Respiratory
Your patient is a 63-year-old man admitted with pancreatitis and a left lower leg infection. A central venous catheter (CVC) was just placed in the right subclavian vein for fluid administration, prolonged antibiotic use, and possible parenteral nutrition. You are called to the patient's room by his wife, who has noticed her husband has become progressively short of breath. He tells you, "I can't breathe." He is tachypneic and tachycardic. What additional diagnostic assessment tests do you anticipate and why?
A chest x-ray can be very informative in this situation. Depending on the agency and your scope of practice, you might consider requesting a stat portable chest x-ray while awaiting the physician or Rapid Response Team. At the very least, radiology should be notified to be on stand-by. The purpose of the chest x-ray is to determine if a pneumothorax or hemothorax exists and, if so, how large it is. If the patient did not incur a pneumothorax, the chest x-ray will verify the position of the central venous catheter. Ch 29 p. 561, Safety; Teamwork and Collaboration; Quality Improvement
Your patient is a 63-year-old man admitted with pancreatitis and a left lower leg infection. A central venous catheter (CVC) was just placed in the right subclavian vein for fluid administration, prolonged antibiotic use, and possible parenteral nutrition. You are called to the patient's room by his wife, who has noticed her husband has become progressively short of breath. He tells you, "I can't breathe." He is tachypneic and tachycardic. How could this problem have been prevented or discovered earlier?
A chest x-ray should always be obtained immediately following placement of a central venous catheter. The patient should have been continuously monitored until a chest x-ray determined proper positioning and the absence of complications. Ch 29 p. 561, Safety; Teamwork and Collaboration; Quality Improvement
Your patient is a 66-year-old man with end-stage COPD. He was unable to be successfully extubated after several attempts and subsequently required a tracheostomy. He was weaned from the ventilator 7 days ago and transferred from the ICU to your floor yesterday. A fenestrated tracheostomy was placed by the surgical team before transfer. He has been successfully capped intermittently so that he can communicate with his family. Shortly after trach care is performed and his trach is capped by another member of the health care team, the patient's wife calls for help, stating that her husband is unable to breathe. What follow-up should occur?
A follow-up with the health team member who performed the trach care should occur. If the patient's respiratory distress was caused by improperly placing a nonfenestrated cannula within a fenestrated tracheostomy, the health team member should be counseled and re-educated as needed. Ch 30 p. 578, Safety; Patient-Centered Care
The nurse caring for a client who has been NPO for 5 days and receiving only dextrose 5% in lactated Ringer's solution (4 liters daily) reviews the client's most recent arterial blood gas results and observes that the pH is now 7.28. What is the most likely explanation for this finding? A. Acidosis in response to the presence of excessive ketoacids B. Acidosis in response to the presence of excessive lactic acid C. Alkalosis in response to the excessive loss of carbonic acid D. Alkalosis in response to the excessive loss of sulfuric acid
A. Acidosis in response to the presence of excessive ketoacids Rationale: Clients who are NPO and receiving only crystalloid solutions (including glucose) are in a condition of starvation. Each liter of 5% dextrose contains only a little over 170 calories. Four liters daily provides approximately 700 calories, not nearly enough to support adult metabolic needs. These clients are breaking down body fat for fuel, which increases the production of ketoacids. Ch 14 p. 203, Physiological Integrity
A client who has a pulmonary embolism and a venous thromboembolism is to be started on oral warfarin (Coumadin) while still receiving intravenous heparin. What is the nurse's best action? A. Administer the medications as prescribed. B. Remind the prescriber that two anticoagulants should not be administered concurrently. C. Hold the dose of warfarin until the client's partial thromboplastin time is the same as the control value. D. Monitor the client for clinical manifestations of internal or external bleeding at least every 2 hours.
A. Administer the medications as prescribed. Rationale: Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the client is still receiving heparin in order to maintain a safe level of anticoagulation. Ch 34 p. 668, Safe and Effective Care Environment
The client is 1 day postoperative after an open thoracotomy and has two chest tubes in place on the right side. The nurse notes that the client's trachea is pointing toward the left upper chest. What is the nurse's best first action? A. Immediately notify either the Rapid Response Team or the thoracic surgical resident. B. Check the suction setting for chamber three and compare it with the prescribed setting. C. Assess the client's oxygen saturation, and attempt to reposition the trachea within the midline. D. No action is needed because the trachea is deviated toward the unaffected side rather than the affected side
A. Immediately notify either the Rapid Response Team or the thoracic surgical resident Rationale: A tracheal deviation away from the midline after a thoracotomy is not normal. In this case, a tension pneumothorax is most likely because the deviation is away from the operative side. This is a life-threatening emergency. The deviated trachea cannot be manually corrected because the problem is in the chest. The suction setting is not responsible for the tension pneumothorax. Ch 32 p. 637, Safe and Effective Care Environment
A client reaches for the salmeterol (Serevent) inhaler with the onset of an asthma attack. What is the nurse's best action? A. Instruct the client to use the albuterol (Proventil) inhaler instead. B. Assist the client to use oxygen for three breaths between the two puffs of the inhaled drug. C. Instruct the client to attach the spacer to the inhaler before using it and inhale as rapidly as possible. D. Remind the client to take a deep breath, hold it for 15 seconds, and then exhale before using the inhaler
A. Instruct the client to use the albuterol (Proventil) inhaler instead. Rationale: Salmeterol is a long-acting beta2 agonist. This type of drug needs time to build up an effect and is useful in preventing asthma attacks. The effects of this drug are longer lasting but are not of value during an acute asthma attack. The client should use albuterol in this case. Ch 32 p. 610, Health Promotion and Maintenance
Why can oxygen therapy cause hypoventilation in clients who have hypercarbia? A. Low arterial oxygen levels are the neurologic trigger for these clients to breathe. B. Excessive carbon dioxide levels reduce the ability of hemoglobin molecules to carry oxygen. C. High concentrations of oxygen cause sedation, which reduces the strength of respiratory muscle contractions. D. Unlike people who do not have hypercarbia, these clients are no longer sensitive to changing levels of arterial oxygen.
