TAKE ACTIONS CASE STUDY 3-16

7

8

9

10

Multiple Select

Choose the TOP 3 NURSING INTERVENTIONS that are PRIORITY to implement for the client.

(2 interventions are combined into 1)

• Increase oxygen to 50% per venti mask and elevate head of bed 30-45 degrees.

• Encourage oral fluids of at least 8 glasses of water per day.

• Promote turning side to side, coughing, and deep breathing, every 2 hours while awake.

• Administer albuterol 2 puffs as a inhalation prn every 4-6 hours as prescribed.

• Instruct client on importance of effective use of incentive spirometer every 2 hours while awake.

Multiple Select

Which of the following actions would the nurse implement for this client with pneumonia who is experiencing respiratory compromise?

• Elevate the head of the bed 30-45 degrees.

• Monitor pulse oximetry every shift.

• Encourage oral fluids of at least 8 glasses of water per day.

• Place client in an airborne infection isolation room (negative pressure).

Multiple Select

Which of the following actions would the nurse implement for this client with pneumonia who is experiencing respiratory compromise?

• Promote turning side to side, coughing, and deep breathing every 2 hours while awake.

• Request an order for computer tomography (CT) scan of the chest.

• Increase or maintain oxygen to 50% per venti mask.

• Instruct the client on the importance of effective use of incentive spirometer every 2 hours while awake.