A client with emphysema reports difficulty breathing and exhibits audible wheezing.
The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Choice A rationale:

Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.

Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.

Choice C rationale:

Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.

Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.

The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.

Choice D rationale:

Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.

While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.

Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.

Choice B rationale:

Tachypnea is the most likely condition indicated by the client's vital signs.

Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.

This can lead to rapid, shallow breathing, which is called tachypnea.

Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing

Wheezing Chest pain

Feeling short of breath

Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring

Cyanosis (a bluish tint to the skin)

Choice A rationale:

Diminished breath sounds in the right lung: This finding suggests that there is still some inflammation or fluid in the right lung, which is not consistent with fully effective treatment. Normal breath sounds should be clear and equal bilaterally.

PaCO2 55 mm Hg on a blood gas: This finding is slightly elevated, indicating that the patient may be having some difficulty clearing carbon dioxide from the lungs. A normal PaCO2 is 35-45 mm Hg.

Rhonchi in the right lung: Rhonchi are a type of abnormal breath sound that is caused by secretions in the airways. This finding suggests that there is still some inflammation or infection in the right lung.

Choice B rationale:

Oxygen saturation greater than 94%: This finding is within the normal range and indicates that the patient is getting enough oxygen.

Client ambulates without shortness of breath: This finding is a positive sign that the patient's respiratory status is improving. Symmetric chest expansion: This finding indicates that both lungs are expanding equally, which is a good sign.

Choice C rationale:

The assessment findings are mixed, with some findings suggesting improvement (oxygen saturation, ambulation without shortness of breath, symmetric chest expansion) and some findings suggesting that the infection is not fully resolved (diminished breath sounds, elevated PaCO2, rhonchi). This suggests that the treatment has been partially effective, but that the patient may need further treatment to fully resolve the pneumonia.

Choice D rationale:

It is important to evaluate the effectiveness of treatment over time, but the assessment findings in this case are clear enough to determine that the treatment has been partially effective.