A nurse is caring for a 75.year.old male client who is experiencing difficulty breathing and shortness of breath.

Exhibits

The nurse is caring for the client following a thoracentesis. Select the 3 findings that require immediate follow.up.

A. Wear a mask when caring for the client. Influenza B is transmitted through droplet particles, so healthcare providers should wear a mask within 3 to 6 feet of the client to reduce the risk of transmission.
B. Place the client on airborne precautions. Airborne precautions are not necessary for influenza B. Droplet precautions are required, which involve wearing a mask and placing the client in a private room if possible. Airborne precautions are typically reserved for infections like tuberculosis, measles, and varicella.
C. Place the client in a private room. Clients with influenza should be placed in a private room or cohorted with another client with the same strain of the virus to prevent the spread of infection. This is a standard infection control measure for droplet precautions.
D. Prepare to administer an antibiotic to the client. Influenza B is a viral infection, and antibiotics are ineffective against viruses. Antiviral medications like oseltamivir (Tamiflu) may be prescribed instead, particularly if the client is within the first 48 hours of symptom onset.
E. Encourage the client to increase fluid intake. Fever, increased respiratory rate, and flulike symptoms can contribute to dehydration, so increasing oral fluid intake helps prevent dehydration, loosen respiratory secretions, and support overall recovery.

A. The client has hypertension and anuria. Hypertension is not a common feature of postoperative shock. Instead, shock is typically characterized by hypotension due to inadequate perfusion. Anuria, while concerning, is usually a later sign of severe hypovolemia or organ failure rather than an early indicator of shock.
B. The client develops bradycardia and bradypnea. Shock generally triggers a compensatory response, leading to tachycardia as the body attempts to maintain cardiac output. Bradycardia and bradypnea are more commonly associated with conditions such as neurogenic shock or opioid overdose rather than hypovolemic or septic shock, which are more frequent in postoperative settings.
C. The client has hypotension and is confused. Hypotension is a hallmark sign of postoperative shock, often resulting from blood loss, fluid shifts, or sepsis. Confusion occurs due to decreased cerebral perfusion and oxygenation. These symptoms indicate a state of inadequate circulation requiring immediate intervention, making this the most appropriate answer.
D. The client has metabolic alkalosis and warm extremities. Postoperative shock is more commonly associated with metabolic acidosis due to poor tissue perfusion and lactic acid buildup rather than alkalosis. Additionally, warm extremities are typical in early septic shock, whereas most types of shock, such as hypovolemic or cardiogenic shock, lead to cool, clammy skin due to vasoconstriction.