. While it is relevant to gastrointestinal health, it does not have significant interactions with the H. pylori treatment regimen. Therefore, it is not a priority to review in this context.
Choice D rationale
Loperamide is an antidiarrheal medication used to manage diarrhea. It does not have significant interactions with the medications prescribed for H. pylori treatment, so it is not a priority to review in this context.
Correct Answer is A
Explanation
Choice A rationale
Asking the client to describe the pain is the best approach to assess the quality of pain. This allows the nurse to gather detailed information about the pain’s characteristics.
Choice B rationale
Identifying effective pain relief measures is important but does not directly assess the quality of pain.
Choice C rationale
Observing body language and movement can provide clues about pain but is not as effective as directly asking the client to describe the pain.
Choice D rationale
Providing a numeric pain scale helps quantify the pain but does not provide detailed information about the pain’s quality.