EAQ Lower Respiratory Problems
Which assessment finding for a client with pneumonia would be most important for the nurse to communicate to the health care provider? A. Cough productive of rust-colored sputum B. Sharp chest pain with deep inspiration C. Oral temperature 103°F (39.4°C) D. Respiratory rate 38 breaths per minute
D. Respiratory rate 38 breaths per minute A respiratory rate of 38 breaths per minute indicates respiratory distress and the nurse would communicate the rate immediately to the provider and anticipate implementation of actions such as oxygen administration using a nonrebreather mask or mechanical ventilation. A cough productive of rust-colored sputum is typical with pneumonia. Sharp chest pain with deep inspiration may occur with inflammation of the parietal pleura. Fever is frequently seen with pneumonia.
In which order will the emergency department nurse take the prescribed actions for a client with hypoxemia and possible pneumonia? 1. Start oxygen to keep oxygen saturation higher than 93%. 2. Obtain blood cultures from 3 sites. 3. Administer levofloxacin 750 mg intravenously. 4. Admit client to the inpatient medical unit.
1. Start oxygen to keep oxygen saturation higher than 93%. 2. Obtain blood cultures from 3 sites. 3. Administer levofloxacin 750 mg intravenously. 4. Admit client to the inpatient medical unit.
A client with which diagnosis will be at risk for development of a pulmonary embolism? A. Atrial Fibrillation B. Forearm laceration C. Migraine headache D. Respiratory infection
A. Atrial Fibrillation Inadequate atrial contraction that occurs during fibrillation leads to pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism, whereas dislodgement of thrombus in the left atria may lead to embolic stroke. A forearm laceration does not increase pulmonary embolism risk. Pulmonary embolism is not a complication of migraine headache. Respiratory infections do not increase pulmonary embolism risk.
Which finding would be of most concern when the nurse is assessing a client with pulmonary embolism diagnosis who is receiving intravenous heparin? A. Client reports stools are black. B. Oxygen saturation is 93% C. Respiratory rate is 25 breaths per minute D. Client has an ecchymosis on the ankle.
A. Client reports stools are black. Because anticoagulant use increases the risk for gastrointestinal bleeding, the nurse would report the black-colored stools to the health care provider and anticipate action such as testing stools for occult blood, administration of protein pump inhibitor to decrease ulcer risk, and checking complete blood count. An oxygen saturation of 93% in a client with pulmonary embolus is acceptable. A slightly elevated respiratory rate in a client with a pulmonary embolus is a compensatory mechanism to prevent hypoxemia. Because low platelet counts increase risk for bleeding, an ecchymosis on this client's ankle would not be of high concern.
Which action would the nurse take first when a client with acute bronchitis and emphysema reports feeling anxious and short of breath? A. Obtain the oxygen saturation B. Provide oxygen at 2 L per minute C. Offer the prescribed rescue inhaler D. Suggest use of pursed-lip breathing
A. Obtain the oxygen saturation More assessment is needed before further actions are taken; the nurse would check the client's oxygen saturation as the initial action. If oxygen saturation is low, then oxygen administration would be needed. The rescue inhaler may be needed if the client has wheezes or decreased breath sounds. Pursed-lip breathing may be helpful if anxiety is causing hyperventilation, but the first action would be to assure that the client is not hypoxemic.
Which clinical manifestations indicate a possible pulmonary embolism in a client after a total hip replacement? Select all that apply. One, some, or all responses may be correct. A. Sudden chest pain B. Flushing of the face C. Elevation of temperature D. Abrupt onset of SOB E. Hip pain rating increased from 2 to 8
A. Sudden chest pain D. Abrupt onset of SOB
When palpating the chest during a respiratory assessment, which finding would the nurse expect in a client with pneumonia? A. Bilateral decreased chest expansion B. Increased fremitus over the affected area C. Tracheal deviation away from the affected side D. Decreased chest expansion on the affected side
B. Increased fremitus over the affected area Fremitus is the vibration that can be felt on the chest wall when the client talks. Because vibration is carried more easily through denser tissue, increased fremitus is felt when palpating over the area of pneumonia than would normally be felt over air-filled alveoli. Pneumonia does not cause changes in bilateral chest expansion, which might be seen in a client with a chronic obstructive pulmonary disease, such as emphysema. Tracheal deviation away from the affected side would not occur with pneumonia, but might be seen in a client with a pleural effusion or pneumothorax. There is no decreased chest expansion of the affected side with pneumonia, but unilateral decrease in chest expansion might be seen in a client with pneumothorax or pleural effusion.
A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the health care provider, which action would the nurse take? A. Place the client on the unaffected side B. Administer 60% oxygen via a Venturi mask C. Give oxygen at 2 L per minute via nasal cannula D. Prepare for intravenous (IV) administration of electrolytes
C. Give oxygen at 2 L per minute via nasal cannula Oxygen is supplied to prevent anoxia, but not in high concentrations without a prescription. In an individual with emphysema, a low oxygen level, not high carbon dioxide level, may be the respiratory stimulus. Placing the client on the unaffected side might increase the risk for mediastinal shift and interfere with expansion of the unaffected lung. Although oxygen is administered to prevent hypoxia, this concentration is too high for a client with emphysema because it may precipitate carbon dioxide narcosis. Preparing for an IV administration of electrolytes requires prescriptions as to specific electrolytes.
Which collaborative action would the nurse anticipate when caring for a client with pneumonia whose arterial blood gases are pH 7.24, PaCO 2 60 mm Hg (7.98 kPa), HCO 3 20 mEq/L (20 mmol/L), PaO 2 54 mm Hg (7.18 kPa), and O 2 saturation 88% (0.88)? A. Oxygen at 6 L/minute by nasal cannula B. Nebulized albuterol treatment C. Intubation and mechanical ventilation D. Sodium bicarbonate intravenously
C. Intubation and mechanical ventilation The client's low pH, high PaCO 2, low HCO 3, low PaO 2, and low oxygen saturation indicate respiratory failure and the need for mechanical ventilation. The client has respiratory acidosis due to poor ventilation and CO 2 retention and lactic (metabolic) acidosis secondary to hypoxemia. Oxygen at 6 L/minute will not be adequate to resolve hypoxemia. Nebulized albuterol would improve ventilation, but not enough to resolve the respiratory acidosis. Sodium bicarbonate would help correct pH and HCO 3, but would not correct hypoxemia.
When the oxygen saturation of a client with pneumonia is at 89% to 90% while using a nonrebreather mask, which collaborative action would the nurse anticipate? A. Administration of oxygen using a simple face mask B. Use of a Venturi mask for administration of high-flow oxygen C. Continued oxygen administration with the nonrebreather mask D. Oxygen administration with bi-level positive airway pressure (BiPAP)
D. Oxygen administration with bi-level positive airway pressure (BiPAP) The client's oxygen saturation is low even with the fraction of inspired oxygen (FiO 2) levels of up to 95% that can be administered with a nonrebreather mask, and another method of oxygen administration is needed. BiPAP adds positive pressure during inspiration to oxygen administration, decreasing some of the work of breathing and improving tidal volumes and gas exchange without some of the risks that are associated with intubation and mechanical ventilation. The FiO 2 levels of 40% to 60% that can be delivered by a simple face mask are adequate to improve oxygenation for this client. A Venturi mask can provide FiO 2 levels of up to 50%, which is less than the client is already receiving. A nonrebreather mask can deliver FiO 2 levels of up to 95%, but this is not adequate for this client who has hypoxemia even with use of the nonrebreather mask.
