The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider?
a. Scattered crackles bilaterally in the posterior lung bases.
b. Persistent cough that is productive of blood-tinged sputum.
c. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy.
d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.
ANS: D
The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.
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