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A nurse is caring for a client in the intensive care unit.

Exhibits

Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Most Likely Condition:

The client is most likely experiencing Hospital-acquired pneumonia ©. This is indicated by the recent admission for pneumonia, persistent cough with greenish sputum, increased WBC count, and bilateral infiltrates on the chest X-ray.

Actions to Take:
  1. Administer IV antibiotics as prescribed (already in the provider’s prescriptions).
  2. Perform chest physiotherapy © to help clear the lungs.
 
   

Parameters to Monitor: 

  1. Oxygen saturation (A) to ensure the client is maintaining adequate oxygen levels.
  2. White blood cell count (D) to monitor the infection and response to antibiotics.
 
   

 

 


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Related Questions

Correct Answer is ["A","C","D","E","F"]

Explanation

Choice A rationale
Double-checking all dosage calculations is a critical step in preventing medication errors. This ensures that the correct dose is administered and helps avoid potentially harmful mistakes.
Choice B rationale
The option “nusually large or small doses” seems to be a typographical error and does not provide a clear action to prevent medication errors. Therefore, it is not considered a correct choice.
Choice C rationale
Comparing the medication label to the order is essential to ensure that the correct medication is being administered. This step helps verify that the medication matches the provider’s prescription.
Choice D rationale
Using at least two client identifiers before administering a dose is a standard safety practice to confirm the client’s identity and prevent administering medication to the wrong person.
Choice E rationale
Involving and educating clients in medication administration can help prevent errors by ensuring that clients are aware of their medications and can alert the nurse to any discrepancies or concerns.
Choice F rationale
Documenting all medication in the electronic record as soon as it is given is crucial for maintaining accurate records and ensuring that all healthcare providers have up-to-date information about the client’s medication administration.

Correct Answer is []

Explanation

Most Likely Condition:

The client is most likely experiencing Hospital-acquired pneumonia ©. This is indicated by the recent admission for pneumonia, persistent cough with greenish sputum, increased WBC count, and bilateral infiltrates on the chest X-ray.

Actions to Take:
  1. Administer IV antibiotics as prescribed (already in the provider’s prescriptions).
  2. Perform chest physiotherapy © to help clear the lungs.

Parameters to Monitor:

  1. Oxygen saturation (A) to ensure the client is maintaining adequate oxygen levels.
  2. White blood cell count (D) to monitor the infection and response to antibiotics.

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