A. Low arterial oxygen levels are the neurologic trigger for these clients to breathe. Rationale: In a healthy person, a rising PaCO2 level is the drive to breathe and stimulates an increased rate and depth of respiration. When the PaCO2 rises gradually, resulting in hypercarbia, the central chemoreceptors lose their sensitivity and are no longer the drive to breathe—a condition called CO2 narcosis. Therefore the only trigger to stimulate breathing in clients with CO2 narcosis is hypoxemia, a declining PaCO2 level. When arterial oxygen levels increase with oxygen therapy, the higher oxygen level is perceived as the client no longer needing to breathe as often or as deeply. Ch 30 p. 565, Physiological Integrity
The client's oxygen saturation by pulse oximetry on the finger is 84%. What is the nurse's best first action? A. Recheck the value on the forehead. B. Assess the client's cognitive function. C. Notify the Rapid Response Team immediately. D. Apply supplemental oxygen by mask or nasal cannula.
A. Recheck the value on the forehead Rationale: Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented. p. 556, Safe and Effective Care Environment Ch 29 p. 556, Safe and Effective Care Environment
Your patient is a 44-year-old woman with stage IV ovarian cancer. The surgical and oncology teams have confirmed that there are no curative surgical or medical treatment options available to her. She and her family have decided to institute a do-not-resuscitate (DNR) comfort care (DNR-CC) order. Later that evening she becomes increasingly short of breath. The patient does not wish for her morphine infusion to be increased at this point. The physician offers the family a trial of noninvasive positive-pressure ventilation (NPPV). Your colleagues are concerned this is a violation of the patient's and family's wishes. Explain why the use of NPPV may be acceptable in this situation
According to the Society of Critical Care Medicine (SCCM) guidelines, it is imperative that discussions be held with the patient and family to outline the goals of therapy and discontinuation of NPPV if those goals are no longer achieved. For example, in this scenario, the patient may be provided relief from her dyspnea with an increased use of opioids, which may alter her level of conciousness (which she does not want). Ch 30 p. 569, Patient-Centered Care; Teamwork and Collaboration
The patient is a 74-year-old woman who is 5 days postoperative from a right total hip arthroplasty. Her past medical history includes an 80-pack-year smoking history, COPD, and atrial fibrillation. She reports that she is short of breath. Your physical examination reveals diminished breath sounds and dullness on percussion over her right lower lobe. Her oxygen saturation (SpO2) is 87% on 2 liters of oxygen per nasal cannula. What additional referrals might be appropriate for this patient?
Additional referrals include discharge planning (either social work or case management) to assist with arranging for any home medical devices, home oxygen therapy, or skilled nursing services that may be needed. Ch 29 p. 556, Patient-Centered Care; Teamwork and Collaboration
Your patient is a 44-year-old woman with stage IV ovarian cancer. The surgical and oncology teams have confirmed that there are no curative surgical or medical treatment options available to her. She and her family have decided to institute a do-not-resuscitate (DNR) comfort care (DNR-CC) order. Later that evening she becomes increasingly short of breath. The patient does not wish for her morphine infusion to be increased at this point. The physician offers the family a trial of noninvasive positive-pressure ventilation (NPPV). Your colleagues are concerned this is a violation of the patient's and family's wishes. Is this a violation of the DNR-CC order?
Although still somewhat controversial, it has become a more accepted practice to offer NPPV to patients to provide comfort in the form of relief from dyspnea. Ch 30 p. 569, Patient-Centered Care; Teamwork and Collaboration
The patient is a 74-year-old woman who is 5 days postoperative from a right total hip arthroplasty. Her past medical history includes an 80-pack-year smoking history, COPD, and atrial fibrillation. She reports that she is short of breath. Your physical examination reveals diminished breath sounds and dullness on percussion over her right lower lobe. Her oxygen saturation (SpO2) is 87% on 2 liters of oxygen per nasal cannula. What age-related changes are important to consider?
Alveolar surface area decreases, elastic recoil decreases, and the body's response to hypoxia and hypercarbia decreases. This patient is at risk for increased respiratory complications. Ch 29 p. 556, Patient-Centered Care; Teamwork and Collaboration
The patient is a 22-year-old college student who has had asthma since childhood. She is being managed with fluticasone (Flovent) 50 mcg/puff, 2 puffs twice daily; salmeterol (Serevent) 1 puff twice daily; albuterol (Ventolin) 1-2 puffs every 4-6 hours as needed for wheezing. She reports that she is using the fluticasone and salmeterol as prescribed but needs to use the albuterol about every 2 hours. She also tells you that she is having difficulty sleeping and feels "like my heart is skipping some beats." Her vital signs are BP, 136/88; P, 96 and irregular; R, 30, with slight wheezing on exhalation. Her oxygen saturation is 92%, and you notice that she has a slight tremor in both hands. What questions should you ask?
Ask her how many times a day she uses the albuterol, and ask her how long the extra rescue has been needed. Determine whether the albuterol reduces or eliminates her symptoms and for how long. Also ask her whether she experiences any asthma symptoms at night. Ch 32 p. 611, Patient-Centered Care; Evidence-Based Practice; Safety
The patient is a 42-year-old woman with a traumatic brain injury from a car crash who has been at a skilled nursing/rehabilitation center for 3 weeks. During that time, she has been unresponsive. Her family reports that the patient has very bad breath and seems to have food in her mouth (she is fed by gastrostomy tube). When you assess the patient's mouth, you find that she has many layers of thickened material on all aspects of her palate, teeth, and tongue. When you check with the nursing assistant who is assigned to her, the nursing assistant admits that she and other assistants have not been performing oral care for this patient, stating "Her mouth is so gross I would rather change her soiled diapers than brush her teeth." What should you do first?
Assess the patient's respiratory effectiveness, especially oxygen saturation, immediately. Clear the patient's oral cavity Ch 31 p. 587, Patient-Centered Care; Quality Improvement; Safety; Teamwork and Collaboration
A client with moderate chronic obstructive pulmonary disease (COPD) is preparing to go home and has thrown away the information regarding smoking cessation. He states, "Why should I quit now after I have already caused this disease." What is the nurse's best response? A. "You are not responsible for this disease. It is a matter of a gene-environment interaction." B. "Choosing to quit smoking can slow the progression of COPD and make you feel better about yourself." C. "Blaming yourself is counterproductive and is likely to make your anxiety and depressive symptoms worse." D. "You shouldn't be so negative. After all, COPD is manageable, not like lung cancer."
