Question

the nurse is caring for the client with pneumonia. an expected client outcome is, \the client will maintain adequate oxygenation by discharge.\ which outcome criterion indicates the goal is met?

client drinks at least 2 to 3 liters of water each day.
client no longer requires supplemental oxygen.
client does not demonstrate signs of orthostatic hypotension when ambulating.
client completes coughing and deep breathing exercises hourly.

Explanation:

Analyze the goal and target concept

Using the Nursing Process Phases knowledge point, we identify that the nurse is evaluating a specific client outcome: "The client will maintain adequate oxygenation by discharge." To determine if this goal is met, we must find the outcome criterion that directly measures and validates adequate oxygenation.

Evaluate the options against the goal

Using the Evaluative Statements knowledge point, we assess each option:

• Client drinks at least 2 to 3 liters of water each day: This measures hydration status and fluid intake, which helps thin secretions but does not directly measure oxygenation.
• Client no longer requires supplemental oxygen: This directly indicates that the client's respiratory system is functioning sufficiently on room air to maintain adequate systemic oxygenation, meaning the goal is met.
• Client does not demonstrate signs of orthostatic hypotension when ambulating: This measures cardiovascular stability and fluid balance, not primary oxygenation.
• Client completes coughing and deep breathing exercises hourly: This is a nursing intervention or client action to prevent atelectasis, not a direct measure of the oxygenation outcome itself.

Select the correct outcome criterion

The only criterion that directly demonstrates the client has achieved and maintained adequate self-oxygenation is that they no longer require supplemental oxygen therapy.

Answer:

• Client drinks at least 2 to 3 liters of water each day.
• Client no longer requires supplemental oxygen. (Correct answer)
• Client does not demonstrate signs of orthostatic hypotension when ambulating.
• Client completes coughing and deep breathing exercises hourly.