Breathing Patterns - Case Study - Fundamentals

The antitussive medication label reads, "take 2 teaspoonfuls every 4 hours as needed." the nurse gives James some mL medication cups and teaches James and his mother how to pour the medication into the mL cup. To what mL level should the medication be poured?

10 mL

What immediate actions should the nurse implement? (SATA) a. reposition the finger clip and obtain another reading b. assess James for signs and symptoms of respiratory distress c. encourage James to begin coughing and deep breathing d. increase the oxygen flow to 3 to 4 L/min e. notify the HCP immediately

a, b, c Rationale: since james is not in any distress, the nurse should first reapply the clip and obtain another reading to confirm the sudden drop in oxygenation; assessment for signs and symptoms of respiratory distress is a priority; coughing helps clear mucous from airway which will allow for optimal lung expansion.

The HCP prescribes a CBC as a part of the diagnostic workup on James. Which is the best explanation for the HCP's prescriptions? a. A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults b. a CBC is obtained so that the HCP can rule out the possibility of appendicitis c. Anemia is suspected, so a CBC is drawn to measure hemoglobin and hematocrit. d. Sickle cell anemia is suspected and must be identified by a CBC to begin treatment.

a. A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults Rationale: the HCP is concerned that James may have pneumonia

The nurse auscultates vesicular breath sounds in the peripheral lung fields. What action should the nurse take? a. record the presence of clear breath sounds b. tell James' mother that his lungs are still congested c. Assist James to cough to clear his lungs and listen again. d. Notify the HCP of the abnormal lung sounds

a. Record the presence of clear breath sounds Rationale: vesicular breath sounds are a normal finding in the peripheral lung fields

What action should the nurse implement prior to applying the sensor? a. determine if James has a latex allergy. b. clean the site with an iodine solution c. "milk" the capillary blood flow of the site d. apply gauze padding to protect the skin

a. determine if James has a latex allergy Rationale: the disposable sensor pads may be made of latex. If they are, the nurse should confirm, that the client does not have a latex sensitivity or allergy

When assessing James' breath sounds, where should the nurse listen first? a. Lung bases b. Lung apices c. Aortic site d. Pulmonic site

b. Lung apices Rationale: an accepted method for lung auscultation is to begin at the top of the chest, comparing one side of the chest to the other, moving downward in a systematic method, finishing at the lung base.

Which outcome statement should the nurse use for James' plan of care? a. James will receive oxygen at 2 L/minute per nasal cannula. b. James' oxygen saturation will be monitored continuously c. James' oxygen saturation will be greater than 95% on room air. d. The client's respiratory function will be stable.

c. James' oxygen saturation will be greater than 95% on room air. Rationale: this client-centered outcome statement describes the desired outcome in measurable terms.

Which serum lab value confirms the resolution of James' infection? a. Red blood cell count (RBC) 4.5 million/mm3 b. White blood cell count (WBC) 6,000/mm3 c. Hemoglobin at 12 g/dL d. Hematocrit at 40%.

b. White blood cell count (WBC) 6,000/mm3 Rationale: this is a normal value for a child, confirming the resolution of the infection. Infection generally causes an elevation in the WBC

Which is the most important approach for the nurse to use when applying a nasal cannula? a. ensure the cannula tubing stays snugly around the ears and under the chin. b. check that the openings in the nasal prongs are aimed into the nose to prevent skin breakdown. c. never allow the humidifier to run out of water. d. keep some type of padding around the ears and over the cheekbones.

b. check that the openings in the nasal prongs are aimed into the nose to prevent skin breakdown. Rationale: this is the most important action to take when applying a nasal cannula.

To measure capillary refill, the nurse must first perform which action? a. count the radial pulse rate b. compress the nailbed of one finger until it blanches c. obtain a healthcare provider's prescription. d. elevate the extremity to be assessed.

b. compress the nailbed of one finger until it blanches Rationale: to measure capillary refill, the nurse should first compress the client's nailbed, then note how many seconds it takes for the return of normal color to the nailbed.

