Case Study 2 (Dyspnea and Shortness of Breath) - Prioritization, Delegation, and Assignment
Mr. W is receiving an IV dose of potassium 10 mEq/100 mL (10 mmol/100 mL) normal saline to run over 1 hour. The UAP asks the nurse why it takes so long to infuse such a small amount of fluid. What should the nurse explain to the UAP? *Select all that apply.* •"IV potassium is very irritating to the veins and can cause phlebitis." •"Tissue damaged by potassium can become necrotic." •"Oral potassium can cause nausea, so IV potassium is preferred." •"The maximum recommended infusion rate for IV potassium is 5 to 10 mEq/hr (5 to 10 mmol/hr)." •"That's a good question, and I will ask the HCP if I can give the drug IV push." •"The goal is to prevent infiltration into the tissue."
•"IV potassium is very irritating to the veins and can cause phlebitis." •"Tissue damaged by potassium can become necrotic." •"The maximum recommended infusion rate for IV potassium is 5 to 10 mEq/hr (5 to 10 mmol/hr)." •"The goal is to prevent infiltration into the tissue." •A dilution no greater than 1 mEq (1 mmol) of potassium to 10 mL of solution is recommended for IV administration. The maximum recommended infusion rate is 5 to 10 mEq/hr (5 to 10 mmol/hr); this rate is never to exceed 20 mEq/hr (20 mmol/hr) under any circumstances. In accordance with National Patient Safety Goals, potassium is not given by IV push to avoid causing cardiac arrest. Oral potassium can cause nausea, and vomiting (give it with food to prevent this), but this does not answer the UAP's question.
The UAP tells the nurse that Mr. W is unable to complete his morning care without assistance and wonders if he is being lazy. What is the nurse's *best* response? •"Encourage the patient to do as much as he can as quickly as he can." •"If the patient is short of breath, increase his oxygen flow." •"Remind the patient to take his time and not to rush his morning care." •"He may not need as much help as he is asking for, so try to get him to do more."
•"Remind the patient to take his time and not to rush his morning care." •The patient with COPD often has chronic fatigue and needs help with activities. Teaching the patient not to rush through activities is important because rushing increases dyspnea, fatigue, and hypoxemia. Reminding a patient of what has already been taught is within the scope of practice for a UAP. Patients with COPD should be kept on low-flow oxygen because their stimulus to breathe is a low arterial oxygen level.
The nurse reports the morning assessment findings (crackles bilaterally) to the HCP. Which prescribed intervention is *most* directly related to the nurse's assessment findings? •Administer furosemide 20 mg IV push now •Keep accurate records of intake and output. •Administer potassium 20 mEq (20 mmol) orally every morning •Weigh the patient every morning
•Administer furosemide 20 mg IV push now •Furosemide is a loop diuretic. The uses of this drug include treatment of pulmonary edema, which is most directly related to the new finding. Intake and output records and daily weights are important in documenting the effectiveness of the medication. A side effect of this drug is hypokalemia, and some patients are also prescribed a potassium supplement when taking this medication.
An LPN/LVN tells the RN that the patient is now receiving oxygen at 2 L/min via nasal cannula and his pulse oximetry reading is now 91%, but he still has crackles in the bases of his lungs. What intervention should the RN assign to the LPN/LVN? •Begin creating a plan for discharging the patient •Administer furosemide 20 mg orally each morning •Get a baseline weight for the patient now •Administer cefotaxime IV piggyback every 6 hours
•Administer furosemide 20 mg orally each morning •Discharge planning and IV administration of antibiotics are more appropriate to the scope of practice of the RN. However, in some states, LPN/LVNs with special training may administer IV antibiotics. (Be aware of state regulations and nursing practice laws in your state.) Administering oral medications is appropriate to assign to LPN/LVNs, and in this case, furosemide may help clear up the crackles. Although the LPN/LVN could weigh the patient, this intervention is also appropriate to the scope of practice of the UAP.
Based on the patient's ABG results, what are the nurse's priority actions at this time? *Select all that apply.* •Administer oxygen at 2 L/min via nasal cannula •Initiate a rapid response •Teach the patient how to cough and deep breathe •Begin IV normal saline at 100 mL/hr •Arrange a transfer to the intensive care unit (ICU) •Remind the patient to practice incentive spirometry every hour while awake
•Administer oxygen at 2 L/min via nasal cannula •Initiate a rapid response •Teach the patient how to cough and deep breathe •Remind the patient to practice incentive spirometry every hour while awake •The patient's major problem at this time is impaired gas exchange with hypoxemia. Strategies to compensate include administration of low-flow oxygen as well as interventions to improve gas exchange, such as having the patient cough and deep breathe and perform incentive spirometry. These strategies may improve the patient's condition and prevent the need to initiate a code, transfer to the ICU, or both. A saline lock is a good idea, but giving the patient too much fluid may worsen his condition by producing a fluid overload. The patient's symptoms call for initiation of a rapid response to treat him now and prevent the need for a code.
