A nurse admits a client from the emergency department. Client data are listed below:
History
Physical Assessment
Laboratory Values
70 years of age
History of diabetes
On insulin twice a day
Reports new-onset dyspnea and productive cough
Crackles and rhonchi heard throughout the lungs
Dullness to percussion LLL
Afebrile
Oriented to person only
WBC: 5,200/mm3
PaO2 on room air 65 mm Hg
What action by the nurse is the priority?
a.
Administer oxygen at 4 liters per nasal cannula.
b.
Begin broad-spectrum antibiotics.
c.
Collect a sputum sample for culture.
d.
Start an IV of normal saline at 50 mL/hr.
ANS: A
All actions are appropriate for this client who has manifestations of pneumonia. However, airway and breathing come first, so begin oxygen administration and titrate it to maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics.
You might also like to view...
The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several weeks. The physicians predict that the patient will need to remain on a ventilator for at least several more weeks before
he will be able to maintain his airway and breathe on his own. What procedure does the nurse anticipate will be planned for the patient to facilitate his recovery? a. Placement of a tracheostomy tube b. Diagnostic thoracentesis c. Pulmonary angiogram d. Lung transplantation surgery
The nurse explains the action of a beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor as inhibiting what?
A) An enzyme that controls the final step in production of cellular cholesterol B) An enzyme used immediately for energy C) An enzyme that combines with proteins to become chylomicrons D) An enzyme used to make bile acids
The nurse is providing care for a patient who has a respiratory infection. Because the infection is in the lung, the nurse expects which immunoglobulin level to be most elevated?
1. Immunoglobulin D 2. Immunoglobulin E 3. Immunoglobulin A 4. Immunoglobulin M
The nurse knows that the purpose of aspiration on IM injections is to
a. Ensure proper placement of the needle. b. Increase the force of the injection. c. Reduce the discomfort of the injection. d. Prolong the absorption time of the medication.