When applying a nasal cannula in the ED, what action is most important for the nurse to implement to ensure client safety? a. ensure the bed is in low position and the call light is within reach b. determine that all electrical equipment in the room is functioning correctly and is properly grounded. c. use aseptic technique to prevent contamination when applying the cannula. d. use petroleum gel on the cannula prongs to prevent irritating the nostrils.

b. determine that all electrical equipment in the room is functioning correctly and is properly grounded. Rationale: an electrical spark in the presence of oxygen can result in a serious fire.

Which nursing diagnosis is most relevant to James' current status? a. excess fluid volume b. inability to sustain spontaneous breathing c. impaired gas exchange d. decreased cardiac output

c. impaired gas exchange Rationale: normal saturation is 95-100%. James's oxygen saturation is well below normal, indicating that his gas exchange is impaired.

James' respiratory rate is 36 breaths/min. How should the nurse describe James' respiratory pattern? a. eupnea b. bradypnea c. tachypnea d. orthopnea

c. tachypnea Rationale: a rapid respiratory rate, which is consistent with the rate of 36 breaths/min. Normal respiratory rate is 16-30 breaths/,in for a school-aged child.

Which response is best for the nurse to provide? a. "yes, but the pain will only last a very short time." b. "no, you will not even know the clip is on your finger." c. "the clip feels like squeezing your finger with your other hand." d. "you seem to be worried about experiencing pain."

c. the clip feels like squeezing your finger with your other hand. Rationale: this is an honest response to James's question regarding pain and one that places the sensation he will feel in a context he can understand.

James' mother further states that she is worried her 2 year old daughter at home may also become ill. What is an appropriate and therapeutic response to the mother's concern about her daughter? a. if you breastfed your daughter, she will have natural immunity. b. she will be protected from illness if she has had all her scheduled vaccinations. c. there is a chance she may also become ill. please call your pediatrician right away if she develops any symptoms d. she is young enough that she will not be as ill as her brother. There is nothing serious to worry about

c. there is a chance she may also become ill. please call your pediatrician right away if she develops any symptoms Rationale: viral infections can spread from person to person by droplets from sneezing or coughing and by direct contact.

James' mother states that this is the third time in recent months she has brought him to the ED with a cough and shortness of breath. The nurse asks the mother how many respiratory or other infections James has had within the past year. Why does the nurse ask this? a. to assess for suspected child neglect or abuse. b. to explore the possibility of antibiotic resistance developing. c. to assess for a possible immune deficiency disorder. d. to explore the need for a primary care provider to avoid ED visits.

c. to assess for a possible immune deficiency disorder. Rationale: preschool and school-aged children may have 6 to 12 infections per year. the clinical hallmark of immune deficiency is a tendency to develop unusual of recurrent, severe infections.

Which documentation reflects subjective data? a. James' respirations are 36 breaths/min b. James appears anxious by repeatedly reaching for his mother's hand and asks, "am I going to be okay?" c. James' mother is present in the room d. James reports that he is coughing a lot

d. James reports that he is coughing a lot Rationale: subjective data is the information reported by the client

How should the nurse respond? a. this sounds like a mistake. take 1 pill with each dose b. two pills every 12 hours is the usual dose c. let me contact the pharmacist to clarify these directions d. a large first dose allows the medication to start working faster

d. a large first dose allows the medication to start working faster Rationale: a large first dose, loading dose, is often used to achieve a therapeutic level more rapidly in the bloodstream

Upon further observation the nurse describes James' sputum as "Tenacious." To what does this refer? a. Color b. Odor c. Frequency d. Consistency

d. consistency Rationale: sputum with a thick consistency may be described as "tenacious" (sticking together)

Which assessment finding further supports diagnosis? a. restlessness and fatigue b. skin is warm and flushed c. complaints of being thirsty d. blood pressure of 102/62 mmHg

a. restlessness and fatigue Rationale: indications of hypoxia. Restlessness is an early sign of hypoxia that is often missed.

