The practical nurse (PN) notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8°F (37.66°C); pulse 94; respirations 22; and blood pressure (BP) 108/54. Which intervention is most important for the PN to implement?
A.
Monitor the client’s temperature hourly.
B.
Offer the client fluids frequently.
C.
Provide care to moisten oral mucosa.
D.
Report the findings to the charge nurse.
The correct answer and Explanation is :
The most important intervention for the practical nurse (PN) to implement is:
D. Report the findings to the charge nurse.
Explanation:
The client’s symptoms—a nonproductive cough and increased confusion—alongside the vital signs (temperature of 99.8°F, pulse of 94, respirations of 22, and blood pressure of 108/54), suggest that there may be an underlying issue that requires immediate attention.
- Potential Causes and Concerns:
- Nonproductive Cough: This could indicate an infection, such as pneumonia or bronchitis, especially in an older adult who might be more susceptible to respiratory infections.
- Increased Confusion: This is a significant change in the client’s mental status, which could be related to several issues including infections (like a urinary tract infection or pneumonia), dehydration, or metabolic imbalances. Confusion can be an early sign of an infection or other acute condition in older adults.
- Vital Signs: The temperature is slightly elevated, which may indicate a low-grade fever, possibly from an infection. The blood pressure is on the lower end of normal, which could suggest dehydration or sepsis, and the respiration rate is elevated, which may be associated with an underlying respiratory issue.
- Importance of Reporting:
- The combination of increased confusion and changes in vital signs requires a thorough assessment by a more experienced healthcare provider, such as the charge nurse or physician. These findings could be indicative of a serious condition that needs prompt evaluation and intervention.
- Other Interventions:
- While monitoring the temperature (Option A), offering fluids (Option B), and moistening oral mucosa (Option C) are important for overall care and comfort, they are secondary to addressing the potential underlying cause of the symptoms. Reporting the findings to the charge nurse ensures that the client receives a comprehensive assessment and appropriate diagnostic testing, which is critical for addressing any potentially serious conditions promptly.
In summary, the priority is to report the client’s condition to the charge nurse to ensure that further evaluation and necessary interventions are promptly carried out.