B. "Choosing to quit smoking can slow the progression of COPD and make you feel better about yourself." Rationale: Continuing to smoke causes continuing damage to the lung tissue, which worsens symptoms and increases the progression of the disease to the severe category, resulting in severe limitations in all of the client's activities. Slowing the progression of COPD can allow the client to continue to enjoy many activities and help him retain his independence as long as possible. Although smoking cessation is not an easy task, most people who are successful experience a greatly improved self-image. Ch 32 p. 622, Psychosocial Integrity
The 75-year-old client tells the nurse he is not planning to receive a "flu shot" this year because he had one just a year ago. What is the nurse's best response? A. "Because you are older and your immune system is more fragile, you should have one this year too as a booster." B. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." C. "The 'flu shot' you had last year should still protect you for seasonal influenza, but you still need a vaccination for H1N1." D. "The fact that you have been vaccinated by injection just last year makes you a candidate to use the nasal vaccination this year."
B. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." Rationale: The influenza vaccine is changed every year because the strains of virus that hit a geographic area are usually different each year, which means that last year's vaccination is not likely to be effective against this year's influenza. The yearly vaccine is changed based on which specific viral strains are most likely to pose a problem during the influenza season. Usually, the vaccines contain three antigens for the three expected viral strains (trivalent influenza vaccine [TIV]). The nasal vaccination is an attenuated live virus and is not approved for anyone older than 49 years of age. Ch 33 p. 645, Health Promotion and Maintenance
At the hourly assessment of an intubated client after positive end-expiratory pressure (PEEP) has been discontinued, the nurse notes all of the following changes. For which one does the nurse notify the physician? A. The client is now talking around the endotracheal tube. B. Breath sounds are reduced over the left lung compared with the right. C. Oxygen saturation has increased from 90% to 95% at an FiO2 of 40%. D. The PIP dial now drops to zero at the end of exhalation instead of to only 10 cm H2O
B. Breath sounds are reduced over the left lung compared with the right. Rationale: Reduced breath sounds over the left lung indicate that the endotracheal tube has probably slipped from the trachea into the right mainstem bronchus and needs to be repositioned. The other changes are either normal or an improvement. Ch 34 p. 681, Safe and Effective Care Environment
A client with active tuberculosis who has been taking isoniazid (INH, Nydrazid) and rifampin (RIF, Rifadin) reports having urine that is an orange color. What is the nurse's best action? A. Obtain a specimen for culture and test the urine for occult blood. B. Reassure the client that this is a normal drug side effect. C. Hold the dose and contact the health care provider. D. Document the report as the only action.
B. Reassure the client that this is a normal drug side effect Rationale: Rifampin normally turns urine an orange color. No intervention is needed; however, the color change can be very distressing to clients. The client should be reassured that this color change is normal and taught how to manage this change so that clothing does not become stained. No documentation of this normal side effect is needed. Ch 33 p. 657, Health Promotion and Maintenance
How does atelectasis reduce gas exchange? A. Airway obstruction B. Reduced alveolar surface area C. Failure of pulmonary circulation to fully perfuse lung tissue D. Increased bronchial secretions filling the alveoli with fluid rather than with air
B. Reduced alveolar surface area Rationale: With atelectasis, some alveoli are collapsed. When alveoli collapse, the surface area is unavailable for gas exchange. Ch 29 p. 548, Physiological Integrity
Which technique or action does the nurse use to prevent tracheal stenosis in a client after a tracheotomy has been performed? A. Assessing breath sounds bilaterally every 2 hours B. Securing the tracheostomy tube in a midline position C. Holding the tube continually when changing the tracheostomy ties D. Suctioning the tracheostomy tube with as small a catheter as possible
B. Securing the tracheostomy tube in a midline position Rationale: Tracheal stenosis, a narrowed tracheal lumen, is the result of scar tissue formation from irritation. Two methods of preventing this complication is to keep the tube from moving in the trachea and to maintain proper cuff pressure. Ch 30 p. 574, Safe and Effective Care Environment
A client who works in a furniture factory reports that he is worried about his health because two co-workers have been diagnosed with sinus cancer in the past year. Which suggestion does the nurse make to reduce this client's risk for sinus cancer? A. Avoid the use of over-the-counter nasal sprays. B. Wear a fine particulate mask when working with wood. C. Spend as much time as possible outdoors, away from cities. D. Wear gloves when working with paint thinners and liquid glue.
B. Wear a fine particulate mask when working with wood. Rationale: Chronic exposure to fine particulates, especially wood dust, is associated with an increased incidence of nose and sinus cancer. Wearing a mask that blocks the inhalation of fine particulates can help reduce this exposure. Ch 31 p. 583, Health Promotion and Maintenance
A client with leukoplakia just above the glottis has just received the results of a biopsy and is confirmed to have squamous cell carcinoma in situ. She begins to cry and says that she would not be able to stand a surgery that would take away her ability to speak. What is the nurse's best response? A. "Your loss of speech would only be temporary until you learned to use esophageal speech." B. "Cancers at this stage are usually treated with chemotherapy alone, which does not permanently affect your ability to speak." C. "Cancers at this stage are usually treated with radiation therapy, which does not permanently affect your ability to speak." D. "A speech and language pathologist will work with you to select the method of communication that fits your lifestyle best."
C. "Cancers at this stage are usually treated with radiation therapy, which does not permanently affect your ability to speak." Rationale: Early-stage cancers often can be managed with less radical surgery, such as radiation therapy, that spares the vocal cords. With intact vocal cords, the client can usually speak, although the tone or timbre of the voice may be somewhat altered. Ch 31 p. 591, Psychosocial Integrity
The client is a 62-year-old man who has smoked one pack of cigarettes per day from the time he was 13 years old until he was 19 and then smoked two packs of cigarettes per day from age 19 to the present. How should the nurse calculate this client's pack-year smoking history? A. 62 pack-years B. 55 pack-years C. 92 pack-years D. 99 pack-years
C. 92 pack-years Rationale: Smoking history is documented in pack-years (Number of packs per day smoked × Number of years the client has smoked). Ages 13 to 19 is 6 years × 1 pack per days = 6 pack years. From ages 19 to 62 is 43 years × 2 packs per day = 86 pack years. 6 + 86 = 92. Ch 32 p. 631, Physiological Integrity
Which action does the nurse take to prevent hypoxia in a client during nasotracheal suctioning? A. Measuring pulse oximetry throughout the procedure B. Inserting the suction catheter through the vocal cords only when the client exhales C. Administering 100% oxygen by manual resuscitation bag before initiating suctioning D. Removing the suction tube from the nasopharynx as soon as the client begins to cough
C. Administering 100% oxygen by manual resuscitation bag before initiating suctioning Rationale: Hyperoxygenating the client before the procedure helps to prevent hypoxia. Although measuring pulse oximetry throughout the procedure can help identify when hypoxia is occurring, it does not prevent the complication. Ch 30 p. 575, Safe and Effective Care Environment
Which assessment finding indicates to the nurse that the client with chronic obstructive pulmonary disease (COPD) needs to be suctioned? A. Documentation indicates the client was last suctioned 12 hours ago. B. The client is unable to speak more than six words without clearing the throat. C. Although the client is coughing, breath sounds indicate continued presence of secretions in the airways. D. The oxygen saturation, as measured by pulse oximetry, decreases while the client performs controlled coughing.
