A nurse in an emergency department is caring for a client. Nurses' Notes.

1200:.

Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.

1210:.

Client noted to keep head down and makes limited eye contact. Speaks very softly and looks at adult child before answering interview questions. Has strong body odor and clothes are unclean. Client's adult child answers most questions. Client grimacing and guarding right arm.

Client weighed, is 56.2 kg (124 lb) and 175 cm (69 in) tall. BMI 18.3.

1230:.

Client's adult child left facility to go home and get the client’s prescribed medications. Client visibly more relaxed and now speaking more openly to staff with improved eye contact. Client reports that he has lived with his adult child for the past several.

Vital Signs. 1200:.

Temperature 36.7° C (98° F). Heart rate 96/min.

Blood pressure 142/96 mm Hg. Respiratory rate 16/min.

SpO2 97% on room air.

The nurse is preparing to speak to the facility's Social Worker about the client's condition.

Select the 5 findings the nurse should plan to include in the report.

The correct answer is choice B. Use an ibuterol inhaler.

Choice A rationale:

Completing oral hygiene is important for overall health, but it is not specifically related to the preparation for postural drainage in cystic fibrosis patients. Postural drainage is a technique used to clear mucus from the lungs, and oral hygiene does not directly affect this process.

Choice B rationale:

Using a bronchodilator, such as an ibuterol inhaler, is recommended before postural drainage because it helps to open the airways, making the drainage process more effective. Bronchodilators are often used to relax the muscles around the airways, which can become constricted in conditions like cystic fibrosis.

Choice C rationale:

Taking pancrelipase is related to aiding digestion in cystic fibrosis patients who have pancreatic insufficiency. While it is an important part of the overall management of cystic fibrosis, it is not directly related to the preparation for postural drainage.

Choice D rationale:

Eating a meal before postural drainage is not recommended because a full stomach can make the process uncomfortable and less effective. It is generally advised to perform postural drainage on an empty stomach to ensure that the mucus can be cleared from the lungs more easily.

The correct answer is choice D. Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is a flammable substance that can ignite in the presence of oxygen.

Using nail polish remover around the client can increase the risk of fire and burn injuries.

Choice A is wrong because synthetic fabrics can generate static electricity, which can also cause sparks and ignite oxygen.

The client’s bedding should be made of cotton or wool, which are natural fabrics that do not produce static electricity.

Choice B is wrong because petroleum jelly is a petroleum-based product that can react with oxygen and cause skin irritation or burns.

The client should use water-based moisturizers to soothe the mucous membranes.

Choice C is wrong because alcohol-based cleaning products are also flammable and can cause fires or explosions when exposed to oxygen.

The client should use mild soap and water to clean the equipment, and follow the manufacturer’s instructions for maintenance.

Some general safety tips for home oxygen therapy are:

• Keep away from heat and flame, such as candles, matches, lighters, stoves, fireplaces, etc.
• Do not smoke or allow others to smoke near the oxygen source
• Do not use aerosols, vapor rubs, oils, or other products that contain flammable substances near the oxygen source
• Store oxygen tanks or cylinders in a well-ventilated area away from direct sunlight and heat sources
• Secure oxygen tanks or cylinders to prevent them from falling or rolling
• Use the exact rate of oxygen prescribed by the doctor for each activity
• Check the oxygen gauge or level regularly and call the medical supply company when it is low
• Use a humidifier bottle if prescribed by the doctor to prevent dryness of the mucous membranes
• Change the nasal cannula, mask, and tubing as instructed by the medical supply company to prevent