The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results.
Which diagnostic test should the nurse review to confirm the diagnosis of TB?

B. Place patient on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.

Rationale:

Hypoxemia: Patients who have undergone cholecystectomy are at risk for developing hypoxemia due to various factors, including:

Atelectasis: Collapsed lung tissue can impair gas exchange, leading to low oxygen levels in the blood.

Pneumonia: A potential post-operative complication that can cause inflammation and fluid buildup in the lungs, hindering oxygen uptake.

Pain: Post-surgical pain can inhibit deep breathing and coughing, which are essential for maintaining adequate lung function.

Oxygen Therapy: Supplementing oxygen helps to increase oxygen saturation and improve overall tissue oxygenation, reducing the strain on the heart and other organs.

Oxygen Saturation Goal: Maintaining oxygen saturation at or above 95% ensures that the patient's tissues are receiving sufficient oxygen to meet their metabolic needs.

C. Stat 2 views chest x-ray.

Rationale:

Chest X-ray: A valuable diagnostic tool that can visualize the lungs and surrounding structures, aiding in the assessment of: Atelectasis: Appears as areas of increased density on the x-ray, indicating collapsed lung tissue.

Pneumonia: May present as consolidation (solid white areas) or infiltrates (patchy areas of increased density) on the x-ray. Pleural effusion: Fluid accumulation in the pleural space, which can impair lung expansion and gas exchange.

Pneumothorax: Presence of air in the pleural space, which can cause lung collapse and respiratory distress.

Early Detection: Prompt identification of respiratory complications through chest x-ray allows for timely interventions and prevents further deterioration of the patient's condition.

E. Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.

Rationale:

CBC: Assesses for signs of infection or inflammation, including:

Elevated white blood cell count (leukocytosis) Increased neutrophils (neutrophilia)

Anemia (low red blood cell count)

BMP: Evaluates electrolyte and kidney function, which can be affected by infections and post-operative complications.

Blood Cultures: Determines the presence of bacteria in the bloodstream, allowing for identification of the causative organism and guiding appropriate antibiotic therapy.

F. Start the patient on antibiotic therapy.

Rationale:

Infection Risk: The patient's history of cholangitis and recent surgery increase the risk of infection. Prophylactic Antibiotics: Often administered after cholecystectomy to prevent post-operative infections.

Early Intervention: Prompt initiation of antibiotic therapy is crucial in managing infections and preventing serious complications such as sepsis.

Choice A rationale:

Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.

Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.

Choice C rationale:

Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.

Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.

The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.

Choice D rationale:

Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.

While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.

Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.

Choice B rationale:

Tachypnea is the most likely condition indicated by the client's vital signs.

Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.

This can lead to rapid, shallow breathing, which is called tachypnea.

Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing

Wheezing Chest pain

Feeling short of breath

Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring

Cyanosis (a bluish tint to the skin)