When assisting James to obtain a sputum specimen, what action should the nurse take? a. instruct James to cough deeply from the chest and spit into the specimen cup. b. gently wipe a sterile, cotton-tipped applicator along the back of the oropharynx c. insert a soft-tipped catheter through the nares to suction secretions d. use a hard-tipped Yankauer catheter device to remove oral secretions

a. instruct James to cough deeply from the chest and spit into the specimen cup Rationale: this technique is the least invasive and will provide sputum rather than mucus.

Because of James' dyspnea, the nurse is concerned that he may need to receive oxygen. To determine the need for supplemental oxygen, which assessment is most important for the nurse to perform? a. measure oxygen saturation b. auscultate breath sounds c. measure capillary refill d. observe chest excursion

a. measure oxygen saturation Rationale: provides important data about the percentage of hemoglobin that is saturated with oxygen - a valuable reflection of the client's overall oxygenation.

Which documentation best reflects the nurse's objective assessment? a. James reports that he has been coughing up large amounts of sputum b. Frequent deep cough, producing small amounts of pale yellow sputum c. James seems anxious and short of breath, and he has a constant productive cough d. Cough is frequent, and James produces some yellow sputum when he coughs.

b. frequent deep cough, producing small amounts of pale yellow sputum Rationale: this is an objective report of the nurse's observations. This documentation provides a thorough description of the cough and the sputum produced.

The liquid cough syrup is labeled as an antitussive. The nurse explains this medication should have what effect? a. liquefy the respiratory secretions b. reduce the frequency of the cough c. decrease any pain with coughing d. prevent nausea due to the sputum

b. reduce the frequency of the cough Rationale: antitussives are used to reduce the frequency of a cough. This may be desirable for James at night, to allow him to sleep.

Which action by the nurse demonstrates the use of trust in the nurse-client relationship? a. teaching James and his mother how to read the oximeter b. returning to the room at the time promised c. offering the mother reassurance that James is stable d. providing a phone so that James' mother can call home

b. returning to the room at the time promised. Rationale: trust and rapport is important to develop during the orientation stage so the client has the most optimal outcome

The client-care technician plans to transport the sputum specimen to the lab. Which instructions should the nurse provide? a. wear clean gloves to carry the specimen to the lab b. wear clean gloves to place the specimen cup in a biohazard bag for transport c. wear gloves and a gown for the best protection d. wash hands after carrying the cup to the lab.

b. wear clean gloves to place the specimen cup in a biohazard bag for transport Rationale: this protects the person transporting the specimen, as well as the lab personnel receiving the specimen

In assessing James' breath sounds, the nurse should ask him to perform which action? a. hold his breath for fifteen seconds b. observe the color of the nailbeds and lips. c. cough deeply after each breath. d. breathe deeply through the mouth

d. breathe deeply through the mouth Rationale: James should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breath sounds

After determining the priority nursing diagnoses, what step should the nurse take next in developing the plan of care? a. determine the need for client teaching. b. reassess James for any changes c. implement the priority nursing actions d. establish goals and expected outcomes

d. establish goals and expected outcomes Rationale: after analysis of the data to prioritize nursing diagnoses, the nurse should establish nursing care goals and expected outcomes.

To encourage the mother to share more about her feelings, how should the nurse respond? a. james will be just fine. you don't need to worry. b. I worried just like you when my son was sick. c. perhaps you would rather wait outside d. it sounds like this has been a very frightening experience for you.

d. it sounds like this has been a very frightening experience for you. Rationale: this open-ended statement acknowledges the difficult situation the mother is experiencing and encourages further discussion

The nurse assesses James' vital signs. His respirations are rapid and shallow. Which is the best technique for the nurse to use to assess James' respirations accurately? a. observe chest expansion for 15 seconds and multiply by 4. b. encourage James to breathe as deeply and slowly as possible. c. watch for nasal flaring and count the air exchanges with each movement. d. place a hand on James' upper abdomen and observe the rise and fall of the chest.

d. place a hand on James' upper abdomen and observe the rise and fall of the chest. Rationale: this technique allows the nurse to observe and count each ventilatory cycle, even when respirations are shallow.