Chapter 4

The oxygen saturation of 89 percent and increasing shortness of breath are the most concerning findings at this time. The x-ray results are also significant, as they confirm the presence of pneumonia. The sputum culture results should be monitored closely because the pharmacological treatment will be tailored to the specific pathogen causing the infection. The priority action for the nurse is to prepare the patient for transfer to local hospital which includes clinic discharge instructions for the patient, transfer documentation for the emergency transport employees, and giving report to the admitting facility per telephone call.

c Rationale: The son’s comment about suicide or wanting to die if his mother dies is a red flag and is a priority to address.

a Rationale: A possible airway obstruction from tongue and throat swelling is the priority concern because it could lead to respiratory distress and/or arrest. Rash, temperature, and oxygen saturation of 96 percent are not a priority concern at this time.

The nurse should recognize the severity of the situation and call for help. If possible, the nurse should call a rapid response or the equivalent to it since they are still in the clinic setting. The provider should be notified immediately so that they may address the underlying cause of the facial and tongue swelling and prevent further respiratory compromise.

a

After administering the IV Benadryl, the nurse should see a decrease in swelling of the face and tongue. The rash should subside as well, but the main focus should be on the swelling of the face as that can quickly become life threatening. A worsening condition would be characterized by a lack of improvement in the facial swelling, indicating the need for further intervention or possibly another dose of Benadryl. Additionally, the nurse should closely monitor the patient for any side effects of the medication, especially lethargy.