Jeron is admitted to the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client?
A. Prevention of fluid volume excess
B. Maintenance of adequate oxygenation
C. Education about infection prevention
D. Pain reduction
Correct Answer: B. Maintenance of adequate oxygenation
For the client with asthma and infection, oxygenation is the priority. Maintaining adequate oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading cause of cell death. The purpose of oxygen therapy is to maintain PaO2 above 60 mmHg. Oxygen is administered by the method that provides appropriate delivery within the patient’s tolerance.
Option A: A fluid volume deficit resulting from fever and diaphoresis, not excess, is more likely for this client. Assess respirations: note quality, rate, rhythm, depth, use of accessory muscles, ease, and position assumed for easy breathing.
Option C: Teaching about infection control is not appropriate at this time but would be appropriate before discharge. Observe the color of skin, mucous membranes, and nail beds, noting the presence of peripheral cyanosis (nail beds) or central cyanosis (circumoral).
Option D: No information regarding pain is provided in this scenario. Monitor body temperature, as indicated. Assist with comfort measures to reduce fever and chills: addition or removal of bedcovers, comfortable room temperature, tepid or cool water sponge bath.
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