Patient Data

Exhibits

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia. At least one finding could be indicated for each system.

Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

A. Assisting with giving sips of water could pose a choking risk if the client's swallowing ability is impaired.

B. Using a straw could increase the risk of aspiration for a client with swallowing difficulties.

C. Obtaining thickening powder might be necessary, but first the nurse must assess the client's ability to swallow safely.

D. Assessing the client's swallowing reflex is the priority to ensure safe swallowing and prevent aspiration.

A. Instituting droplet precautions, placing the client in a private room, and keeping the door closed are critical actions to prevent the spread of COVID-19 within the healthcare facility. These measures protect other clients and healthcare workers from potential exposure to the virus.

B. Notifying the charge nurse is important but should follow the immediate action of instituting droplet precautions to prevent transmission.

C. Updating the client and family about available COVID-19 vaccines is essential for future prevention but does not address the immediate need to prevent virus spread.

D. Teaching the client to wear a mask, hand wash, and social distance is important, but immediate isolation and droplet precautions take precedence to contain potential spread within the facility.