A nurse is caring for a client in the emergency department.

Which of the following interventions should the nurse include in the plan of care? Select all that apply.

Place the client in a supine position.

Instruct the client to perform diaphragmatic breathing.

Increase oxygen flow rate to 4 L/min.

Assess the client's breath sounds.

Restrict the client's fluid intake.

Perform chest percussion and vibration.

Answer and Explanation

Correct Answer : B,D,F

A. Place the client in a supine position: The supine position can worsen dyspnea by limiting diaphragmatic movement and decreasing lung expansion. Clients with respiratory distress should be positioned upright or semi-Fowler’s to facilitate breathing.

B. Instruct the client to perform diaphragmatic breathing: Diaphragmatic breathing helps improve oxygenation and ventilation by promoting deeper, more efficient breaths. It also reduces accessory muscle use and can decrease anxiety associated with shortness of breath.

C. Increase oxygen flow rate to 4 L/min: Oxygen should be titrated to maintain target saturation (usually 92–94% for COPD risk patients). The client’s current oxygen saturation is 92% on 2 L/min, so increasing the flow is unnecessary at this time.

D. Assess the client's breath sounds: Ongoing assessment of breath sounds is essential to monitor for changes such as wheezing, crackles, or diminished air entry, which guide interventions and evaluate response to therapy.

E. Restrict the client's fluid intake: Fluid restriction is not indicated in this client’s current presentation. Adequate hydration helps thin secretions, making coughing and airway clearance more effective.

F. Perform chest percussion and vibration: Chest physiotherapy techniques like percussion and vibration can help loosen and mobilize secretions, improving airway clearance in clients with productive cough and retained secretions.

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Correct Answer is B

Explanation

A. Morphine 2 mg IV bolus every 4 hr PRN pain: The prescription clearly indicates the dose, route, frequency, and PRN instructions, making it complete and appropriate for administration.

B. Acetaminophen 1,000 PO three times daily: The prescription is missing the unit of measure (mg, g, etc.), which is essential to ensure safe dosing. Without the unit, there is a risk of overdose or underdose, so the nurse must verify this prescription with the provider before administration.

C. Ibuprofen 800 mg PO every 8 hr: This prescription includes the dose, route, and frequency, making it complete. While monitoring for side effects is important, there is no issue requiring verification.

D. Ceftriaxone 250 mg IM x1 dose now: The prescription specifies the dose, route, and single administration, making it clear and safe to administer without additional verification.

A. Withhold the medication if the client does not appear to be in pain. B. Withhold the medication if the client has a fever. C. Count the current number of unit doses available in the medication dispensing system. D. Document administration of the medication upon removal from the medication dispensing system

Correct Answer is C

Explanation

A. Withhold the medication if the client does not appear to be in pain: Pain is subjective, and nurses must rely on the client’s self-report rather than appearance. Withholding analgesia based solely on observation may lead to undertreatment of pain.

B. Withhold the medication if the client has a fever: Fever is not a contraindication for hydromorphone administration. Pain management should be based on client need and assessment, while fever is monitored and treated separately if necessary.

C. Count the current number of unit doses available in the medication dispensing system: Counting controlled substances like hydromorphone ensures accurate inventory and accountability, which is a legal and safety requirement. This step helps prevent diversion and maintains compliance with regulations.

D. Document administration of the medication upon removal from the medication dispensing system: Documentation should occur after administration to accurately reflect what the client actually received. Recording upon removal can lead to errors if the medication is not given.

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Which of the following interventions should the nurse include in the plan of care? Select all that apply.