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
Serum blood glucose level is not directly related to the presence of purulent drainage at a wound site. While blood glucose levels can affect wound healing, they do not provide specific information about the presence of infection.
Choice B rationale
Culture for sensitive organisms is the most appropriate laboratory value to note when purulent drainage is observed. This test helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment.
Choice C rationale
C-reactive protein (CRP) level is a marker of inflammation and can indicate the presence of an infection, but it does not provide specific information about the bacteria causing the infection.
Choice D rationale
Blood pH level is not directly related to the presence of purulent drainage at a wound site. While blood pH can be affected by severe infections, it is not a specific indicator of wound infection.
Correct Answer is D
Explanation
Choice A rationale
Counting the apical and radial pulses simultaneously is important for assessing pulse deficits, but it is not the most critical assessment for a client receiving hydromorphone.
Choice B rationale
Measuring the client’s capillary glucose level is important for clients with diabetes, but it is not directly related to the administration of hydromorphone.
Choice C rationale
Observing for edema around the ankles is important for assessing fluid retention, but it is not the most critical assessment for a client receiving hydromorphone.
Choice D rationale
Auscultating the client’s bowel sounds is crucial because hydromorphone is a potent opioid analgesic that can slow peristalsis and frequently causes constipation. Monitoring bowel sounds helps prevent complications such as bowel obstruction. .