The nurse is reviewing the Nurses Notes in the female clients medical record.

Click to highlight the findings that indicate the client is progressing in their plan of care. To deselect a finding, click on the finding again.

Nurses' Notes

 Day 4, 1030

Client states is easier to breathe and I'm not as short of breath" Lung sounds still diminished with crackles. No wheezes detected. Client is on oxygen at 1L/min via nasal cannula and oxygen saturation is 92%. Client reports pleuritic chest pain as 3 on a scale of 0 to 10. Cough is productive and sputum is yellow. Drinking 2 L/per day, voided 200 ml of clear yellow urine.

Rationale for correct choices

• Client states "It is easier to breathe and I'm not as short of breath": The client’s subjective report of improved breathing reflects a positive response to oxygen therapy, antibiotics, and pulmonary interventions. Decreased dyspnea indicates that oxygenation and lung function are improving. This aligns with expected outcomes for pneumonia management and shows clinical progress.

• Oxygen at 1 L/min via nasal cannula with oxygen saturation of 92%: The reduction in supplemental oxygen from 2 L/min to 1 L/min, while maintaining oxygen saturation above 90%, indicates improved respiratory status and better gas exchange. This demonstrates that the client is stabilizing and responding to therapy, a key indicator of progress.

• Client reports pleuritic chest pain as 3 on a scale of 0 to 10: A decrease in pain from 6/10 to 3/10 shows that inflammation and respiratory effort are improving. Lower pain levels enhance the client’s ability to cough, deep breathe, and participate in pulmonary exercises, supporting recovery.

Rationale for incorrect findings

• Lung sounds still diminished with crackles: Although lung sounds are still diminished with crackles, this finding indicates residual congestion in the lungs rather than full resolution. Crackles can persist for several days after pneumonia begins to improve and do not yet signify complete clinical improvement.

• Cough productive with yellow sputum: The presence of yellow sputum indicates ongoing infection and inflammation. While productive coughing helps clear secretions, the sputum color shows that the infection has not fully resolved, so this is not a definitive indicator of progress.