CS- COPD with Pneumonia

Which instruction should the nurse provide Mr. Johnson for an acute episode of asthma? A. "Administer the Vanceril as soon as possible." B. "Use the albuterol inhaler for acute asthma attacks." C. "Call your healthcare provider before administering any medication." D. "Take an extra dose of salmeterol for an acute attack."

"Use the albuterol inhaler for acute asthma attacks." Albuterol is a bronchodilator that is used for acute asthmatic attacks.

Client Teaching: Metered Dose Inhaler (MDI) The nurse observes Mr. Johnson as he uses his inhalers. Using a spacer, Mr. Johnson takes 2 puffs of the salmeterol, followed a minute later by 2 puffs of the beclomethasone. After observing Mr. Johnson, which instruction by the nurse is most important for client teaching? Select all that apply A. "Administer the beclomethasone first, followed by the salmeterol." B. "Using a spacer reduces medication absorption." C. "Wait at least 5 minutes between each medication." D. "Wait at least 1 minute between each puff of the same medication."

"Wait at least 5 minutes between each medication." Mr. Johnson should wait at least 5 minutes before using the second medication. "Wait at least 1 minute between each puff of the same medication." Mr. Johnson should wait 1 to 2 minutes between each puff of the same medication. In addition, he should be instructed to wait 5 minutes before using the second medication.

Which statement by the nurse promotes effective communication with Mr. Johnson? A. "I will inform the charge nurse of this and she will instruct the night staff to keep your door closed at night." B. "You seem pretty upset this morning." C. "Why are you feeling so angry?" D. "I can warm up your breakfast tray or order a fresh one for you."

"You seem pretty upset this morning." This statement allows an opportunity for Mr. Johnson to clarify his feelings.

Assessment The physical examination reveals the following:Vital signs: T 101.6° F, P 110, R 32, BP 132/78.Respirations shallow and labored, with use of respiratory accessory muscles.Increased anteroposterior (AP) diameter of the chest.Skin dry and warm to touch, with inelastic skin turgor, and fingernail clubbing present. Which assessment is most important for the nurse to complete next? A. Auscultate breath sounds. B. Auscultate heart sounds.. C. Assess for peripheral edema. D. Assess capillary refill.

Auscultate breath sounds. This is the highest priority because Mr. Johnson is clearly exhibiting respiratory distress.

The levofloxacin 500 mg IVPB is supplied in 100 mL of D5W to be delivered over 60 minutes. There is no IV pump available so the nurse will infuse the antibiotic by gravity. The drop factor on the tubing is 20 gtts/mL. The nurse should set the IVIVPB to infuse at how many gtts per min? (Enter numerical value only. If rounding is necessary, round to the whole number.) Submit

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Oxygen Saturation and Therapy Continuous monitoring of Mr. Johnson's oxygen saturation indicates readings ranging between 92%-93%. (Normal oxygen saturation values are 90% to 100%). After checking the sensor site to make sure the readings are accurate, the nurse should then initiate which intervention? A. Decrease the oxygen to 4 L/minute per nasal cannula. B. Elevate the head of the bed to a high-Fowler's position. C. Remove the pulse oximeter to reduce anxiety. D. Assess the client's respiratory rate and rhythm.

Assess the client's respiratory rate and rhythm. This is an acceptable oxygen saturation level for a client with COPD. The first action by the nurse is to assess the client's respiratory status and observe his effort of breathing.

While taking the client's blood pressure, the nurse observes the reading on the pulse oximeter to be fluctuating from 60 to 80. Which action should the nurse implement to ensure accurate oxygen saturation readings with the pulse oximeter? A. Place the extremity to which the sensor is attached at heart level. B. Assess the adequacy of circulation prior to applying the sensor. C. Lower the lighting in the room. D. Remove the sensor when taking the B/P.

Assess the adequacy of circulation prior to applying the sensor. The sensor will provide the most accurate reading if circulation is adequate. At regular intervals, the nurse should assess circulation and move the sensor to a new site.

Ethical-Legal Considerations As Mr. Johnson's condition improves, his son expresses concern that his father will continue to smoke. He asks the nurse if anti-smoking hypnosis tapes could be played during the night while his father is asleep. Which ethical principle is most important for the nurse to consider when responding to the son? Veracity. Beneficence. Autonomy. Nonmaleficence.

Autonomy. This ethical principle refers to the individual's right to make his own decisions regarding his care. It is an important principle, which would be violated if the nurse allowed the son to play hypnosis tapes without his father's knowledge or consent.

Which additional discharge instructions should the nurse include in the teaching plan to promote optimal health for Mr. Johnson? Select all that apply A. Decrease physical activity. B. Avoid crowds and people with infections. C. Increase intake of oral fluids. D. It is all right to go outside anytime. E. Store prescribed inhalers away from extreme heat and cold.

Avoid crowds and people with infections. This is an important measure to avoid future infections. Mr. Johnson should also be encouraged to get an annual pneumonia vaccine. Increase intake of oral fluids. Mr. Johnson needs to increase his oral fluid intake to maintain adequate hydration and thin respiratory secretions. Store prescribed inhalers away from extreme heat and cold. Extreme heat and cold can alter the composition of the inhaler medication and render it ineffective.

