The nurse is caring for a client with pneumonia and has obtained the following vital signs: Temperature 101.2ºF (oral), BP 100/70, Pulse Rate 110/min, and Respirations 22. The client's oxygen saturation level is 96%
The nurse should clarify which of the following orders? 1. Administer acetaminophen (Tylenol) 650 mg every 4 hours prn fever.
2. Administer intravenous (IV) fluids: 0.9% Normal Saline Solution at 125 ml/hour.
3. Start oxygen therapy at 3L/minute via nasal cannula.
4. Send for chest x-ray.
3
Rationale 1: The order for acetaminophen (Tylenol) is appropriate and is to be given as needed for fever.
Rationale 2: The order for IV fluids is appropriate as fluids help to thin secretions and make up for increased insensible loss due to fever and increased respiratory rate.
Rationale 3: The nurse should clarify the oxygen therapy order. Although the client's respiratory rate is slightly increased, this is an expected finding in a client with fever and a diagnosis of pneumonia. The client's oxygen saturation level of 96% is within normal limits; therefore the client does not need oxygen therapy.
Rationale 4: A chest film would be indicated to determine the extent of pulmonary involvement.
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