Question

Prioritize the nurse's interventions based on the client's symptoms and diagnostic results.

a) Altered mental status, decreased appetite
b) Shortness of breath, productive cough
c) Capillary refill less than 2 seconds, diaphoresis
d) Increased opacity in bilateral posterior lobes

Answer 1

Based on the client's symptoms and diagnostic results, the nurse should prioritize interventions for capillary refill, diaphoresis, shortness of breath, productive cough, altered mental status, and decreased appetite in that order.

Step-by-step explanation:

Based on the client's symptoms and diagnostic results, the nurse should prioritize the interventions as follows:

1. Capillary refill less than 2 seconds, diaphoresis: These symptoms indicate poor perfusion and potential cardiovascular compromise. The nurse should assess vital signs, administer oxygen, and notify the healthcare provider immediately.
2. Shortness of breath, productive cough: These symptoms suggest respiratory distress. The nurse should provide oxygen therapy, encourage deep breathing and coughing, and obtain sputum for analysis.
3. Altered mental status, decreased appetite: While still important, these symptoms are secondary priorities to the ones mentioned above. The nurse should assess the client's cognitive function, monitor for signs of dehydration, and collaborate with the healthcare team for further evaluation.
4. Increased opacity in bilateral posterior lobes: This finding on the chest radiograph is an important clue but does not require immediate intervention. The nurse should communicate the results to the healthcare provider for further evaluation and treatment.