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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View Related questions
Correct Answer is C
Explanation
Choice A rationale
Attaching humidification to oxygen delivery can help with comfort but is not the immediate priority in assessing the client’s respiratory status.
Choice B rationale
Coaching through using huff coughing is a useful technique for clearing secretions but should follow the assessment of the client’s oxygenation status.
Choice C rationale
Obtaining a pulse oximetry reading is the next immediate action after positioning the client upright. It provides essential information about the client’s oxygen saturation and helps guide further interventions.
Choice D rationale
Providing a nebulizer breathing treatment can help relieve symptoms but should be based on the assessment of the client’s oxygenation status.
Correct Answer is A
Explanation
Choice A rationale
Acute pancreatitis is a potential complication after cholecystectomy. The persistent upper abdominal pain radiating to the back is a classic symptom of acute pancreatitis. This condition can occur due to the migration of gallstones or other factors affecting the pancreas.
Choice B rationale
Biliary duct obstruction can cause upper abdominal pain, but it is less likely to present with pain radiating to the back. This condition typically presents with jaundice and other symptoms.
Choice C rationale
Surgical site infection can cause abdominal pain, but it is usually localized to the surgical site and does not typically radiate to the back. Other signs of infection, such as fever and redness, would also be present.
Choice D rationale
Hepatorenal failure is a severe condition that can occur in patients with liver disease, but it is not commonly associated with pain radiating to the back. It typically presents with symptoms of liver and kidney dysfunction.