Question

An older client who is agitated, dyspneic, orthopnetic and using accessory muscles to breath is admitted to further treatment. Initial assessment includes a heart rate of 128 and irregular respiration's 38 per minute. Blood pressure 168/100 wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg, which assestmemnt should the nurse obtain to determine the client response to treatment ? SATA

Select one or more

a- skin elasticity

b oxygen saturation

c- pain scale

d lung sounds

e urinary output

Answer 1

Answers are oxygen saturation and lung sounds.

From the findings it is clear that the patient is suffer from respiratory problems and to assess the response of patient to the treatment we should monitor the respiratory status such as oxygen saturation and lung sounds.

Oxygen saturation is the baseline status which will help us to identify the proper gas exchange and functioning of body tissues . Any abnormal lung sounds indicate the lung deformities.

Skin elasticity should be monitored in case of dehydration.if the patient is suffering from dehydration, vomiting or diarrhoea skin elasticity should be monitored. Urine output is also help to get a baseline data about fluid electrolyte balance.