Question

The nurse is reviewing the client's medical record.

Select the 3 findings that require nursing intervention.

Nurses' Notes
Day 1
1000:
Client is short of breath and has a productive cough with yellow mucus. Client reports feeling sick for the last few days and states, "I could barely breathe when I got up this morning and I had a throbbing headache."
Client is alert and oriented to person, place, and time.
Capillary refill less than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs. Pedal pulses +2 bilaterally.
Client reports decreased appetite for the past 2 days.Day 3
0800:
Supplemental oxygen in use at 2 L/min via nasal cannula. Client reports difficulty coughing up mucus. Encouraged the client to cough and deep breathe

Diagnostic Results
Day 1
1000:
Sodium 150 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL)
BUN 24 mg/dL (10 to 20 mg/dL)
WBC count 12,000/mm3​ (5,000 to 10,000/mm3)ABGs:
pH 7.35 (7.35 to 7.45)
PCO2 50 mm Hg (35 to 45 mm Hg)
HCO​3-​ 24 mEq/L (22 to 26 mEq/L)Chest x-ray reveals increased opacity in the bilateral posterior lobes.Day 3
0800:
Sodium 146 mEq/L (136 to 145 mEq/L)
Potassium 5.4 mEq/L (3.5 t

Answer 1

Nursing interventions should address the client's shortness of breath, cough, elevated WBC count, and high PCO₂ level, which are indicative of a respiratory issue such as pneumonia.

Step-by-step explanation:

The three findings in the client's medical record that require nursing intervention are the shortness of breath and productive cough with yellow mucus, increased white blood cell (WBC) count indicating a possible infection, and abnormal blood gas values showing elevated PCO₂ which suggests possible respiratory acidosis or inadequate ventilation. These symptoms and lab results are indicative of a respiratory condition such as pneumonia, which aligns with the findings of crackles in the posterior lungs and an increased opacity noted in the chest x-ray. Nursing interventions would include monitoring the client's respiratory status, ensuring supplemental oxygen is administered as ordered, and assisting with expectoration of mucus.