Mr. Hannigan

The respiratory therapist is notified about the HCP's prescription for drawing arterial blood gases (ABGs) on Mr. Hannigan. Which actions should be implemented after the specimen is drawn? Select all that apply Apply direct pressure to the puncture site Position Mr. Hannigan in the Fowler's position Check Mr. Hannigan's blood pressure Arrange for immediate transport of the specimen to the laboratory Ensure an airtight seal for the blood specimen container

Apply direct pressure to the puncture site Because of the potential for hemorrhage from an arterial puncture site, pressure should be applied to the site for at least five minutes (longer for clients on anticoagulants). Agency protocols may vary. Arrange for immediate transport of the specimen to the laboratory Freshly oxygenated blood is needed for accurate blood gas analysis. Immediate transport of the specimen (in ice) to the laboratory is necessary, and will decrease the chance that air might enter the specimen. Inaccurate results can be obtained if the specimen is contaminated with air. Notifying the laboratory when a blood gas specimen is being sent will ensure that the proper laboratory equipment is ready to analyze the specimen when it arrives. If the client is receiving oxygen, details of oxygen therapy should be provided with the laboratory specimen. Ensure an airtight seal for the blood specimen container An airtight seal is needed to prevent air from entering the blood sample. Inaccurate results can be obtained if the specimen is contaminated with air. After a blood specimen is obtained, an airtight seal can be accomplished by taking the needle off the syringe, eliminating air bubbles from the specimen, and putting the syringe cap on. This is followed by rolling the syringe between hands to insure mixing of blood with the heparin used to coat the syringe before puncture. Heparin prevents the blood from clotting.

Which nursing measures should you incorporate into Mr. Hannigan's care? Select all that apply Encourage oral fluids Use of side rails Bed in low position Assist with activities of daily living Preparation for thoracentesis Frequent position changes Tepid sponge baths

Encourage oral fluids Oral fluids should be encouraged. Fluid intake should be increased to help liquefy respiratory secretions and make them easier to expectorate. Extra fluids are indicated to prevent crystalluria, a side effect of Levaquin (levofloxacin). A minimum intake of 2000 mL of fluid is recommended. Use of side rails Mr. Hannigan is confused. Side rails should prevent Mr. Hannigan from falling out of bed and injuring himself. Agency protocols for use of side rails should be followed. Ongoing assessment of Mr. Hannigan's mental status and need for side rails is indicated. Bed in low position Mr. Hannigan is confused. Keeping his bed in the low position should help prevent injury if he tries to get out of bed. Assist with activities of daily living Mr. Hannigan's oxygenation is compromised. Activity should be restricted so that oxygen is available for major organ function and not used for unnecessary activity. Mr. Hannigan should receive assistance with activities of daily living and he should be allowed frequent rest periods. As oxygenation improves, activity tolerance should improve. Frequent position changes Frequent position changes are indicated to help mobilize respiratory secretions. Frequent position changes will improve circulation and help prevent pressure ulcers and deep vein thrombosis, secondary to immobility. Ambulation should resume as soon as possible, when oxygenation is adequate.

Mr. Hannigan is receiving the broad-spectrum antiinfective drug levofloxacin. Levofloxacin is active against Strep pneumonia. Based on your knowledge of the potential complications of this drug, you will be alert for which adverse effects? (Select all that apply.) Tachycardia Peripheral edema Loose, watery stools Tendon Rupture Photosensitivity

Loose, watery stools Gastrointestinal side effects that may occur include abdominal pain, constipation, diarrhea, dyspepsia, nausea and vomiting. Tendon Rupture Levfloxacin may increase the risk of tendinitis and rupture. Monitor client for tendon pain or inflammation. Photosensitivity Sun exposure can cause photosensitivity reactions so advise client to stay out of sun or wear protective clothing.

When evaluating your plan of care for Mr. Hannigan with regard to the problem of impaired gas exchange, which criteria would indicate a successful outcome? Mr. Hannigan has a heart rate below 100 per minute Mr. Hannigan has a PaO2 (arterial oxygen) above 80 mm Hg Mr. Hannigan has a PaCO2 (arterial carbon dioxide) above 45 mm Hg Mr. Hannigan has a temperature below 37.2 degrees C (98.8 degrees F)

Mr. Hannigan has a PaO2 (arterial oxygen) above 80 mm Hg A PaO2 (arterial oxygen) above 80 mm Hg is normal. It is a good indicator of adequate gas exchange at the alveoli level.