Which nursing diagnosis has the highest priority when the nurse is planning care for Mr. Johnson? Imbalanced nutrition, less than body requirements. Impaired physical mobility. Deficient fluid volume. Ineffective airway clearance.

Ineffective airway clearance. There are adventitious breath sounds present, tachypnea, changes in depth of respirations, fever, and cough, which support this as a priority diagnosis. Additional priority diagnoses are impaired gas exchange and ineffective breathing patterns. Impaired gas exchange is reflected in Mr. Johnson's hypercapnia and hypoxia. The diagnosis of ineffective breathing pattern is supported by his tachypnea, use of accessory muscles, and changes in the depth of respiration.

Delegation and Supervision Later that morning, the unlicensed assistive personnel (UAP) helps Mr. Johnson transfer to the bedside commode. After Mr. Johnson is back in bed, the nurse enters his room and observes that Mr. Johnson's oxygen saturation level is 85% and that he is not wearing his nasal cannula. He states that the cannula tubing wouldn't reach all the way to the commode, so the UAP removed it. What is the best nursing action? A. Report the UAP to the charge nurse for performing an act that was not allowed. B. Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. C. Request that a second UAP assist the UAP the respiratory therapist to assist with Mr. Johnson's activities. D. Assign the UAP to a different client.

Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. Helping Mr. Johnson to the commode is an appropriate action for a UAP to perform, but this UAP requires some additional instruction and individual supervision with oxygen equipment..

While Mr. Johnson is undergoing nebulizer treatments with albuterol, it is most important for the nurse to perform which assessment? A. Monitor pulse oximeter readings. B. Monitor respiratory rate. C. Monitor pulse and BP. D. Monitor temperature.

Monitor pulse and BP. Albuterol (Ventolin) is a beta-adrenergic agonist with a bronchodilating effect. Because adrenergic agonists mimic sympathetic stimulation, Mr. Johnson must be monitored carefully for cardiac arrhythmias, hypertension, nervousness, and restlessness.

Which nursing action should be implemented before the prescribed levofloxacin is administered? Auscultate lung sounds. Assess oral intake. Obtain a sputum culture. Assist client to the bathroom.

Obtain a sputum culture. The sputum specimen should be obtained prior to initiation of the first dose of antibiotics. Since levofloxacin is a broad-spectrum bactericidal antibiotic, it is likely to be effective against the causative organism. Once the culture and sensitivity results are obtained, a different antibiotic may be used if necessary. Another important nursing intervention is assessment of Mr. Johnson for previous allergic reactions to antibiotics.

Which intervention should the nurse initiate immediately? Place resuscitation equipment in the room. Increase the O2 to 6 L/min. Initiate CPR. Set defibrillator at 200 joules.

Place resuscitation equipment in the room. This is a high priority because Mr. Johnson's O2 saturation is dangerously low. The nurse should also prepare to transfer Mr. Johnson to the critical care unit for close monitoring.

Which assessment finding supports Mr. Johnson's diagnosis of pneumonia? A. Pulse rate of 110. B. BP of 132/78. C. Increased AP diameter of the chest. D. Inelastic skin turgor.

Pulse rate of 110. Tachycardia is consistent with an infectious process. In addition, Mr. Johnson's fever and rapid respiratory rate are also vital sign findings that indicate a problem, such as an infection.

In response to the nurse's effective communication, Mr. Johnson explains, "It seems like I've been sick so much. It's all the fault of those cigarette companies. I wouldn't be so sick if they had warned us about the dangers of smoking. I'll probably end up with cancer, and then I'll sue them." What is the nurse's best response? "You may be one of the lucky ones and not get cancer." "I understand that. I have been trying to quit smoking for a few years but have not been successful." "You should focus on getting better and try not to worry about that now." Remain silent.

Remain silent. This is the best choice. Silence can be a very effective communication technique. The nurse should express interest nonverbally when silence is used.

Arterial Blood Gas (ABG) Analysis Arterial Blood Gases were obtained with the following results: pH 7.25 pCO2 58 HCO3 26 pO2 87 These ABG results indicate that Mr. Johnson is experiencing which acid-base imbalance? Metabolic acidosis. Metabolic alkalosis. Respiratory acidosis. Respiratory alkalosis.

Respiratory acidosis. The low pH indicates that acidosis is present. The elevated pCO2 indicates that the problem is respiratory in nature. Clients with any condition that depresses respirations are prone to developing respiratory acidosis. Even though Mr. Johnson has a rapid respiratory rate, his underlying COPD causes the retention of CO2.

The National Council of State Boards of Nursing has defined five rights of delegation. Which one of these rights was violated in this situation? Right Task. Right Circumstance. Right Person. Right Direction/Communication.

Right Direction/Communication. Since continuous oxygenation was a high priority for this client, the nurse's directions to the UAP should have emphasized the need for the nasal cannula to be left on the client at all times, especially during any activity. The fifth right, Right Supervision includes direction/guidance, evaluation/monitoring, and follow-up.

Which outcome statement is the best indicator that Mr. Johnson's pneumonia is resolved and he is ready to be discharged? Sputum culture is negative. Levafloxacin peak and trough levels are within normal limits. Oxygen saturation level is 92%. Clear sputum.

Sputum culture is negative. This is a significant indicator that the pneumonia is resolved.