C. Although the client is coughing, breath sounds indicate continued presence of secretions in the airways. Rationale: Suctioning is only performed when needed, not on a routine basis. The client who needs suction is one whose cough is too weak to clear secretions effectively. This problem is identified by breath sounds that indicate the presence of secretions in the airways after the client has coughed. Ch 32 p. 620, Physiological Integrity
Which assessment finding in a client with an endotracheal tube most strongly indicates to the nurse that the tube remains correctly in the trachea and is not in the esophagus? A. Stomach contents cannot be aspirated. B. Oxygen saturation is greater than 50%. C. End-tidal carbon dioxide level is 38 mm Hg. D. No air is heard in the stomach when auscultated with a stethoscope.
C. End-tidal carbon dioxide level is 38 mm Hg. Rationale: The end-tidal carbon dioxide level is normal. If the endotracheal tube was in the esophagus or stomach rather than the trachea, it would be very low. The lack of aspiration of stomach contents is not conclusive for correct placement and neither is the fact that air cannot be heard in the stomach. Ch 34 p. 675, Safe and Effective Care Environment
The client, in a panicky voice, tells the nurse during a thoracentesis that he feels as if he is being pushed off the table. What is the nurse's best response? A. Stop the procedure to administer an anxiety-reducing drug. B. Remind the client not to talk or breathe during the procedure. C. Reassure the client this is a normal sensation as the needle is inserted into the chest cavity. D. Relay this information to the health care provider performing the procedure so that the needle can be repositioned.
C. Reassure the client this is a normal sensation as the needle is inserted into the chest cavity. Rationale: The tissues of the thorax can be thick, and significant pressure may need to be applied to insert the needle. The client can indeed feel as though he is being pushed. This is a normal sensation and does not indicate a problem. Reassure the client first, then remind him not to move. Ch 29 p. 560, Psychosocial Integrity
In performing a chest assessment, the nurse observes or determines all of the following findings in a 70-year-old client. Which finding indicates to the nurse that the client may have an increased residual lung volume? A. Exhalation is twice as long as inhalation. B. Breath sounds are absent at the lung edges. C. The intercostal spaces measure 4 centimeters. D. Vibrations can be felt on the chest wall when the client speaks.
C. The intercostal spaces measure 4 centimeters Rationale: The expected distance between the ribs is the width of the client's fingerbreadth, or about 2 centimeters. Distances greater than this are abnormal and usually indicate some degree of air trapping that causes an increased residual lung volume Ch 29 p. 555, Physiological Integrity
A 6-foot, 6-inch tall 38-year-old man is being mechanically ventilated at a tidal volume of 500 mL and a respiratory rate of 16 breaths per minute. His most recent arterial blood gas (ABG) results are: pH = 7.33; PaO2 = 85 mm Hg; PaCO2 = 55 mm Hg. What is the nurse's interpretation of these results? A. Ventilation is adequate to maintain oxygenation. B. Ventilation is excessive; respiratory alkalosis is present. C. Ventilation is inadequate; respiratory acidosis is present. D. Ventilation status cannot be determined from the information presented
C. Ventilation is inadequate; respiratory acidosis is present Rationale: The average-size adult has a normal tidal volume of 500 mL, and 18 breaths per minute is toward the upper end of normal for respiratory rate. However, at 6 feet, 6 inches tall, this man would have a much larger tidal volume (perhaps as high as 750 to 900 mL). The settings of the ventilator are underventilating him, causing respiratory acidosis. Ch 34 p. 679, Safe and Effective Care Environment
Your patient is a 63-year-old man admitted with pancreatitis and a left lower leg infection. A central venous catheter (CVC) was just placed in the right subclavian vein for fluid administration, prolonged antibiotic use, and possible parenteral nutrition. You are called to the patient's room by his wife, who has noticed her husband has become progressively short of breath. He tells you, "I can't breathe." He is tachypneic and tachycardic.
Ch 29 p. 561, Safety; Teamwork and Collaboration; Quality Improvement
The 60-year-old client's smoking history includes smoking 2 packs of cigarettes per day since the age of 15 until the age of 40, and then smoking 3 packs per day to the present. How does the nurse document this smoking history? A. 45 pack-years B. 80 pack-years C. 90 pack-years D. 110 pack-years
D. 110 pack-years Rationale: Smoking history is documented in pack-years (number of packs per day smoked multiplied by the number of years the client has smoked). Ages 15 to 40 is 25 years × 2 packs per day = 50 pack-years. From ages 40 to 60 is 20 years × 3 packs per day = 60 pack years. 50 + 60 = 110. Ch 29 p. 551, Physiological Integrity
Which action is most important for the nurse to teach the family of a client who is receiving oxygen therapy at home by continuous nasal cannula? A. Providing mouth care every 8 hours B. Lubricating the lips with water-soluble jelly C. Draining the condensation in the tubing every 2 hours D. Changing the position of the elastic band every 4 hours
D. Changing the position of the elastic band every 4 hours Rationale: Clients receiving oxygen by nasal cannula are prone to skin breakdown on the ears, back of the neck, and face. Changing the position of the elastic band relieves pressure and prevents skin breakdown. Ch 30 p. 570, Health Promotion and Maintenance
Which nursing action has the highest priority when caring for a client with facial trauma? A. Managing pain B. Providing nutrition C. Assessing self-image D. Maintaining a patent airway
D. Maintaining a patent airway Rationale: Facial trauma has the potential to interfere with breathing by occluding the upper airways. This can occur from swelling, tissue displacement, bleeding, emesis, or as a response to therapy. Maintaining a patent airway remains a nursing priority until the trauma has healed. Ch 31 p. 584, Safe and Effective Care Environment
The client with severe dyspnea has all of the following ABG results. Which one does the nurse report immediately to the health care provider? A. pH = 7.18 B. HCO3 = 31 mEq/L C. PaCO2 = 68 mm Hg D. PaO2 = 68 mm Hg
D. PaO2 = 68 mm Hg Rationale: The elevated carbon dioxide level, or hypercarbia, is expected and not really that high for someone with COPD. The elevated bicarbonate level demonstrates kidney compensation. The low arterial oxygen level (hypoxemia) is a cause for concern and may indicate a sudden worsening of the client's condition. Ch 32 p. 617, Safe and Effective Care Environment
For what reason is pandemic influenza a bigger health threat than seasonal influenza? A. No vaccines are available for immunization to prevent pandemic influenza. B. Unlike seasonal influenza, pandemic influenza does not respond to antibiotics. C. Seasonal influenza viruses are killed by exposure to heat, and pandemic viruses are not. D. Pandemic influenzas began from animal viruses, and humans have no natural immunity to them.