Which considerations are critical for the nurse to make when assigning a room to a client with community acquired pneumonia (CAP)? Select all that apply Mr. Hannigan's confusion Infection control The high anxiety level of Mr. Hannigan's family members Mr. Hannigan's gray skin color

Mr. Hannigan's confusion Mr. Hannigan's confusion is an important consideration for room assignment. The fact that Mr. Hannigan is confused places him at risk for injury. An initial assessment found Mr. Hannigan to be disoriented to time, place, and person. Bed placement as close to the nurses' station as possible is important. Infection control Infection control is an important consideration for room assignment. Mr. Hannigan has pneumonia, although the specific organism responsible for infection is not known at this time. The means of transmission is not yet known. To decrease risk for hospital-acquired pneumonia or other nosocomial infections in other clients, Mr. Hannigan was assigned to a private room.

As you care for Mr. Hannigan, which intervention is the most important to implement? Preventing pressure ulcers Preventing deep vein thrombosis (DVT) Promoting oxygenation Reorientation

Promoting oxygenation Promoting oxygenation takes priority with Mr. Hannigan. Without adequate oxygenation, hypoxemia can result in subsequent generalized tissue hypoxia.

The results of Mr. Hannigan's arterial blood gases, taken on admission, are available. You expect results to reflect which type of acid-base imbalance? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis

Respiratory alkalosis On admission, Mr. Hannigan was breathing rapidly. His increased respiratory rate was an effort to compensate for hypoxemia and take in more oxygen. An increase in the rate of breathing causes a decrease in arterial carbon dioxide levels. This can lead to respiratory alkalosis.

Which risk factors for community acquired pneumonia does Mr. Hannigan have in his medical history? Cigarette smoking 20 years ago Splenectomy 10 years ago Drinks beer each evening (one can) Asymptomatic mitral valve prolapse

Splenectomy 10 years ago The spleen normally serves important immunologic functions, keeping the blood free of unwanted substances and infecting organisms. Individuals without a spleen are at increased risk of bacterial infection, especially those caused by Streptococcus pneumoniae, Haemophilus influenzae, and others. Mr. Hannigan received the pneumococcal vaccine (which helps prevent infection due to the bacteria Streptococcus pneumoniae) about 10 years ago, when his spleen was removed. To maintain immunity, a one-time repeat vaccination is recommended. However, Mr. Hannigan was never revaccinated.

According to Centers for Disease Control (CDC) guidelines, which isolation precautions are indicated for Mr. Hannigan at this time? Select all that apply Standard Precautions Airborne Precautions Droplet Precautions Contact Precautions

Standard Precautions Centers for Disease Control (CDC) Guidelines for Isolation Precautions in Hospitals require that Standard Precautions be used with all hospitalized persons, regardless of diagnosis or presumed diagnosis. Droplet Precautions Centers for Disease Control (CDC) Guidelines for Isolation Precautions in Hospitals require that Droplet Precautions be used with persons who have suspected or known infections that are transmitted by large particle droplets, including some pneumonias. These pneumonias are contagious with coughing, sneezing, talking, and procedures requiring close contact. Usually transmission is by nasopharyngeal/respiratory secretions and/or sometimes saliva. It is possible that Mr. Hannigan has a pneumonia that will not require Droplet Precautions. However, it is prudent that Droplet Precautions be instituted to prevent transmission of infection until such time that a diagnosis suggesting otherwise is determined. Contact Precautions Centers for Disease Control (CDC) Guidelines for Isolation Precautions in Hospitals require that Contact Precautions be used with persons who have suspected or known infections that can be transmitted by direct (personal) or indirect (environmental surfaces) contact. Some pneumonias spread easily through direct contact with infected persons or indirect contact with contaminated objects or surfaces. For these pneumonias, transmission is usually by nasopharyngeal/respiratory secretions. It is possible that Mr. Hannigan has a pneumonia that will not require Contact Precautions. However, it is prudent that Contact Precautions be instituted to prevent transmission of infection until such time that a diagnosis suggesting otherwise is determined.

How can the nurse best alleviate Mr. Hannigan's discomfort? Suggest that a narcotic analgesic be prescribed for Mr. Hannigan Apply a chest binder to act as a splint for Mr. Hannigan's thoracic cavity Suggest that acetaminophen be prescribed to alleviate chest discomfort Suggest that a sedative be prescribed for Mr. Hannigan

Suggest that acetaminophen be prescribed to alleviate chest discomfort An analgesic such as acetaminophen should reduce Mr. Hannigan's chest discomfort without suppressing his cough and gag reflexes. Cough and gag reflexes are needed to expectorate secretions and avoid aspiration. Sedatives and narcotic analgesics suppress these reflexes. Restriction of chest movement with a chest binder would limit airflow and increase hypoxia, predisposing Mr. Hannigan to more serious respiratory complications. Mr. Hannigan needs full lung expansion to insure maximum lung inflation and optimal gas exchange.

Mr. Hannigan will be discharged very soon. Which discharge instructions are indicated? Select all that apply Take frequent rest periods as needed Stop antibiotics when feeling better Avoid carbonated drinks Drink lots of fluid each day Remain indoors while taking levofloxacin

Take frequent rest periods as needed Recovery from pneumonia takes time. The disease process depletes the body of energy. Fatigue may persist for several weeks. Frequent rest periods are indicated. Drink lots of fluid each day Fluid intake of 2000-3000 mL per day should continue to help liquefy and loosen respiratory secretions and avoid crystalluria, a possible side effect of levofloxacin therapy.

