A patient's data shows consolidation in the right middle and lower lobe, consistent with pneumonia.
What actions can the nurse take to assist the patient in improving their ventilation and oxygenation? Select all that apply.

Choice A rationale:

Diminished breath sounds in the right lung: This finding suggests that there is still some inflammation or fluid in the right lung, which is not consistent with fully effective treatment. Normal breath sounds should be clear and equal bilaterally.

PaCO2 55 mm Hg on a blood gas: This finding is slightly elevated, indicating that the patient may be having some difficulty clearing carbon dioxide from the lungs. A normal PaCO2 is 35-45 mm Hg.

Rhonchi in the right lung: Rhonchi are a type of abnormal breath sound that is caused by secretions in the airways. This finding suggests that there is still some inflammation or infection in the right lung.

Choice B rationale:

Oxygen saturation greater than 94%: This finding is within the normal range and indicates that the patient is getting enough oxygen.

Client ambulates without shortness of breath: This finding is a positive sign that the patient's respiratory status is improving. Symmetric chest expansion: This finding indicates that both lungs are expanding equally, which is a good sign.

Choice C rationale:

The assessment findings are mixed, with some findings suggesting improvement (oxygen saturation, ambulation without shortness of breath, symmetric chest expansion) and some findings suggesting that the infection is not fully resolved (diminished breath sounds, elevated PaCO2, rhonchi). This suggests that the treatment has been partially effective, but that the patient may need further treatment to fully resolve the pneumonia.

Choice D rationale:

It is important to evaluate the effectiveness of treatment over time, but the assessment findings in this case are clear enough to determine that the treatment has been partially effective.

Choice A rationale:

Chronic pain is a significant concern for this client, but it is not the immediate priority. Pain can be managed with medications and comfort measures, while aspiration can be life-threatening.

Tissue destruction by the tumor is likely contributing to the pain, but addressing the risk of aspiration takes precedence.

Uncontrolled pain can exacerbate anxiety and make it difficult to focus on other interventions, but ensuring airway safety is paramount.

Choice B rationale:

Anxiety and grieving are expected reactions to a diagnosis of esophageal cancer, and they should be addressed as part of the client's care plan. However, they are not the immediate priority in this case.

The progression of the disease is a significant stressor, but attending to the risk of aspiration is essential for the client's safety. Psychological distress can negatively impact coping and quality of life, but addressing physical needs takes precedence.

Choice D rationale:

Imbalanced nutrition is a concern for this client due to dysphagia and anorexia. However, it is not the immediate priority. Nutritional interventions can be implemented once the risk of aspiration is addressed.

Difficulty swallowing can lead to inadequate intake and malnutrition, but ensuring airway safety is the primary concern.

Anorexia can further contribute to nutritional deficits, but preventing aspiration is the most pressing issue.

Choice C is the priority nursing problem because:

The client's dysphagia puts them at immediate risk for aspiration, which can lead to pneumonia, respiratory failure, and even death.

Addressing the risk of aspiration is essential to ensure the client's safety and prevent life-threatening complications. It's crucial to implement interventions to minimize the risk of aspiration, such as:

Elevating the head of the bed during meals and for 30-60 minutes after eating Thickening liquids and pureeing foods

Encouraging small, frequent meals

Monitoring for signs of aspiration, such as coughing, choking, or difficulty breathing