D. Pandemic influenzas began from animal viruses, and humans have no natural immunity to them. Rationale: A new avian virus is the H5N1 strain, known as "avian influenza" or "bird flu," that has infected millions of birds, especially in Asia, and now has started to spread by human-to-human contact. World health officials are concerned that this strain could become a pandemic because humans have essentially no naturally occurring immunity to this virus. Therefore the infection could lead to a worldwide pandemic with very high mortality rates. There is a stockpiled vaccine for this viral strain. No viral disease responds to (is killed by) antibiotics. Ch 33 p. 647, Physiological Integrity
A client who has been receiving heparin subcutaneously for 10 days has all of the following laboratory blood test values. Which value does the nurse report immediately to the prescriber? A. Activated partial thromboplastin time 1.5 B. International normalized ratio 1.7 C. Red blood cells 4.2 million/mm3 D. Platelets 20,000/mm3
D. Platelets 20,000/mm3 Rationale: The normal range for platelets is 200,000 to 400,000/mm3. Platelets are needed for blood clotting. This client's platelet count is extremely low and he or she is at grave risk for severe bleeding. The low platelet count is an indication of an adverse reaction to heparin known as heparin-induced thrombocytopenia (HIT). The heparin must be discontinued and the client needs to receive platelet therapy before life-threatening hemorrhage occurs. Ch 34 p. 667, Physiological Integrity
The spouse of a client who has had a partial vertical laryngectomy is working with the client to use the supraglottic method of swallowing. Which direction given by the spouse to the client indicates to the nurse that more instruction is needed? A. Sit up as straight as you can when eating. B. Clear your throat before taking a bite of food. C. Only take just a teaspoonful of food at one time. D. Swallow once, then take a breath, and swallow again
D. Swallow once, then take a breath, and swallow again Rationale: The supraglottic swallowing method follows this sequence: Sitting in an upright, preferably out-of-bed, position Clearing the throat Taking a deep breath Placing a small amount of food into the mouth Holding the breath, or "bearing down" (Valsalva maneuver) Swallowing twice Releasing the breath and clearing the throat Swallowing twice again Breathing normally Ch 31 p. 595, Health Promotion and Maintenance
What are some possible new-onset health problems associated with these findings?
Diminished breath sounds and dullness to percussion could suggest atelectasis, pneumonia, or pleural effusion Ch 29 p. 556, Patient-Centered Care; Teamwork and Collaboration
Your patient is a 44-year-old woman with stage IV ovarian cancer. The surgical and oncology teams have confirmed that there are no curative surgical or medical treatment options available to her. She and her family have decided to institute a do-not-resuscitate (DNR) comfort care (DNR-CC) order. Later that evening she becomes increasingly short of breath. The patient does not wish for her morphine infusion to be increased at this point. The physician offers the family a trial of noninvasive positive-pressure ventilation (NPPV). Your colleagues are concerned this is a violation of the patient's and family's wishes. What discussions should be held with the family and patient, if possible, before starting NPPV?
Discussions should include the goal of treatment. Options to alleviate the discomfort associated with dyspnea using NPPV should also include how and when to add narcotics to the treatment plan. NPPV can provide an opportunity to assist with respirations but still allow the patient to communicate more effectively than if intubated. Develop a plan if NPPV fails to provide the stated goals. Be clear about the plan. Ch 30 p. 569, Patient-Centered Care; Teamwork and Collaboration
The patient is a 55-year-old salesman who returned from a business trip to Mexico 2 days ago. He started feeling nauseated on the plane trip home and has been vomiting for the last 40 hours. His current arterial blood gas results are pH = 7.49; HCO3 = 26 mEq/L; PaCO2 = 40 mm Hg; PaO2 = 98 mm Hg. His current therapy includes IV antiemetics and an infusion of dextrose 5% in lactated Ringer's solution at 250 mL/hr. His other health problems include moderate hypertension managed with losartan (Cozaar) 50 mg daily and hydrochlorothiazide (HydroDIURIL) 25 mg daily, benign prostatic hyperplasia managed with tamsulosin (Flomax) 0.4 mg daily, and gastroesophageal reflux disease managed with esomeprazole (Nexium) 10 mg four times daily. What nursing interventions for safety are most appropriate for this patient?
