Question

Scenario update:

You assess B.T. and find that he has diminished lung sounds with inspiratory and expiratory wheezes in all lung fields with a nonproductive cough and accessory muscle use. His skin is pale, warm and dry. The electrocardiogram (ECG) shows sinus tachycardia without ectopy. He is alert and oriented×4 spheres. He appears anxious and is sitting upright, leaning over the bedside table, and continuing to complain of shortness of breath

1. What is your primary nursing goal at this time?
2. Describe six interventions you must implement based on this priority.
3. You will need to monitor B.T. closely for the next few hours. What is the most serious complication to anticipate?

Answer 1

Ans) The primary nursing goal at this time:

- My nursing priority would be to improve B.T.’s respiratory status.

Six actions to implement based on this priority:

- Administer respiratory medications as prescribed.

- Maintain oxygen therapy.

- Frequently measure vital signs with continuous pulse oximetry and ECG.

- Perform a respiratory assessment, auscultating lung sounds and observing chest movement, at least every hour.

- Maintain IV therapy

- Place him in a minimum of a semi-Fowler’s position.

Monitor B.T. closely for the next few hours as the most serious complication to anticipate is respiratory failure.