Mr. W is to be transferred back to the long-term care facility after lunch. Which nursing care intervention would be *best* for the RN to assign to the experienced LPN/LVN? •Administer the patient's 12:00 pm oral medications •Check and record a set of vital signs at 12:00 pm •Pack the patient's personal items to be taken with him •Change Mr. W's incontinence pad before he is transferred
•Administer the patient's 12:00 pm oral medications •The scope of practice for an experienced LPN/LVN includes administering oral medications. Although the LPN could certainly check the patient's vital signs, pack his personal belongings, and change his incontinence pad, these interventions are also within the scope of practice for a UAP.
Which interventions would the acute care RN delegate to an experienced unlicensed assistive personnel (UAP)? *Select all that apply.* •Changing the patient's incontinence pad as needed •Performing pulse oximetry every shift •Teaching the patient to cough and deep breathe •Reminding the patient to use incentive spirometry every hour while awake •Assessing the patient's breath sounds every shift •Encouraging the patient to drink adequate oral fluids
•Changing the patient's incontinence pad as needed •Performing pulse oximetry every shift •Reminding the patient to use incentive spirometry every hour while awake •Encouraging the patient to drink adequate oral fluids •Assisting patients with activities of daily living such as toileting are within the scope of practice of UAPs. After licensed nurses or respiratory therapists have taught the patient to use incentive spirometry, the UAP can play a role in reminding the patient to perform it. UAPs can participate in encouraging patients to drink adequate fluids. Assessing and teaching are not within the scope of practice of UAPs. Performing pulse oximetry is appropriate for experienced UAPs after they have been taught how to use the pulse oximetry device to gather additional data.
What is the *priority* nursing concern for this patient? •Skin care due to incontinence •Clearance of thick secretions •Rapid heart rate •Elevated temperature
•Clearance of thick secretions •The patient's major problems at this time relate to airway and breathing including thick sputum, difficulty breathing, and respiratory distress. The patient's skin care, blood pressure, and elevated temperature will need to be followed up on soon but are not as urgent at this time as his respiratory status.
What is the nurse's interpretation of these results? •Compensated metabolic acidosis with hypoxemia •Compensated metabolic alkalosis with hypoxemia •Compensated respiratory acidosis with hypoxemia •Compensated respiratory alkalosis with hypoxemia
•Compensated respiratory acidosis with hypoxemia •The pH is on the low side of normal, and the Paco2 is elevated, which indicates an underlying respiratory acidosis. The HCO3− level is elevated, which indicates compensation. Both the Pao2 and the oxygen saturation levels are low, which points to hypoxemia. These blood gas results are typically expected when a patient has a chronic respiratory problem such as COPD.
Mr. W's emergency department lab values include a serum potassium of 2.8 mg/dL (2.8 mmol/L). What is the *priority* nursing action at this time? •Teach the patient about potassium-rich foods •Provide the patient with oxygen at 2 L per nasal cannula •Contact and notify the HCP immediately •Initiate 0.9% saline at 20 mL/hr
•Contact and notify the HCP immediately •A low serum potassium places the patient at risk for cardiac dysrhythmias, which can be life threatening. The HCP should be notified immediately and will likely order IV or oral potassium supplements to move the patient's level back into the normal range. Later, before discharge, the nurse would certainly want to teach the patient about potassium-rich foods, but this is not urgent. Oxygen is essential for the patient's respiratory problem but will not correct the low potassium, nor will IV normal saline.
During morning rounds, the nurse notes all of these assessment findings for Mr. W. Which finding indicates a *worsening* of the patient's condition? •Barrel-shaped chest •Clubbed fingers on both hands •Crackles bilaterally •Frequent productive cough
•Crackles bilaterally •Barrel chest and clubbed fingers are signs of COPD. The patient had a productive cough on admission to the hospital. Bilateral crackles are a new finding and indicate fluid-filled alveoli and pulmonary edema. Fluid in the alveoli affects gas exchange and can result in worsening ABG concentrations.
The RN administers the patient's first dose of IV cefotaxime. Within 15 minutes, Mr. W develops a rash with fever and chills. What is the nurse's *first* action at this time? •Discontinue the IV infusion •Administer 2 tablets of acetaminophen •Measure the area of the rash •Check for numbness and tingling
•Discontinue the IV infusion •Serious side effects of cefotaxime include rashes, fever, and chills, as well as diarrhea, bruising, numbness, tingling, and bleeding. If the patient is taking this drug as an outpatient, the HCP should be notified immediately. Because the drug is being given IV, the first step would be to stop the infusion. The HCP should be notified, and the patient should be assessed for additional symptoms of a serious reaction to the drug.
The RN assesses Mr. W in the emergency department. Which assessment findings are consistent with a diagnosis of COPD? *Select all that apply.* •Enlarged neck muscles •Forward bent posture •Respiratory rate 15 to 25 breaths/min •Inspiratory and expiratory wheezes •Blue-tinged dusky appearance •Symmetrical lung expansion
•Enlarged neck muscles •Forward bent posture •Inspiratory and expiratory wheezes •Blue-tinged dusky appearance •The presence of wheezes, enlarged neck muscles, bluish dusky appearance, and forward bent posture are all classic manifestations in a patient with COPD. The respiratory rate is usually higher than normal and during an exacerbation can be as high as 30 to 40 breaths/min. Lung expansion in patients with COPD is usually asymmetrical.
