Question

The nurse is caring for a 32-year-old client in the med-surg unit.

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DAY 1: The client is admitted for lower extremity weakness and a tingling sensation in the feet. The client had an upper respiratory infection 2 weeks ago. The lungs are clear to auscultation. The client had decreased muscle strength and absent deep tendon reflexes in the lower extremities. Vitals: HR 85, RR 18, BP 110/70, 99% on RA
DAY 2: the client appears restless with increased difficulty breathing and nasal flaring, as well as difficulty staying awake. Abnormal vitals: HR 122, RR 26, BP 124/82, 89% on RA
Which of the following are expected interventions:
☐ administer O2
☐ administer diuretics
☐ Prepare the client for intubation
☐ Place the client on droplet precautions
☐ Elevate the head of bed to 45 degrees

Answer 1

The expected interventions for the client on Day 2 are administering O2, elevating the head of bed to 45 degrees, and preparing the client for intubation.

Step-by-step explanation:

The expected interventions for the client on Day 2 are:

• Administer O2: The client is experiencing increased difficulty breathing and low oxygen saturation levels, so administering oxygen can help improve oxygenation.
• Elevate the head of bed to 45 degrees: Elevating the head of bed can aid in improving breathing and reducing respiratory distress.
• Prepare the client for intubation: The client's worsening respiratory status and need for increased oxygen support may indicate the need for intubation to secure the airway.