Question

A nurse is caring for a client. Same client. The nurse is reviewing the client's medical record.

Day 3: 0800
Supplemental oxygen is use at 2 L/min via nasal cannula. Client reports difficulty coughing up mucus. Encouraged the client to cough and deep breathe.

Sodium 146 mEq/L (136-145) - previously 150
Potassium 5.4 mEq/L (3.5-5) - previously 4.8
BUN 22 mg/dL (10-20) - previously 24
WBC count 15,000/mm3 (5,000-10,000) - previously 12,000
Sputum culture and sensitivity results indicate streptococcal pneumonia.
Temperature 38.6C (101.5F)
Respiratory rate 22
Oxygen saturation 97% on 2 L/min

Select the 3 findings that require nursing intervention

A. Heart rate
B. Temperature
C. Potassium level
D. WBC count
E. Oxygen saturation

Answer 1

The nurse should intervene in the client's elevated potassium level, elevated white blood cell count, and difficulty in coughing up mucus.

Step-by-step explanation:

The nurse should intervene in the following three findings:

1. Potassium level: The client's potassium level is elevated at 5.4 mEq/L, which is above the normal range of 3.5-5 mEq/L. Elevated potassium levels can lead to cardiac dysrhythmias and require intervention.
2. WBC count: The client's white blood cell (WBC) count is elevated at 15,000/mm3, which is above the normal range of 5,000-10,000/mm3. This indicates an infection and requires nursing intervention.
3. Oxygen saturation: The client's oxygen saturation is 97% on 2 L/min of supplemental oxygen via nasal cannula. Although this is within the normal range (95%-100%), the difficulty in coughing up mucus suggests inadequate oxygenation and should be addressed by the nurse.