A patient’s data shows the following: Oxygen saturation is 94% on room air, pain is 4 on a scale of 0 to 10, temperature is 99.6°F (37.6°C) orally, and heart rate is 95 beats/minute.
Which physician orders would the nurse anticipate being prescribed after reporting these findings? Select all that apply.
A Place client on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
B Stat ventilation/perfusion (V/Q) of chest.
C Stat 2 views chest x-ray.
D Stat Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.
E Send sputum for culture & sensitivity.
The correct answer and Explanation is :
Based on the patient’s data, the nurse would likely anticipate the following physician orders:
A. Place client on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
D. Stat Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.
E. Send sputum for culture & sensitivity.
Explanation:
- Oxygen Therapy (Option A):
The patient’s oxygen saturation is at 94%, which is below the typical threshold for maintaining adequate oxygenation (generally considered 95% or higher). While the saturation is not critically low, it may warrant supplemental oxygen, especially if there are signs of respiratory distress or if the patient’s clinical picture suggests a risk of further deterioration. Administering oxygen at 2 to 4 liters will help increase the saturation to a safer level. - Laboratory Tests (Options D and E):
Given the patient’s elevated temperature (99.6°F) and moderate pain level (4/10), there may be an underlying infection or inflammatory process. A CBC can help identify signs of infection (like elevated white blood cell count), while a BMP provides insights into renal function and electrolytes, which are crucial for overall assessment. Blood cultures are essential for identifying any bacteremia or sepsis.
Furthermore, sending sputum for culture and sensitivity is critical if there are respiratory concerns, such as pneumonia or bronchitis, indicated by the vital signs and symptoms. - V/Q Scan (Option B) and Chest X-ray (Option C):
While these options could be considered, they are not immediate priorities based on the current data. A V/Q scan is more specific for assessing pulmonary embolism, which isn’t indicated without further respiratory distress or clinical suspicion. A chest x-ray might be helpful for a more detailed assessment of the lungs, but it’s not as urgent as the above interventions, particularly in the presence of potential infection.
In summary, the anticipated orders focus on correcting oxygen levels, diagnosing potential infections, and ensuring overall patient stability before further diagnostic imaging.