The nurse is caring for a client with pneumonia and has obtained ...

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The nurse is caring for a client with pneumonia and has obtained the following vital signs:
 
  Temperature 101.2 F (oral), BP 100/70, pulse rate 110/min., and respirations 22. The client's oxygen saturation level is 96. Based on these findings, which order requires further clarification?
  1. Administer acetaminophen (Tylenol) 650 mg every 4 hours prn temperature greater than 100.5 F.
  2. Administer intravenous (IV) fluids: 0.9 Normal Saline Solution at 125 ml/hour.
  3. Start oxygen therapy at 3L/minute via nasal cannula.
  4. Send for chest x-ray.

Question 2

The nursing staff is admitting a client diagnosed with diabetic ketoacidosis (DKA).
 
  The licensed practical nurse (LPN) asks the registered nurse (RN) if the pulse oximeter needs to be placed on the client. Which response by the RN to the LPN is the most appropriate?
  1. Please place the pulse oximeter on the client.
  2. I will let you know after I complete my assessment.
  3. Thanks, but that is something I have to do for the client.
  4. We don't have an order to do that.

[honnalora]

Answer to Question 1

Correct Answer: 3

The nurse should clarify the oxygen therapy order. Although the client's respiratory rate is slightly increased, this is an expected finding in a client with fever and a diagnosis of pneumonia. The client's oxygen saturation level of 96 is within normal limits; therefore the client does not need oxygen therapy. The order for acetaminophen (Tylenol) is appropriate and is to be given as needed for fever. The order for IV fluids is appropriate as fluids help to thin secretions and make up for increased insensible loss due to fever and increased respiratory rate. A chest film would be indicated to determine the extent of pulmonary involvement.

Answer to Question 2

Correct Answer: 2
The nurse should complete the assessment to determine any respiratory abnormalities before using the pulse oximeter. Clients in DKA may not require a pulse oximeter as it does not provide information about acid-base balance or blood glucose levels. It reflects only the percentage of oxygen saturation of hemoglobin. If the RN determines the pulse oximeter is needed, the RN could delegate the task to the LPN. This would not require a healthcare provider's order.

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Excellent

[at]

Gracias!