Patient data

For each medication, chose the most likely option for drug classification and treatment goal.

Medication	Drug Classification	Treatment Goals
Furosemide	_______________	_______________
Digoxin	_______________	_______________
Captopril	_______________	_______________

A. Applying a fitted respirator mask, such as an N95, is not required for routine care of clients with influenza. Influenza is transmitted via droplets, not airborne particles, so standard droplet precautions, including a surgical or procedure mask, are sufficient. Recommending a respirator mask is unnecessary and could create confusion or unnecessary expense.

B. Instructing the UAP to notify the nurse of changes in respiratory status is important for ongoing monitoring, but it does not address the immediate infection control concern observed. While important, it is a secondary action rather than the priority in this scenario.

C. Reviewing the need for the UAP to wear a face mask while in close contact with the client is correct. Droplet precautions are indicated for influenza, and wearing a surgical mask is necessary to prevent transmission to healthcare workers. The nurse should ensure the UAP understands and consistently implements this precaution along with gloves and gown to maintain infection control standards.

D. Assigning the UAP to another client and assuming full care is unnecessary if the UAP can safely provide care using appropriate personal protective equipment (PPE). This action would disrupt workflow without addressing the knowledge gap regarding proper infection control practices.

Rationale for correct answers:

• Client states, "It's been hard to catch my breath.": This subjective report of dyspnea (shortness of breath) is a significant indicator of respiratory distress or cardiovascular compromise, especially given her oxygen saturation was only 83% on room air.
• Crackles are heard in the bases of bilateral lungs: Crackles (rales) typically indicate fluid in the alveolar spaces. In a patient with a history of MI and hypertension, this is a classic sign of pulmonary edema related to left-sided heart failure.
• Heart rate is 118 beats/minute with a regular rhythm: This is tachycardia (a heart rate over 100 bpm). The heart is likely overcompensating for low oxygen levels or decreased cardiac output.
• Bilateral peripheral pitting edema of 2+ is present in both legs: Pitting edema indicates systemic fluid volume overload, commonly associated with right-sided heart failure or the heart's inability to pump effectively.

Rationale for incorrect choices:

• Client is alert and oriented to person, place, time, and situation: This is a normal neurological finding (A&O x4), indicating that brain perfusion is currently adequate.
• S1 and S2 heart sounds noted: These are the "lub-dub" sounds of normal heart valve closure. Their presence is a baseline normal finding.
• Client denies pain: At 0125, the absence of pain is a stable finding (though follow-up became necessary at 0135 when she began reporting "heavy" chest pain).
• Reports voiding prior to coming to hospital: This indicates recent renal perfusion and bladder function, which is a normal historical detail.