Question 16
FLAG QUESTION
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0930 Admitted with shortness of breath and confusion in orthopneic/tripod position 02 21/NC in place VS BP 148/72, HR 98 and regular, PR 22, Temp 580, 84% on 21/NC. BMI 14. Clubbing of nails. Diminished vesicular lung sounds with faint crackles to the bilateral bases. Bronchial breath sounds over the trachea Cyanotic nails with the angle of nailbeds greater than 180 degrees General skin with dusky appearance Finger tips to right hand with yellow discoloration. H smoking
The nurse understands the client is having decreased tissue perfusion related to decreased gas exchange as evidenced by client in orthopneic/tr 2, SpO2 84% on 2L/NC, clubbing of nails, dusky skin and cyanotic nails. The nurse would create a plan of care by including which priority actio rop the three priority actions from the left column to the right column.
tential Priority Actions
Priority Actions
struct client to lie in recumbent position
Raise the head of bed
truct client to breathe faster
Increase 02 to 3L per nasal cannula
e the client breathe in paper bag
Teach purse-lip breathing
m
FY VERSION 3W.9.0