A nurse is providing care to a client who is immunocompromised.
Which of the following should the nurse identify as a possible source of infection?

Answer is: A, B, and C.Respiratory rate, oxygen saturation level, and heart rate are the three findings that require immediate follow-up. These findings indicate that the client is experiencing respiratory distress and possible complications of pneumonia, such as sepsis and cardiac arrhythmia. The client needs prompt intervention to improve oxygenation, stabilize the heart rhythm, and treat the infection.

• Statement D is wrong because the chronic health condition of the client (Parkinson’s disease) is not an acute problem that needs immediate attention. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease.
• Statement E is wrong because the current level of consciousness of the client (alert and oriented to self) is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation.
• Statement F is wrong because the tremors of the client are likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures.

Normal ranges for the vital signs and arterial blood gas are as follows:

• Respiratory rate: 12 to 20 breaths per minute
• Oxygen saturation level: 95% to 100%
• Heart rate: 60 to 100 beats per minute
• Blood pressure: less than 120/80 mmHg
• Temperature: 36.5°C to 37.2°C
• Arterial blood gas: pH 7.35 to 7.45, PaO2 80 to 100 mmHg, PaCO2 35 to 45 mmHg, HCO3 22 to 26 mEq/L

Correct answer is: A, B, and C.

Choice A rationale: Respiratory rate is 28 breaths per minute and labored. This is above the normal range of 12 to 20 breaths per minute and indicates that the client is experiencing respiratory distress. Respiratory distress can lead to hypoxia, tissue damage, and organ failure. Therefore, this finding requires immediate follow-up to improve the client’s oxygenation and ventilation.

Choice B rationale: Oxygen saturation level is 88% on room air. This is below the normal range of 95% to 100% and indicates that the client is hypoxemic. Hypoxemia can result from pneumonia, which causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. Hypoxemia can also cause dysrhythmias, confusion, and cyanosis. Therefore, this finding requires immediate follow-up to administer supplemental oxygen and monitor the client’s response.

Choice C rationale: Heart rate is 110 beats per minute and irregular. This is above the normal range of 60 to 100 beats per minute and indicates that the client has tachycardia and atrial fibrillation. Tachycardia can result from hypoxia, fever, infection, dehydration, or anxiety. Atrial fibrillation is a type of cardiac arrhythmia that causes irregular and rapid contractions of the atria, reducing the cardiac output and increasing the risk of thromboembolism. Therefore, this finding requires immediate follow-up to identify and treat the underlying cause, stabilize the heart rhythm, and prevent complications.

Choice D rationale: Chronic health condition is Parkinson’s disease. This is not an acute problem that requires immediate follow-up. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease, as they can affect the client’s mobility, safety, and quality of life.

Choice E rationale: Current level of consciousness is alert and oriented to self. This is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation, as they can result from hypoxia, infection, or medication side effects.

Choice F rationale: Tremors are in both hands. This is likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures, such as warm blankets, massage, or relaxation techniques.

Choice A rationale:

The nurse's first action when caring for a client with bulimia nervosa should be to observe the client during and after meals. This is essential to monitor for signs of binge-eating followed by compensatory behaviors such as vomiting or the misuse of laxatives. Timely observation can help ensure the client's safety and provide an opportunity for immediate intervention if necessary.

Choice B rationale:

Suggesting that the client assist with meal planning can be a beneficial intervention, but it should not be the first action. Clients with bulimia nervosa often have complex emotional and psychological issues related to their eating habits, so it's crucial to address the immediate risks of binge-purge episodes before moving on to meal planning.

Choice C rationale:

Instructing the client about effective coping strategies is important for long-term recovery, but it should not be the first action. Immediate safety concerns, such as monitoring for binge-purge behaviors, take precedence in the initial care of a client with bulimia nervosa.

Choice D rationale:

Referring the client to a support group is a valuable intervention in the long-term management of bulimia nervosa, but it should not be the first action. The immediate priority is to assess and address any acute risks associated with the disorder, such as binge-purge episodes.