Author Question: A patient with pneumonia is having difficulty maintaining a clear airway. Which actions should the ... (Read 26 times)

newyorker26 · **on:** Jun 25, 2018

A patient with pneumonia is having difficulty maintaining a clear airway. Which actions should the nurse take to ensure this patient is adequately ventilated?

Select all that apply.
1. Assess skin color at least every four hours.
2. Assess breath sounds at least every four hours.
3. Assess oxygen saturation level at least every four hours.
4. Assess vital signs daily.
5. Assess respiratory rates every shift.

Question 2

A patient is prescribed isoniazid (INH) and rifampin for treatment of tuberculosis. Which adverse effects should the nurse instruct the patient to report to the healthcare provider?

Select all that apply.
1. fever
2. yellow tint to the skin
3. episodic pain in the upper-left quadrant
4. diarrhea
5. change in stool color

yeungji · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1, 2, 3
When monitoring a patient with a respiratory illness that induces secretions, the patient must be monitored for ineffective airway clearance. By assessing the skin, vital signs, breath sounds, and oxygen saturation levels at least every four hours, the nurse will be able to detect subtle changes that could indicate impending changes with the patient. Respiratory rates must be assessed on a frequency level similar to the breath sounds assessment, if not more often.

Answer to Question 2

Correct Answer: 2, 5
INH and rifampin can cause hepatitis. Jaundice could indicate hepatitis. A change in stool color could possibly be an indication of hepatitis. A fever or diarrhea would not indicate hepatitis. The pain from hepatitis is on the upper-right quadrant, not the left.