Falls from absolute hypotension and orthostatic hypotension are very possible for this patient. Some of the antiemetics can make him more drowsy, also increasing the risk for falls. Alkalosis is often accompanied by the electrolyte imbalances of low calcium levels (hypocalcemia) and low potassium levels (hypokalemia), which change the function of the nervous, neuromuscular, cardiac, and respiratory systems. Central nervous system (CNS) changes are caused by overexcitement of the nervous systems. Patients have dizziness, agitation, confusion, and hyperreflexia that may progress to tetany or seizure activity. Tingling or numbness around the mouth and in the toes may be present. Neuromuscular changes include increased nervous system activity, causing muscle cramps, twitches, and "charley horses." Deep tendon reflexes are hyperactive. Tetany (continuous contractions) of muscle groups also may be present. Tetany is painful and indicates a rapidly worsening condition. Skeletal muscles may contract as a result of nerve overstimulation, but they become weaker because of the hypokalemia. Handgrip strength decreases, and the patient may be unable to stand or walk. Respiratory efforts become less effective as the skeletal muscles of respiration weaken. Cardiovascular changes occur because alkalosis increases myocardial irritability, especially when accompanied by hypokalemia. Heart rate increases and the pulse is thready. Ch 14 p. 208, Patient-Centered Care; Safety
The patient is a 42-year-old woman with a traumatic brain injury from a car crash who has been at a skilled nursing/rehabilitation center for 3 weeks. During that time, she has been unresponsive. Her family reports that the patient has very bad breath and seems to have food in her mouth (she is fed by gastrostomy tube). When you assess the patient's mouth, you find that she has many layers of thickened material on all aspects of her palate, teeth, and tongue. When you check with the nursing assistant who is assigned to her, the nursing assistant admits that she and other assistants have not been performing oral care for this patient, stating "Her mouth is so gross I would rather change her soiled diapers than brush her teeth." What should you say to the nursing assistants?
Gather all of the nursing assistants together and perform the patient's oral care properly as a way of demonstrating correct technique. Show the narrowed passage and explain to them that not performing proper oral care daily can cause death. Also remind them that performing oral care properly every 6 to 8 hours will improve the patient's breath. Remind them that performing oral care is a required part of their jobs and not something that can be avoided. Ch 31 p. 587, Patient-Centered Care; Quality Improvement; Safety; Teamwork and Collaboration
The patient is a 42-year-old woman with a traumatic brain injury from a car crash who has been at a skilled nursing/rehabilitation center for 3 weeks. During that time, she has been unresponsive. Her family reports that the patient has very bad breath and seems to have food in her mouth (she is fed by gastrostomy tube). When you assess the patient's mouth, you find that she has many layers of thickened material on all aspects of her palate, teeth, and tongue. When you check with the nursing assistant who is assigned to her, the nursing assistant admits that she and other assistants have not been performing oral care for this patient, stating "Her mouth is so gross I would rather change her soiled diapers than brush her teeth." What steps could be taken to either prevent a similar episode or identify it earlier?
Have the nurse inspect the oral cavity daily of every patient who cannot perform his or her own care. Also have frequent "refresher" talks with the nursing assistants about the importance of this intervention. Ch 31 p. 587, Patient-Centered Care; Quality Improvement; Safety; Teamwork and Collaboration
The patient is a 22-year-old college student who has had asthma since childhood. She is being managed with fluticasone (Flovent) 50 mcg/puff, 2 puffs twice daily; salmeterol (Serevent) 1 puff twice daily; albuterol (Ventolin) 1-2 puffs every 4-6 hours as needed for wheezing. She reports that she is using the fluticasone and salmeterol as prescribed but needs to use the albuterol about every 2 hours. She also tells you that she is having difficulty sleeping and feels "like my heart is skipping some beats." Her vital signs are BP, 136/88; P, 96 and irregular; R, 30, with slight wheezing on exhalation. Her oxygen saturation is 92%, and you notice that she has a slight tremor in both hands. What additional physical manifestations should you assess?
Her forced expiratory volume in the first 1 second (FEV1) should be assessed using a peak flowmeter. Ch 32 p. 611, Patient-Centered Care; Evidence-Based Practice; Safety
The patient is a 22-year-old college student who has had asthma since childhood. She is being managed with fluticasone (Flovent) 50 mcg/puff, 2 puffs twice daily; salmeterol (Serevent) 1 puff twice daily; albuterol (Ventolin) 1-2 puffs every 4-6 hours as needed for wheezing. She reports that she is using the fluticasone and salmeterol as prescribed but needs to use the albuterol about every 2 hours. She also tells you that she is having difficulty sleeping and feels "like my heart is skipping some beats." Her vital signs are BP, 136/88; P, 96 and irregular; R, 30, with slight wheezing on exhalation. Her oxygen saturation is 92%, and you notice that she has a slight tremor in both hands. What information indicates this step is effective or ineffective?
Her use of her relief inhaler so frequently indicates that step 4, as it is now practiced, is not effective. Either the dosage levels of the current drugs or their frequency needs to be increased. Ch 32 p. 611, Patient-Centered Care; Evidence-Based Practice; Safety
A patient who had a hemilaryngectomy for laryngeal cancer comes back to the clinic 3 weeks after discharge. He says things are going well at home and that he is glad to be alive. You notice a strong odor of cigarette smoke coming off his clothes. When you ask him how the smoking-cessation program is going, he looks away from you and says "fine." What other health care professional or resource could be consulted for this issue?
His surgeon or regular health care professional can prescribe drugs that assist in smoking cessation. There are many smoking cessation programs and support groups that can be helpful to this patient. Ch 31 p. 598, Patient-Centered Care; Evidence-Based Practice; Teamwork and Collaboration
Your patient is a 66-year-old man with end-stage COPD. He was unable to be successfully extubated after several attempts and subsequently required a tracheostomy. He was weaned from the ventilator 7 days ago and transferred from the ICU to your floor yesterday. A fenestrated tracheostomy was placed by the surgical team before transfer. He has been successfully capped intermittently so that he can communicate with his family. Shortly after trach care is performed and his trach is capped by another member of the health care team, the patient's wife calls for help, stating that her husband is unable to breathe. What are some possible causes for the patient's inability to breathe? Explain how these causes affect breathing
If the patient has an upper airway obstruction and the trach is capped, he will be unable to ventilate. Increased secretions and the need for suctioning or thickened secretions that require increased humidity or mucolytics can cause respiratory distress. Ch 30 p. 578, Safety; Patient-Centered Care
Your patient is a 66-year-old man with end-stage COPD. He was unable to be successfully extubated after several attempts and subsequently required a tracheostomy. He was weaned from the ventilator 7 days ago and transferred from the ICU to your floor yesterday. A fenestrated tracheostomy was placed by the surgical team before transfer. He has been successfully capped intermittently so that he can communicate with his family. Shortly after trach care is performed and his trach is capped by another member of the health care team, the patient's wife calls for help, stating that her husband is unable to breathe. What else could you do to troubleshoot this problem?
