A nurse is caring for a client who has pneumonia on a medical-surgical unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale
The nurse should administer a bronchodilator and prepare the client for intubation because the client is likely experiencing respiratory acidosis and respiratory distress. The nurse should then monitor for the correct placement of the ETT following intubation as well as the client's arterial blood gases to normalize.
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Related Questions
Correct Answer is D
Explanation
A. Positioning the head of the bed at 10 degrees is not sufficient for optimizing respiratory function. Typically, the head of the bed should be elevated to 30–45 degrees to help with breathing and reduce the risk of aspiration.
B. Encouraging fluid intake of 1500 mL/day may be too low for a client with pneumonia. Adequate hydration is important to thin mucus and help with expectoration, especially in the context of pneumonia. Typically, fluid intake should be higher unless contraindicated.
C. Coughing and deep breathing every 8 hours is insufficient. To prevent atelectasis and promote effective clearance of secretions in clients with pneumonia, coughing and deep breathing should be done more frequently, typically every 2 hours.
D. Obtaining a sputum culture is a priority for determining the specific pathogen causing the pneumonia and guiding antibiotic treatment. A sputum culture helps identify bacterial, viral, or fungal organisms that may be present, which is crucial for managing recurrent pneumonia, especially in an immunocompromised client with AIDS.
Correct Answer is C
Explanation
A. A rosebud-like stoma orifice is a normal finding. It refers to a stoma that has a rounded, pink appearance, which is healthy and typical after surgery.
B. A shiny, moist stoma is a normal finding. This appearance indicates good circulation and healing.
C. A purplish-colored stoma is abnormal and should be reported to the provider immediately. This color suggests possible ischemia or poor circulation, which may require intervention to prevent complications such as necrosis of the stoma.
D. Stoma oozing red drainage is normal, especially in the early postoperative period. It indicates that the stoma is healing properly. However, if the drainage is excessive or if the client shows signs of infection, it would need further evaluation.
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