Exhibits

A nurse is assisting with the care of a client in the emergency department. The client is alert and oriented x3. Wheezing is noted on exhalation with a prolonged breathing cycle. The cough is nonproductive. Use of accessory muscles is noted while breathing. The oral mucosa and lips are cyanotic. Nasal flaring is noted. The client experiences difficulty talking.

The nurse is assisting in planning care. Complete the diagram by dragging from the choices below to specify:

1. What condition the client is most likely experiencing.
2. Two actions the nurse should take to address that condition.
3. Two parameters the nurse should monitor to assess the client’s progress.

Choice A rationale

Monthly vitamin B12 injections are not a risk factor for the development of osteoporosis. Vitamin B12 is important for nerve function and the production of DNA and red blood cells, not bone health.

Choice B rationale

Long-term use of prednisone, a corticosteroid, can lead to osteoporosis. Prednisone can decrease the absorption of calcium in the gut and increase the loss of calcium in the kidneys, leading to bone loss and an increased risk of fractures.

Choice C rationale

A congenital heart murmur is not a risk factor for the development of osteoporosis. Heart murmurs are sounds during your heartbeat cycle made by turbulent blood in or near your heart, and they are not associated with bone health.

Choice D rationale

A history of kidney stones is not a risk factor for the development of osteoporosis. Kidney stones are hard deposits made of minerals and salts that form inside your kidneys, and they are not associated with bone health.

Choice A rationale:

Obtain the client’s weight is an important task, particularly in cases where the client's fluid status needs to be monitored or if weight- based medications are prescribed. However, in this scenario, while monitoring the weight is necessary for assessing fluid balance and the patient's general condition, it does not address the immediate need to investigate the cause of the fever and signs of possible infection. The priority in this situation is to collect data that will guide effective treatment, which is why obtaining blood cultures is critical before any antibiotics are administered. Weight measurement does not directly influence the immediate treatment decisions or diagnostics related to the fever and signs of infection.

Choice B rationale:

Assist with administering the antibiotic is important given the patient's fever and possible infection. Vancomycin is a crucial antibiotic for treating infections, particularly those associated with the arteriovenous fistula (AVF) site. However, it is essential to first obtain blood cultures before starting antibiotics to ensure accurate identification of the causative organism and to guide appropriate antibiotic therapy. Administering the antibiotic before blood cultures are taken may affect the results, making it harder to determine the right treatment. Therefore, while administering the antibiotic is important, it should follow the collection of blood cultures to avoid compromising diagnostic accuracy.

Choice C rationale:

Initiate a nutritional consult is relevant for addressing the patient’s nutritional needs, particularly if there are concerns about malnutrition or dietary deficiencies. In this scenario, the immediate concern is managing the fever and potential infection, rather than addressing nutritional needs. The priority should be to diagnose and manage the infection, which will have a more immediate impact on the patient’s overall condition. Nutritional consultation is important but not the immediate priority when the patient is presenting with signs of infection and a high fever.

Choice D rationale:

Administer acetaminophen is a necessary action to manage the patient’s elevated temperature (39.1°C or 102.4°F). Acetaminophen can help reduce fever and provide symptomatic relief. However, addressing the fever with medication does not resolve the underlying cause. Given the presence of erythema at the AVF site and the need to identify the source of infection, obtaining blood cultures should be prioritized. Treating the fever with acetaminophen before obtaining blood cultures may interfere with the interpretation of the results. Thus, while administering acetaminophen is appropriate for fever management, it should not precede the collection of blood cultures.

Choice E rationale:

Administer diphenhydramine, an antihistamine, is generally used to manage allergic reactions or symptoms such as itching. In this scenario, there is no indication of an allergic reaction or symptoms that would warrant the use of diphenhydramine. The primary concern is the patient’s fever and possible infection at the AVF site. Administering diphenhydramine does not address the infection or fever management in a manner that would influence the immediate treatment plan. Hence, while diphenhydramine might be used for symptomatic relief in other situations, it is not the priority in this context.

Choice F rationale:

Obtain blood cultures is the correct priority because it is crucial for diagnosing the source of infection. The patient presents with a high fever and signs of possible infection at the AVF site. Blood cultures need to be obtained before starting antibiotics to identify the causative organism and tailor the antibiotic treatment accordingly. This step is critical to ensure effective and targeted treatment and to avoid compromising the diagnostic process. Accurate identification of the pathogen through blood cultures will guide the appropriate use of antibiotics and other treatments, making this the first action the nurse should take.