If the patient is still unable to breathe after the cap is removed and has a trach with an inner cannula but cannot speak, remove the inner cannula. This patient had a fenestrated trach placed. It is possible the inner cannula was replaced with a nonfenestrated type. Once capped, it is the equivalent of a complete upper airway obstruction. (Remember that fenestrations are openings along the curve of the tracheostomy tube that allow for airflow between the oropharynx and the lungs.) Ch 30 p. 578, Safety; Patient-Centered Care
Your patient is a 63-year-old man admitted with pancreatitis and a left lower leg infection. A central venous catheter (CVC) was just placed in the right subclavian vein for fluid administration, prolonged antibiotic use, and possible parenteral nutrition. You are called to the patient's room by his wife, who has noticed her husband has become progressively short of breath. He tells you, "I can't breathe." He is tachypneic and tachycardic. What problems could have caused this change in breathing status? Explain your response.
The breathing difficulties that developed almost immediately after placement of a central venous catheter suggest that the needle may have caused air to enter the pleural space (pneumothorax) or that bleeding has occurred in the pleural pace (hemothorax). The change in lung volume may be minimal or significant. Ch 29 p. 561, Safety; Teamwork and Collaboration; Quality Improvement
The patient is a 22-year-old college student who has had asthma since childhood. She is being managed with fluticasone (Flovent) 50 mcg/puff, 2 puffs twice daily; salmeterol (Serevent) 1 puff twice daily; albuterol (Ventolin) 1-2 puffs every 4-6 hours as needed for wheezing. She reports that she is using the fluticasone and salmeterol as prescribed but needs to use the albuterol about every 2 hours. She also tells you that she is having difficulty sleeping and feels "like my heart is skipping some beats." Her vital signs are BP, 136/88; P, 96 and irregular; R, 30, with slight wheezing on exhalation. Her oxygen saturation is 92%, and you notice that she has a slight tremor in both hands. At what "step" is her current asthma management?
She is currently at step 4 but has not topped out of this step. Ch 32 p. 611, Patient-Centered Care; Evidence-Based Practice; Safety
The patient is a 22-year-old college student who has had asthma since childhood. She is being managed with fluticasone (Flovent) 50 mcg/puff, 2 puffs twice daily; salmeterol (Serevent) 1 puff twice daily; albuterol (Ventolin) 1-2 puffs every 4-6 hours as needed for wheezing. She reports that she is using the fluticasone and salmeterol as prescribed but needs to use the albuterol about every 2 hours. She also tells you that she is having difficulty sleeping and feels "like my heart is skipping some beats." Her vital signs are BP, 136/88; P, 96 and irregular; R, 30, with slight wheezing on exhalation. Her oxygen saturation is 92%, and you notice that she has a slight tremor in both hands. Should you administer oxygen? Why or why not?
She should use the relief inhaler first and then her oxygen saturation, and FEV1 should be reassessed. If her oxygen saturation comes up at all and her FEV1 improves, she does not need oxygen at this time. Ch 32 p. 611, Patient-Centered Care; Evidence-Based Practice; Safety
A patient who had a hemilaryngectomy for laryngeal cancer comes back to the clinic 3 weeks after discharge. He says things are going well at home and that he is glad to be alive. You notice a strong odor of cigarette smoke coming off his clothes. When you ask him how the smoking-cessation program is going, he looks away from you and says "fine." Why is smoking cessation an important action for this patient?
Smoking cessation increases the risk for developing other cancers. In addition, surgical wound healing is slowed by smoking. Ch 31 p. 598, Patient-Centered Care; Evidence-Based Practice; Teamwork and Collaboration
The patient is a 74-year-old woman who is 5 days postoperative from a right total hip arthroplasty. Her past medical history includes an 80-pack-year smoking history, COPD, and atrial fibrillation. She reports that she is short of breath. Your physical examination reveals diminished breath sounds and dullness on percussion over her right lower lobe. Her oxygen saturation (SpO2) is 87% on 2 liters of oxygen per nasal cannula. Who should you contact and why?
The Licensed Independent Practitioner (LIP) (physician, nurse practitioner, or physician assistant) should be contacted and made aware of a change in the patient's condition. The respiratory therapist should be contacted to assist with pulmonary hygiene and other oxygen delivery methods as needed. Ch 29 p. 556, Patient-Centered Care; Teamwork and Collaboration
The patient is a 55-year-old salesman who returned from a business trip to Mexico 2 days ago. He started feeling nauseated on the plane trip home and has been vomiting for the last 40 hours. His current arterial blood gas results are pH = 7.49; HCO3 = 26 mEq/L; PaCO2 = 40 mm Hg; PaO2 = 98 mm Hg. His current therapy includes IV antiemetics and an infusion of dextrose 5% in lactated Ringer's solution at 250 mL/hr. His other health problems include moderate hypertension managed with losartan (Cozaar) 50 mg daily and hydrochlorothiazide (HydroDIURIL) 25 mg daily, benign prostatic hyperplasia managed with tamsulosin (Flomax) 0.4 mg daily, and gastroesophageal reflux disease managed with esomeprazole (Nexium) 10 mg four times daily. Could any of his prescription drugs have contributed to this problem? If so, which one(s) and how?
The hydrochlorothiazide (HydroDIURIL) increases acid (hydrogen ion) excretion in the urine. Ch 14 p. 208, Patient-Centered Care; Safety
The patient is a 42-year-old woman with a traumatic brain injury from a car crash who has been at a skilled nursing/rehabilitation center for 3 weeks. During that time, she has been unresponsive. Her family reports that the patient has very bad breath and seems to have food in her mouth (she is fed by gastrostomy tube). When you assess the patient's mouth, you find that she has many layers of thickened material on all aspects of her palate, teeth, and tongue. When you check with the nursing assistant who is assigned to her, the nursing assistant admits that she and other assistants have not been performing oral care for this patient, stating "Her mouth is so gross I would rather change her soiled diapers than brush her teeth." What potential problems could occur related to this situation?
