Medical Scenario 1: Kenneth Bronson (H&C)

Which of the following represent initial signs and symptoms of a client in respiratory distress? (Select all that apply.) A. Dyspnea B. Hypoxemia C. Tachypnea D. Cyanosis E. Fever

Answer: A, B, C Rationale: Dyspnea and tachypnea accompanied by low oxygen in the blood are associated with respiratory distress. Cyanosis is a very late indicator of hypoxia to the tissues. Fever is an indication of infection. Remediation: pp. 470-474

When a client presents to the emergency department with pneumonia, which signs and symptoms would the nurse expect the client to exhibit? (Select all that apply.) A. Orthopnea B. Fatigue C. Night sweats D. Fever E. Dyspnea

Answer: A, B, D, E Rationale: Fever is present with the infection. Clients will exhibit dyspnea, preferring to be propped up or sitting up due to orthopnea (shortness of breath when reclining or supine). The client is fatigued from the work of breathing. Remediation: pp. 535-536

Epinephrine is the first-line drug for anaphylaxis because of which of the following properties? A. Lowers blood pressure. B. Relaxes bronchial muscle. C. Decreases urticaria. D. Decreases inflammation.

Answer: B Rationale: Epinephrine relaxes bronchial smooth muscle by stimulating beta2 receptors; this improves oxygenation, decreasing respiratory distress. Epinephrine does not decrease inflammation. Epinephrine increases blood pressure. Although Epinephrine may decrease urticaria, that is not the primary reason it is given during anaphylaxis. Remediation: pp. 1047

The client experiencing an anaphylactic reaction may experience which of the following signs and symptoms? (Select all that apply.) A. Pallor B. Bronchospasm C. Laryngeal edema D. Dyspnea E. Pruritus

Answer: B, C, D, E Rationale: Mild systemic reactions consist of peripheral tingling, warmth, a sensation of fullness in the mouth and throat, nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes. Moderate systemic reactions may include flushing and anxiety in addition to any of the milder symptoms. More serious reactions include bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow. Remediation: pp. 1046

The nurse is auscultating lung sounds. What lung sound is associated with narrowing of the airway? A. Egophony B. Crackles C. Wheezes D. Bronchophony

Answer: C Rationale: Wheezing is a high-pitched, musical sound associated with airway narrowing. Crackles are described as a popping sound heard during inspiration from fluid or delayed opening of collapsed alveoli. Bronchophony or egophony can be auscultated when there is increased lung density from pneumonia and pulmonary edema. Remediation: pp. 483-486

What is the priority action by the nurse when a client experiences sudden respiratory distress? A. Place an intravenous line. B. Lower the head of the bed. C. Call the provider. D. Assess the airway.

Answer: D Rationale: The priority action is to assess the airway. Raising the head of bed will improve lung expansion. The provider should be notified and IV line may be needed, but assessing the client is the priority. Remediation: pp. 1047

Patient Introduction Location: Medical Unit Time: 11:00 Situation: The patient is Kenneth Bronson, a 27-year-old male who just arrived at the Medical Unit from the Emergency Department with the diagnosis of right lower lobe pneumonia confirmed by chest x-ray. Background: He presented to the Emergency Department 2 hours ago with chest tightness and difficulty breathing in addition to the productive cough, fever, and fatigue he's had for about a week. He has a history of smoking for 10 years. Assessment: He was given acetaminophen 650 mg orally in the Emergency Department for a temperature of 102.6 °F (39.2 °C). Heart rate has been in the 80s, respiratory rate is 24, and blood pressure is 132/80 at the right arm. SpO2 on room air was 90%, which increased to 93% with supplemental oxygen 2 L per nasal cannula. He has a 20-gauge IV in the left hand with normal saline infusing at 75 mL/hr. Recommendation: Provider's orders and lab results are available in the chart for you to view. Pharmacy just delivered the IV antibiotic that needs to be given and will bring the oral antibiotic within the next hour.

Medical-Surgical Nursing Care: (Hinkle & Cheever) -Pneumonia, Chapter 19, pp. 531-545 -Respiratory Assessment, Chapter 17, pp. 463-493 -Anaphylaxis, Chapter 33, pp. 1046-1048 -Anaphylactic Shock, Chapter 11, pp. 296-297 Pharmacology: (Expert Clinical Content from Lippincott Advisor) -Acetaminophen -Ceftriaxone -Diphenhydramine -Epinephrine -Methylprednisolone