Which intervention would the RN assign to an experienced LPN/LVN? •Drawing a sample for ABG determination •Administering albuterol by hand-held nebulizer •Measuring vital signs every 2 hours •Increasing oxygen delivery to 2 L/min via nasal cannula
•Increasing oxygen delivery to 2 L/min via nasal cannula •Increasing oxygen flow for a patient based on an HCP's prescription is within the scope of practice of LPN/LVNs. UAPs may measure vital signs. Arterial draws for laboratory tests are not within the LPN/LVN's scope of practice unless they have had additional special training. The RN would need to assess the LPN/LVN's skill before assigning this task. Hand-held nebulizers are usually operated by respiratory therapists.
Mr. W has lost 15 lb (6.8 kg) over the past year. On assessment, he tells the nurse that his appetite is not what it used to be, and he becomes short of breath while eating. Which interventions should be included in his nursing care plan? *Select all that apply.* •Initiate a dietary consult •Stress that he must eat all of his meals or he'll become malnourished •Monitor serum prealbumin levels •Suggest four to six small meals per day •Instruct the patient to use his bronchodilator 30 minutes before meals •Encourage dry foods to avoid coughing
•Initiate a dietary consult •Monitor serum prealbumin levels •Suggest four to six small meals per day •Instruct the patient to use his bronchodilator 30 minutes before meals •A dietitian can help with the selection of foods that are easy to chew, do not form gas, and are high in calories and protein. Serum prealbumin levels are a good indicator of nutritional status and should be monitored. Small meals can help prevent meal-related dyspnea. Using a bronchodilator before meals will reduce bronchospasm. The second response does not demonstrate respect for the patient's role in his care. Dry foods stimulate coughing.
The RN observes the patient's use of the albuterol MDI. The patient takes 2 puffs from the inhaler in rapid succession. Which intervention takes *priority* at this time? •Call the pharmacy to request a spacer for the patient •Notify the provider that the patient will need to continue receiving nebulizer treatments •Ask the UAP to help get the patient into a chair •Instruct the patient about proper techniques for using an MDI
•Instruct the patient about proper techniques for using an MDI •The patient is demonstrating improper use of the MDI by taking 2 puffs in rapid succession, which can lead to incorrect dosage and ineffective action of the albuterol. Teaching is the first priority. As the nurse works with this patient, it may be determined that he would benefit from the use of a spacer. Sitting up in a chair may also be useful, but these interventions are not the first priority. Notifying the provider that the patient needs to continue with nebulizer treatments is not within nursing scope of practice and does not address the problem, which is that the patient does not know how to properly use his MDI.
The UAP checks morning vital signs and immediately reports the following values to the nurse. Which takes *priority* when notifying the HCP? •Heart rate of 96 beats/min •Blood pressure of 160/90 mm Hg •Respiratory rate of 34 breaths/min •Oral temperature of 103.5°F (39.7°C)
•Oral temperature of 103.5°F (39.7°C) •The heart rate and blood pressure are slightly increased from admission, and the respiratory rate is slightly decreased. The continued elevation in temperature indicates a probable respiratory tract infection that needs to be recognized and treated.
Which assessment finding would the nurse instruct the UAP to report *immediately*? •Incontinence of urine and stool • 1-lb (0.45-kg) weight loss since admission •Patient cough productive of greenish-yellow sputum •Eating only half of breakfast and lunch
•Patient cough productive of greenish-yellow sputum •The patient's temperature was elevated on admission, and his cough was productive. The changes in Mr. W's sputum could indicate an ongoing infection. The HCP needs to be notified and an appropriate treatment plan started. All of the other pieces of information are important but are not urgent. The patient's incontinence is not new.
Which *priority* actions will the nurse take when the patient is initially admitted to the emergency department (ED)? *Select all that apply.* •Place the patient on a cardiac monitor •Get a baseline set of vital signs •Draw admission labs and place a saline lock •Change the patient's adult pad •Send the patient for a chest x-ray •Order the patient a lunch tray
•Place the patient on a cardiac monitor •Get a baseline set of vital signs •Draw admission labs and place a saline lock •Send the patient for a chest x-ray •Baseline data that are essential to decisions for the care of this patient take priority at this time including vital signs, cardiac rhythm, lab values, and chest x-ray findings. Placement of a saline lock is essential for administration of fluids and emergency drugs. Changing the patient's incontinence pad is important to protect his skin but is not urgent. Ordering a lunch tray may be premature because the interventions for this patient's care are undecided when he is first admitted to the ED.
The health care provider's (HCP's) prescribed actions for this patient include all of the following. Which intervention should the nurse complete *first*? •Send an arterial blood gas (ABG) sample to the laboratory •Schedule pulmonary function tests •Repeat chest radiography each morning •Administer albuterol via MDI 2 puffs every 4 hours
•Send an arterial blood gas (ABG) sample to the laboratory •Baseline ABG results are important in planning the care of this patient. The unit clerk can schedule the pulmonary function tests and chest radiography. The albuterol therapy is a routine order.
