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This is a positive and desired outcome that shows the client is engaged in their care plan.

This indicates that the interventions are effective, and the client is responding positively.

This is a favorable outcome demonstrating effective management of the respiratory condition.Top of FormBottom of Form

Encourage vigorous exercise- Vigorous exercise can lead to dehydration and hypoxia, both of which can trigger a sickle cell crisis. This is not an appropriate intervention.

Discourage a high level of fluid intake- Clients with sickle cell anemia should be encouraged to maintain adequate hydration to prevent sickling of red blood cells. Discouraging fluid intake is incorrect.

Apply cold compresses to painful, swollen joints- Cold can cause vasoconstriction and worsen symptoms. Warm compresses, not cold, are recommended to relieve pain during a crisis.

Draw blood for an arterial blood gas — While ABG analysis is important in assessing respiratory function, it is not the priority in this emergency. The client is in severe respiratory distress and needs immediate intervention.

Initiate oxygen therapy as prescribed and reassess the client in 10 minutes — Although oxygen therapy is essential, waiting 10 minutes to reassess without addressing bronchoconstriction may delay critical treatment. Immediate bronchodilation is needed.

Encourage the client to relax and breathe slowly through the mouth — This may be helpful as a supportive measure but is not appropriate as the first intervention during acute respiratory distress.

Medications must be taken for the rest of the client's life, even if the client feels better — This is incorrect. TB treatment is not lifelong. The standard course is time-limited, usually 6 to 9 months, depending on the drug regimen and response to treatment.

Medications will need to be taken until the Mantoux test is negative — The Mantoux (PPD) test may remain positive for life after TB infection or vaccination and is not used to monitor treatment progress. This is inaccurate.

The client's family will not need to take medications to prevent infection — Close contacts may need prophylactic treatment, especially if they are at high risk (e.g., young children, immunocompromised). This statement is misleading.

White cell count of 15,000/mm³ (range 4,500–11,000), urine output at 40 mL/hr, no sputum — An elevated WBC count indicates ongoing infection. While urine output is normal, the high WBC count suggests the pneumonia is not yet resolving.

Oral temperature of 101°F (38.3°C), increased chest pain with non-productive cough — Fever and increased chest pain are signs of active infection and inflammation, indicating the patient is not yet responding well to treatment.

Productive cough with thick green sputum, states feeling "tired" — Green sputum suggests ongoing infection, and fatigue is a common symptom during acute illness, indicating incomplete recovery.

Vegetarian diet — A vegetarian diet is not a known risk factor for pneumonia unless it results in nutritional deficiencies, which is not indicated here.

Osteoarthritis — While osteoarthritis affects mobility and comfort, it does not directly increase the risk of developing pneumonia.

Plays golf three times a week — Regular physical activity suggests good overall health and is not a risk factor for pneumonia.

Elevate the head of the bed — This may help ease breathing but is not the first priority. The first step is to stop the infusion to halt the allergic reaction.

Auscultate the client's breath sounds — While assessing respiratory status is important, the immediate priority is to stop the medication causing the reaction.

Call the client's provider — Notifying the provider is necessary, but it is not the first step. Immediate intervention is required to stop the reaction before it worsens.

Call emergency services for the client — While this may be necessary if the client is in severe distress, the nurse must first assess the situation to determine the appropriate level of intervention.

Have the client cough and expectorate secretions — This can help if secretions are causing the breathing difficulty, but assessment should come first to identify the cause.

Increase the oxygen flow to 3 L/min — Increasing oxygen in a client with COPD can be dangerous without proper assessment, as it may suppress their respiratory drive.

Hold the medication in the mouth for 15 seconds before swallowing — This is incorrect. Inhaled glucocorticoids are meant to be inhaled into the lungs, not held in the mouth or swallowed.

Take the medication immediately when an attack starts — Inhaled glucocorticoids are not rescue medications. They are used for long-term control and prevention, not for acute asthma attacks.

Do not abruptly stop taking this medication: it must be tapered off — This applies to systemic (oral or IV) corticosteroids, not inhaled forms. Inhaled glucocorticoids have minimal systemic effects and do not require tapering.

Wash dishes and personal items after use — TB is transmitted through airborne droplets, not by sharing dishes or personal items. This action does not directly prevent transmission.

Reports daily to the public health department — While public health follow-up is important, daily reporting is not typically required and does not directly reflect understanding of transmission prevention.

Demonstrates correct use of medications — Correct medication use is vital for treatment but does not directly address transmission control.