Exhibits A nurse is collecting data from an adolescent who has bacterial pneumonia. Which of the following findings is the priority for the nurse to report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Explanation & Rationale
A. Temperature: A temperature of 38.6°C (101.5°F) is elevated, but fever is a common symptom of bacterial pneumonia. It is important to monitor, but it is not the most critical finding in this case. B. Skin condition: Hives and flushing could be signs of an allergic reaction to medication, but this is not immediately life-threatening. The nurse should report it, but the priority in this case is the oxygen saturation, which reflects the patient's respiratory status. C. Oxygen saturation: Oxygen saturation of 93% is below the typical threshold of 95-100% and indicates mild hypoxemia. In a patient with bacterial pneumonia, low oxygen saturation signify worsening respiratory function. This requires immediate attention and reporting. D. Lung sounds: Coarse crackles in the right lower lobe are expected in pneumonia due to lung consolidation. While it is important to monitor lung sounds, the priority is addressing the oxygen saturation level, which is directly related to the patient's ability to breathe effectively.