Question

A nurse is admitting a client.

The nurse is reviewing the client's medical record. Which of the following actions should the nurse take?
Select all that apply.

Nurses' Notes
0930:
Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days.
1030:
Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia.

Vital Signs
1030:
Blood pressure 110/68 mm Hg, Heart rate 110/min, Respiratory rate 24/min, Temperature 38.6° C (101.5° F), Oxygen saturation 91% on room air


A. Place the client on droplet isolation precautions.
B. Apply oxygen at 2 L/min via nasal cannula.
C. Request a prescription for an antipyretic medication.
D. Wear an N-95 mask when providing care to the client.
E. Request a prescription for an antihypertensive medication.
F. Remain 1 m (3 feets) from the client.

Answer 1

For a client with pneumonia, the nurse should place the client on droplet isolation precautions, apply oxygen at 2 L/min via nasal cannula, and request a prescription for an antipyretic medication to manage fever.

Step-by-step explanation:

When admitting a client with a medical record indicating symptoms such as a sore throat, productive cough, shortness of breath, fever, and a positive chest x-ray for pneumonia, a nurse should take the following actions:

• Place the client on droplet isolation precautions to prevent the spread of the infection.
• Apply oxygen at 2 L/min via nasal cannula, as the client's oxygen saturation is below the normal range, indicating hypoxemia.
• Request a prescription for an antipyretic medication to help lower the client's fever.

An N-95 mask is not typically necessary for standard droplet precautions unless the client is suspected of having an illness transmitted via airborne particles, like tuberculosis. Given the client's symptoms and chest x-ray, we are dealing with pneumonia, which is not an indication for an antihypertensive medication, and staying 1 meter from the client is not a specific isolation precaution for pneumonia.