To achieve the outcome of effective ventilation, which nursing intervention should be included in the plan of care for a client on a ventilator?

A. Serum potassium of 5.2 mEq/L: A potassium level of 5.2 mEq/L is slightly elevated but is still within a potentially acceptable range (normal is 3.5-5.3 mEq/L). While elevated potassium can be a concern, particularly in the context of an MI or with certain medications (like potassium-sparing diuretics), this level is not critically high. The nurse should monitor the potassium levels, but this is not an urgent finding requiring immediate reporting unless it increases further or is accompanied by significant symptoms (such as arrhythmias).

B. T wave depression on electrocardiogram (ECG): T wave depression can be a sign of ischemia or injury, which is common in the setting of an acute myocardial infarction. However, T wave changes are expected in this context and do not indicate an immediate emergency. The nurse should continue to monitor the ECG for any progression or worsening of ischemic changes but should prioritize concerns such as hypotension or worsening clinical status over this finding.

C. Heart rate of 90 beats per minute: A heart rate of 90 beats per minute is within normal limits (60-100 beats per minute), especially in the early stages of an MI. Nitroglycerin may cause a reflex tachycardia as a compensatory response to the decreased blood pressure, but a heart rate of 90 bpm is not an alarming finding. The nurse should continue to monitor the heart rate, but it is not the most pressing concern compared to hypotension. 4o mini

D. Blood pressure of 90/50: A blood pressure of 90/50 mmHg is significantly low and could indicate that the client is experiencing hypotension, which is a known side effect of nitroglycerin infusion. Nitroglycerin causes vasodilation, which can reduce blood pressure, especially in clients who are already at risk due to an acute myocardial infarction (MI). Low blood pressure can compromise perfusion to vital organs, including the heart, brain, and kidneys, and may lead to shock if not corrected promptly. This finding should be reported immediately to the healthcare provider, as it may require adjustment of the nitroglycerin dosage or discontinuation of the infusion.

A. Dextromethorphan 10 mg PO q 4 hr: Dextromethorphan is a cough suppressant, and while it may be useful for controlling a dry, non-productive cough, it is not appropriate for ineffective airway clearance in pneumonia. In fact, suppressing the cough in pneumonia could prevent the patient from clearing mucus from the airways, exacerbating the problem. It is more appropriate for a client who has a dry cough without significant mucus production.

B. Cromolyn MDI 2 puffs daily: Cromolyn is a mast cell stabilizer used for the prevention of asthma and allergy symptoms, and it is not typically used for treating pneumonia or ineffective airway clearance. It works by preventing the release of inflammatory mediators in response to allergens, but it does not address the issue of clearing mucus in the airways during a bacterial infection like pneumonia.

C. Guaifenesin 200 mg PO q 4 hr: Guaifenesin is an expectorant that helps loosen and thin mucus in the airways, making it easier for the client to cough up and clear secretions. This is the most appropriate medication for addressing ineffective airway clearance in a client with pneumonia, as the goal is to facilitate the removal of mucus and improve respiratory function. Guaifenesin does not suppress the cough reflex but instead promotes productive coughing, which is essential for clearing the airways during a respiratory infection like pneumonia.

D. Methylprednisolone 30 mg IV BID: Methylprednisolone is a corticosteroid used to reduce inflammation and control severe allergic or inflammatory conditions. While corticosteroids may be used in certain cases of pneumonia (e.g., in cases of significant inflammation or an underlying condition like COPD), they are not the first-line treatment for ineffective airway clearance. The priority in this case is to promote mucus clearance, which is better addressed by guaifenesin.