Author Question: The nurse admits an alert client with a diagnosis of pneumonia and assesses vital signs and oxygen ... (Read 43 times)

jwb375 · **on:** Jul 22, 2018

The nurse admits an alert client with a diagnosis of pneumonia and assesses vital signs and oxygen saturation. The client's respiratory rate is 26, and oxygen saturation is 89.

What actions can the nurse take independently to support respirations and reduce hypoxia? 1. Apply oxygen.
2. Raise the head of the bed.
3. Administer a bronchodilator.
4. Insert an oral airway.

Question 2

While working the first day in the clinical area, the nursing student receives an emergency call from family, and must leave the unit. The nursing student demonstrates the ability to think critically by:

1. Informing the client that the student must leave immediately.
2. Informing the nursing instructor of the emergency and need to leave.
3. Leaving the unit immediately and calling the nursing instructor on the way home.
4. Telling the nurse in charge of the client that the student must leave immediately.

ttt030911 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2
Rationale: The nurse should raise the head of the bed and place the client in either the high Fowler's or orthopneic position to improve oxygenation. Administration of oxygen and bronchodilators require a physician's order, and cannot be performed independently. Inserting an oral airway would not improve oxygenation, and is contraindicated in an alert adult client who does not have an airway obstruction.

Answer to Question 2

2
Rationale 1: The student nurse thinks of the client's safety, and first informs the nursing instructor of the emergency and need to leave, so adequate client care can be arranged. The nurse never leaves the unit or the client without first informing the person in charge, as this could be viewed as client abandonment. There is no need to inform the client, and the nursing instructor can inform the charge nurse of the change in situation.