The oral cavity could become completely occluded with hardened secretions to the point that the patient cannot breathe. Ch 31 p. 587, Patient-Centered Care; Quality Improvement; Safety; Teamwork and Collaboration
The patient is a 55-year-old salesman who returned from a business trip to Mexico 2 days ago. He started feeling nauseated on the plane trip home and has been vomiting for the last 40 hours. His current arterial blood gas results are pH = 7.49; HCO3 = 26 mEq/L; PaCO2 = 40 mm Hg; PaO2 = 98 mm Hg. His current therapy includes IV antiemetics and an infusion of dextrose 5% in lactated Ringer's solution at 250 mL/hr. His other health problems include moderate hypertension managed with losartan (Cozaar) 50 mg daily and hydrochlorothiazide (HydroDIURIL) 25 mg daily, benign prostatic hyperplasia managed with tamsulosin (Flomax) 0.4 mg daily, and gastroesophageal reflux disease managed with esomeprazole (Nexium) 10 mg four times daily.
The patient is undoubtedly hypotensive. If this is the case, the hydrochlorothiazide and the losartan should be withheld until he is at least normotensive. In addition, tamsulosin also lowers blood pressure and increases the risk for falls. This drug should also be withheld until he is normotensive. Esomeprazole can be given even though it reduces the hydrogen ion content of the stomach contents. Ch 14 p. 208, Patient-Centered Care; Safety
Your patient is a 63-year-old man admitted with pancreatitis and a left lower leg infection. A central venous catheter (CVC) was just placed in the right subclavian vein for fluid administration, prolonged antibiotic use, and possible parenteral nutrition. You are called to the patient's room by his wife, who has noticed her husband has become progressively short of breath. He tells you, "I can't breathe." He is tachypneic and tachycardic. What should your ongoing management include?
The patient should be placed on a cardiac monitor and pulse oximeter. Oxygen administration should be guided by SpO2 levels. In addition, a chest tube insertion kit should be readily available Ch 29 p. 561, Safety; Teamwork and Collaboration; Quality Improvement
The patient is a 55-year-old salesman who returned from a business trip to Mexico 2 days ago. He started feeling nauseated on the plane trip home and has been vomiting for the last 40 hours. His current arterial blood gas results are pH = 7.49; HCO3 = 26 mEq/L; PaCO2 = 40 mm Hg; PaO2 = 98 mm Hg. His current therapy includes IV antiemetics and an infusion of dextrose 5% in lactated Ringer's solution at 250 mL/hr. His other health problems include moderate hypertension managed with losartan (Cozaar) 50 mg daily and hydrochlorothiazide (HydroDIURIL) 25 mg daily, benign prostatic hyperplasia managed with tamsulosin (Flomax) 0.4 mg daily, and gastroesophageal reflux disease managed with esomeprazole (Nexium) 10 mg four times daily. What is the most probable origin of the acid-base imbalance?
The prolonged vomiting is causing a loss of HCl from the stomach. Ch 14 p. 208, Patient-Centered Care; Safety
The patient is a 55-year-old salesman who returned from a business trip to Mexico 2 days ago. He started feeling nauseated on the plane trip home and has been vomiting for the last 40 hours. His current arterial blood gas results are pH = 7.49; HCO3 = 26 mEq/L; PaCO2 = 40 mm Hg; PaO2 = 98 mm Hg. His current therapy includes IV antiemetics and an infusion of dextrose 5% in lactated Ringer's solution at 250 mL/hr. His other health problems include moderate hypertension managed with losartan (Cozaar) 50 mg daily and hydrochlorothiazide (HydroDIURIL) 25 mg daily, benign prostatic hyperplasia managed with tamsulosin (Flomax) 0.4 mg daily, and gastroesophageal reflux disease managed with esomeprazole (Nexium) 10 mg four times daily. What specific type of acid-base problem does this patient have?
This patient likely has metabolic alkalosis (acid deficiency) as indicated by the higher than normal pH and the normal PaCO2 levels. Ch 14 p. 208, Patient-Centered Care; Safety
A patient who had a hemilaryngectomy for laryngeal cancer comes back to the clinic 3 weeks after discharge. He says things are going well at home and that he is glad to be alive. You notice a strong odor of cigarette smoke coming off his clothes. When you ask him how the smoking-cessation program is going, he looks away from you and says "fine." Should you press this question further? Why or why not?
Yes, ask him again, using a slightly different approach, such as, "How hard has smoking cessation been for you? How many fewer cigarettes are you smoking now compared with before your diagnosis?" Losing eye contact with you while giving a very short answer to your question about smoking cessation suggests evasive behavior. Ch 31 p. 598, Patient-Centered Care; Evidence-Based Practice; Teamwork and Collaboration
Your patient is a 63-year-old man admitted with pancreatitis and a left lower leg infection. A central venous catheter (CVC) was just placed in the right subclavian vein for fluid administration, prolonged antibiotic use, and possible parenteral nutrition. You are called to the patient's room by his wife, who has noticed her husband has become progressively short of breath. He tells you, "I can't breathe." He is tachypneic and tachycardic. Is this an emergency situation? Why or why not?
Yes, this is an emergency situation. Regardless of the problem, a significant change in respiratory status is always considered an emergency. With either blood or air continuing to enter the pleural space, the patient's ability to ventilate and exchange gases is in serious jeopardy. Ch 29 p. 561, Safety; Teamwork and Collaboration; Quality Improvement
Your patient is a 66-year-old man with end-stage COPD. He was unable to be successfully extubated after several attempts and subsequently required a tracheostomy. He was weaned from the ventilator 7 days ago and transferred from the ICU to your floor yesterday. A fenestrated tracheostomy was placed by the surgical team before transfer. He has been successfully capped intermittently so that he can communicate with his family. Shortly after trach care is performed and his trach is capped by another member of the health care team, the patient's wife calls for help, stating that her husband is unable to breathe. What is your first action?
Your first action should be to uncap the tracheostomy tube and evaluate the patient's ability to breathe. Ch 30 p. 578, Safety; Patient-Centered Care
Your patient is a 63-year-old man admitted with pancreatitis and a left lower leg infection. A central venous catheter (CVC) was just placed in the right subclavian vein for fluid administration, prolonged antibiotic use, and possible parenteral nutrition. You are called to the patient's room by his wife, who has noticed her husband has become progressively short of breath. He tells you, "I can't breathe." He is tachypneic and tachycardic. What should you do first and why?
Your first course of action should be to support the patient with supplemental oxygen while simultaneously contacting the physician or Rapid Response Team. It is important to keep the patient's oxygen saturation sufficient to prevent hypoxemia and death. Ch 29 p. 561, Safety; Teamwork and Collaboration; Quality Improvement
