A nurse is conducting a Romberg test as part of a patient’s physical assessment. Which of the following methods should the nurse employ?

Choice A rationale: Implementing airborne precautions is not necessary in this case. The client’s symptoms and the progression of their condition suggest a severe respiratory infection, possibly pneumonia, but there is no indication that the infection is airborne.

Airborne precautions are typically reserved for diseases that are spread through tiny droplets in the air, such as tuberculosis, measles, or chickenpox.

Choice B rationale: The client’s worsening respiratory distress, evidenced by increased shortness of breath, use of accessory muscles for breathing, decreased oxygen saturation, and changes in sputum, indicate that the client may require intubation and mechanical ventilation. This would ensure that the client’s airway remains open and that they receive adequate oxygen.

Choice C rationale: The client has a history of well-managed diabetes mellitus. Given the stress of the illness and the initiation of corticosteroid therapy (which can raise blood glucose levels), it would be important to monitor the client’s blood glucose levels frequently.

Choice D rationale: The client has been prescribed Levofloxacin, an antibiotic, which should be administered as prescribed. Given the client’s symptoms and the progression of their condition, it is likely that they have a bacterial infection. Antibiotics are critical for treating bacterial infections.

Choice E rationale: Ensuring strict hand hygiene before and after client contact is a standard precaution in all healthcare settings to prevent the spread of infection.

Choice F rationale: Increasing fluid intake can help thin out the sputum, making it easier for the client to cough it up. This can help improve the client’s respiratory function.

Choice G rationale: There is no current indication for a chest tube insertion. While the client’s chest X-ray shows extensive consolidation and possible pleural effusion, the notes do not indicate that the effusion is large enough to require drainage at this time. A chest tube would be considered if the effusion was large and causing significant respiratory distress, which is not clearly the case here.

Choice A rationale

Assisting the patient into a prone position is not necessary for the use of thigh-length sequential compression sleeves. These devices are typically used while the patient is in bed or sitting in a chair.

Choice B rationale

Placing a sleeve over the top of each leg with the opening facing up is not the correct method for applying sequential compression sleeves. The sleeves should be applied so that they fit snugly and comfortably around the patient’s legs.

Choice C rationale

The nurse should ensure that two fingers can fit under the sleeves. This is to ensure that the sleeves are not too tight, which could impede blood flow and cause discomfort or injury to the patient.

Choice D rationale

Setting the ankle pressure at 65 mm Hg is not related to the use of sequential compression sleeves. The pressure settings for these devices are typically determined by the healthcare provider based on the patient’s specific needs.