CS 2: Dyspnea and Shortness of Breath

You report your morning assessment findings (previous question) to the health care provider. Which order is most directly related to your findings? 1. Administer furosemide (Lasix) 20 mg IV push now. 2. Keep accurate records of intake and output. 3. Administer potassium 20 mEq orally every morning. 4. Weight the patient every morning.

1. Administer furosemide (Lasix) 20 mg IV push now. Furosemide is a loop diuretic. The uses of this drug include treatment of pulmonary edema. 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.

Based on the patient's arterial blood gas results, what are your priority actions at this time? (Select all that apply.) 1. Administer oxygen at 2 L/min via nasal cannula. 2. Initiate a rapid response. 3. Teach the patient how to cough and deep breathe. 4. Begin IV normal saline at 100 mL/hr. 5. Arrange a transfer to the intensive care unit (ICU). 6. Remind the patient to practice incentive spirometry every hour while awake.

1. Administer oxygen at 2 L/min via nasal cannula. 2. Initiate a rapid response. 3. Teach the patient how to cough and deep breathe. 6. Remind the patient to practice incentive spirometry every hour while awake. The patient's major problem at this time is impaired gas exchange with hypoexemia. 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 and/or transfer to the ICU. 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.

Which interventions could you delegate to the new UAP? (Select all that apply.) 1. Helping the patient get up to use the bedside commode. 2. Performing pulse oximetry every shift. 3. Teaching the patient to cough and deep breathe. 4. Reminding the patient to use incentive spirometry every hour while awake. 5. Assessing the patient's breath sounds every shift. 6. Encouraging the patient to drink adequate oral fluids.

1. Helping the patient get up to use the bedside commode. 4. Reminding the patient to use incentive spirometry every hour while awake. 6. Encouraging the patient to drink adequate oral fluids. Assisting patients with activities of daily living such as toileting are within the scope of practice for UAPs. Once 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 could be appropriate for experienced UAPs once they have been taught how to use the pulse oximetry device to gather additional data.

Mr. W has lost 15 pounds over the past year. On assessment, he tells you 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.) 1. Initiate a dietary consult. 2. Stress that he must eat all of his meals or he'll become malnourished. 3. Monitor serum prealbumin levels. 4. Suggest 4 to 6 small meals per day. 5. Instruct the patient to use his bronchodilator 30 minutes before meals. 6. Encourage dry foods to avoid coughing.

1. Initiate a dietary consult. 3. Monitor serum prealbumin levels. 4. Suggest 4 to 6 small meals per day. 5. 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 bronchodilaor 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 health care provider's orders for this patient include all of the following. Which intervention should you complete first? 1. Send an arterial blood gas sample to the laboratory. 2. Schedule pulmonary function tests. 3. Repeat chest radiography each morning. 4. Administer albuterol via MDI 2 puffs every 4 hours.

1. Send an arterial blood gas sample to the laboratory. Baseline arterial blood gas 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.

An LPN/LVN tells you that the patient is now receiving oxygen at 2 L/min via nasal cannula and his pulse oximetry reading is now 91%. What intervention should you assign to the LPN/LVN? 1. Being creating a plan for discharging the patient. 2. Administer furosemide 20 mg orally each morning. 3. Get a baseline weight for the patient now. 4. Administer cefotaxime (Claforan) IV piggyback every 6 hours.

2. 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 LPNs/LVNs with special training may administer IV antibiotics. (Check the regulations in your state.) Administering oral medications is appropriate to delegate to LPNs/LVNs. Although the LPN/LVN could weight the patient, this intervention is appropriate to the scope of practice of the UAP.

What is the priority nursing diagnosis for this patient? 1. Decreased Cardiac Output 2. Ineffective Airway Clearance 3. Risk for Electrolyte Imbalance 4. Anxiety

2. Ineffective Airway Clearance The patient's major problem at this time relates to airway and breathing. The patient's anxiety is most likely directly related to his breathing difficulty. An acid-base imbalance may result from the patient's breathing problem, but this is not the highest priority at the moment.

The UAP tells you that Mr. W is unable to complete his AM care without assistance and wonders if he is being lazy. What is your best response? 1. "Encourage the patient to do as much as he can, as quickly as he can." 2. "If the patient is short of breath, increase his oxygen flow." 3. "Tell the patient to take his time and not to rush his morning care." 4. "He may not need as much help as he is asking for, so try to get him to do more."

3. "Tell 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 before rushing increases dyspnea, fatigue, and hypoxemia. Patients with COPD should be kept on low-flow oxygen because their stimulus to breathe is a low arterial oxygen level.

Mr. W's arterial blood gas results include the following: pH 7.37; arterial partial pressure of carbon dioxide (PaCO2), 55.4 mmHg; arterial partial pressure of oxygen (PaO2), 51.2 mmHg; bicarbonate (HCO3-) level, 38 mEq/L. What is your interpretation of these results? 1. Compensated metabolic acidosis with hypoxemia. 2. Compensated metabolic alkalosis with hypoxemia. 3. Compensated respiratory acidosis with hypoxemia. 4. Compensated respiratory alkalosis with hypoxemia.

3. 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.

During morning rounds, you note all of these assessment findings. Which finding indicates a worsening of the patient's condition? 1. Barrel-shaped chest 2. Clubbed fingers on both hands 3. Crackles bilaterally 4. Frequent productive cough

3. Crackles bilaterally Barrel chest and clubbed fingers are signs of chronic 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 arterial blood gas concentrations.

Which assessment finding would you instruct the UAP to report immediately? 1. Incontinence of urine and stool 2. 1-lb weight loss since admission 3. Increased temperature elevation 4. Eating only half of breakfast and lunch

3. Increased temperature elevation The patient's temperature was elevated on admission. Further elevation indicates ongoing infection. The health care provider 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 intervention would you assign to an experienced LPN/LVN? 1. Drawing a sample for arterial blood gas determination. 2. Administering albuterol by hand-held nebulizer. 3. Measuring vital signs every 2 hours. 4. Increasing oxygen delivery to 2 L/min via nasal cannula.

4. Increasing oxygen delivery to 2 L/min via nasal cannula. Increasing oxygen flow for a patient based on a physician's order is within the scope of practice of LPNs/LVNs. UAPs may measure vital signs. Arterial draws for laboratory tests are not within the LPN/LVN's scope of practice. Hand-held nebulizers are usually operated by respiratory therapists.

You observe 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? 1. Call the pharmacy to request a spacer for the patient. 2. Notify the provider that the patient will need to continue receiving nebulizer treatments. 3. Ask the UAP to help get the patient into a chair. 4. Instruct the patient about proper techniques for using an MDI inhaler.

4. Instruct the patient about proper techniques for using an MDI inhaler. 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 you work with this patient, you may determine 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 your 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 takes morning vital signs and immediately reports the following values to the nurse. Which takes priority when notifying the health care provider? 1. Heart rate of 96 beats/min 2. Blood pressure of 160/90 mmHg 3. Respiratory rate of 34 breaths/min 4. Oral temperature of 103.5 F (39.7 C)

4. 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.