The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is a priority for the nurse to take?
a. Position the patient on the left side.
b. Assist the patient with staged coughing.
c. Place a humidifier in the patient's room.
d. Schedule a 2-hour rest period for the patient.
ANS: B
The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.
You might also like to view...
An adult patient is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The patient has no problem with rubbing, friction, or shear
What is the Braden score for this patient? a. 0 b. 15 c. 20 d. 23
A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would:
a. Place the stethoscope over the temporomandibular joint, and listen for bruits. b. Place the hands over his ears, and ask him to open his mouth "really wide." c. Place one hand on his forehead and the other on his jaw, and ask him to try to open his mouth. d. Place a finger on his temporomandibular joint, and ask him to open and close his mouth.
Which client is most likely to have the least stress adjusting to her role as a mother?
a. A 26-year-old woman who is returning to work in 10 weeks b. A 35-year-old anxious mother who has had no contact with babies or children c. A 16-year-old teenager who lives with her parents and has a strained relationship with her mother d. A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant with twins, who were delivered by cesarean birth
A preterm newborn, after spending 8 weeks in the NICU, is being discharged. The parents of the newborn express apprehension and worry that the newborn may still be in danger. The nurse should recognize that this is:
a. normal. b. a reason to postpone discharge. c. suggestive of maladaptation. d. suggestive of inadequate bonding.