Standard precautions, droplet precautions, and contact precautions apply for Mr. Hannigan. Besides a private room, which of the following infection control requirements are indicated? Select all that apply Wear a mask with close contact Wear a gown when assisting Mr. Hannigan with bathing Keep the door of Mr. Hannigan's room closed Have Mr. Hannigan wear a mask if he leaves his room Wear gloves when handling tissues containing sputum

Wear a mask with close contact When providing close-contact (within three feet) direct care with clients on droplet precautions, the health care provider should wear a face mask. Often, this means wearing a mask when in the client's room. Wear a gown when assisting Mr. Hannigan with bathing A gown should be worn when assisting Mr. Hannigan with bathing. A gown is required with substantial physical contact as part of contact precautions. Client-care activities that might involve splashes of body fluids or secretions require a gown as part of standard precautions. Wear gloves when handling tissues containing sputum. Gloves should be worn when contaminated tissues are touched. As part of standard precautions, gloves are worn when contact with body fluids or secretions is possible. Gloves are worn at all times in Mr. Hannigan's room as part of contact precautions.

The nurse monitors the pulse oximetry to assess for which value? arterial oxygen saturation arterial oxygen content partial pressure of oxygen fraction of inspired oxygen

arterial oxygen saturation Pulse oximetry measures arterial oxygen saturation, the amount of hemoglobin that is saturated with oxygen. Oxyhemoglobin releases oxygen to tissues. Arterial oxygen saturation is an indicator of tissue oxygenation. Arterial oxygen saturation readings are obtained invasively through analysis of arterial blood obtained by arterial line or arterial puncture (SaO2) OR noninvasively with the use of pulse oximetry (SpO2).

Despite being given an NSAID, acetaminophen for pain, Mr. Hannigan continues to complain of chest soreness when coughing. What action by Mr. Hannigan would you suggest to him to decrease his discomfort? hold a pillow across his chest when coughing try to consciously suppress his cough turn his head away when coughing pull on the side rails when coughing

hold a pillow across his chest when coughing Splinting sore chest muscles with a pillow during coughing should lessen musculoskeletal pain experienced when coughing, without interfering with chest expansion on an ongoing basis.

You've noticed that Mr. Hannigan is restless, confused, and picks at his sheets. What cause would be suspected for these behaviors? discomfort hypoxia tachycardia

hypoxia Mr. Hannigan's confusion is probably due to hypoxia. Restlessness and confusion are often early signs of hypoxemia, and reflect cerebral hypoxia.

You review the rationale for Mr. Hannigan's nursing care. What is the underlying pathophysiology of pneumonia? blood clots in the lung collapse of the lung degenerative changes in the lung inflammation and/or infection of the lung

inflammation and/or infection of the lung The pathophysiology of pneumonia involves excess fluid in the lungs associated with an acute inflammatory process that is usually a result of infection. Microorganisms (bacteria, viruses, fungi, parasites) gain entry into the respiratory tract either by inhalation (from airborne transmission with talking, sneezing, coughing) or aspiration (secretions from the oropharynx or nasopharynx). The organisms are not successfully cleared, and they become established.

The HCP prescribes oxygen therapy. As you implement the prescription for oxygen, the therapeutic effect of the nasal oxygen will be enhanced if Mr. Hannigan: also does rigorous coughing is positioned in the Fowler's position uses pursed lip breathing is medicated for pain

is positioned in the Fowler's position The Fowler's position (head of bed 45 degrees or higher) promotes full lung expansion and decreases the work of breathing. It can enhance the effectiveness of oxygen therapy and help increase oxygenation. Resting his arms on an overbed table may increase Mr. Hannigan's tolerance for this position.

You are conducting a physical assessment of Mr. Hannigan. Which findings would the nurse expect? Select all that apply lung crackles tachypnea hoarseness nasal flaring clubbing of fingers

lung crackles Crackles are heard when you auscultate Mr. Hannigan's lungs, and are consistent with a diagnosis of pneumonia. Crackles are abnormal sounds heard during inspiration or expiration. Crackles are a result of air movement through retained respiratory secretions in small air passages. tachypnea Tachypnea, an increased rate of breathing, is common in persons with pneumonia. With pneumonia, gas exchange is impaired. Tachypnea occurs as a compensatory measure to bring oxygen to tissues more quickly. Mr. Hannigan is tachypneic. nasal flaring Nasal flaring is common in persons with acute pneumonia. It is an effort by the body to take in as much oxygen as possible with each breath. Nasal flaring is apparent with Mr. Hannigan as he takes each breath.