The nurse is caring for a client with pneumonia and has obtained the following vital signs:

Question

Temperature 101.2 ºF (oral), BP 100/70, pulse rate 110/min., and respirations 22. The client's oxygen saturation level is 96%. Based on these findings, which order requires further clarification?
1. Administer acetaminophen (Tylenol) 650 mg every 4 hours prn temperature greater than 100.5 ºF.
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.

Answer 1

Correct Answer: 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. The order for acetaminophen (Tylenol) is appropriate and is to be given as needed for fever. 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. A chest film would be indicated to determine the extent of pulmonary involvement.