A nurse in a provider’s office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply)

Choice A reason: Hypotension is not a common manifestation of ARF. Hypotension is a low blood pressure, defined as less than 90/60 mm Hg. Hypotension can have many causes, such as dehydration, blood loss, heart problems, or medications. ARF does not directly cause hypotension, but it can lead to complications such as shock or organ failure, which can lower the blood pressure.

Choice B reason: Decreased level of consciousness is a frequent manifestation of ARF. Decreased level of consciousness is a state of impaired awareness, orientation, memory, or judgment. Decreased level of consciousness can occur in ARF due to several factors, such as hypoxia, hypercapnia, acidosis, or infection. The nurse should monitor the mental status of the client with ARF and report any changes to the provider.

Choice C reason: Severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective sensation of difficulty breathing or shortness of breath. Severe dyspnea can occur in ARF due to the reduced oxygen delivery or increased carbon dioxide retention in the blood. The nurse should assess the respiratory rate, rhythm, depth, and effort of the client with ARF and provide oxygen therapy as prescribed.

Choice D reason: Headache is not a typical manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can have many causes, such as stress, dehydration, sinusitis, or migraine. ARF does not directly cause headache, but it can cause increased intracranial pressure or cerebral edema, which can trigger headache.

Choice E reason: Nausea is not a usual manifestation of ARF. Nausea is a feeling of sickness or discomfort in the stomach that can lead to vomiting. Nausea can have many causes, such as food poisoning, motion sickness, pregnancy, or medications. ARF does not directly cause nausea, but it can cause gastrointestinal bleeding or hepatic encephalopathy, which can induce nausea.

Choice A reason: Attaching a humidifier bottle to the base of the flow meter is a correct action for the nurse to take for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. A humidifier bottle adds moisture to the oxygen gas, which can prevent dryness and irritation of the nasal passages and the mucous membranes. A humidifier bottle is recommended for oxygen flow rates above 4 L/min.

Choice B reason: Securing the oxygen tubing to the bed sheet near the client’s head is not a correct action for the nurse to take for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Securing the oxygen tubing to the bed sheet can cause the tubing to kink or twist, which can reduce the oxygen flow or delivery. The nurse should secure the oxygen tubing to the client’s clothing or gown, and ensure that there is enough slack to allow the client to move comfortably.

Choice C reason: Applying petroleum jelly to the nares as needed to soothe mucous membranes is not a correct action for the nurse to take for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Petroleum jelly is a flammable substance that can ignite when exposed to oxygen. The nurse should avoid using petroleum jelly or any other oil-based products on the client’s face or nose when using oxygen therapy. The nurse should use water-based products, such as saline gel or nasal spray, to moisturize the nares and mucous membranes.

Choice D reason: Removing the nasal cannula while the client eats is not a correct action for the nurse to take for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Removing the nasal cannula can cause hypoxia, which is a low level of oxygen in the blood. The nurse should keep the nasal cannula in place while the client eats, and monitor the client’s oxygen saturation and respiratory status. The nurse should also assist the client with eating, and encourage small bites and sips to prevent aspiration.