NURS624 Case Study: Breathing Patterns

The antitussive medication label reads, "Take 2 teaspoonfuls every 4 hours as needed." The nurse gives the client some mL medication cups and teaches the client and his mother how to pour the medication into the mL cup. To what mL level should the medication be poured? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

1tsp=5ml (5x2=10)

The child is discharged home with prescriptions for the medication and is instructed to follow up with his HCP in a week. The child and his mother return to the HCP's office one week later, after completion of the course of antibiotic therapy. The nurse auscultates vesicular breath sounds in the peripheral lung fields. What action should the nurse take? A. Record the presence of clear breath sounds. B. Tell the client's mother that his lungs are still congested. C. Instruct the client to cough to clear his lungs and listen again. D. Notify the HCP of the abnormal lung sounds.

A Vesicular breath sounds are a normal finding in the peripheral lung fields. THEY ARE CLEAR.

Because of the client's dyspnea, the nurse is concerned that they may need to receive oxygen. Which action should the nurse perform that would be most indicative of the need for supplemental oxygen? A. Measure oxygen saturation. B. Auscultate breath sounds. C. Measure capillary refill. D. Observe chest expansion.

A Oxygen saturation provides important data about the percentage of hemoglobin that is saturated with oxygen, a valuable reflection of the client's overall oxygenation.

Which assessment finding further supports diagnosis? A. Restlessness and dyspnea. B. Skin is warm and flushed. C. Complaints of being thirsty. D. Blood pressure of 102/62 mmHg.

A Restlessness and dyspnea are indications of hypoxia. Restlessness is an early sign of hypoxia that is often missed.

The HCP prescribes a complete blood count (CBC) as a part of the diagnostic workup. Which is the best explanation for the HCP's prescription? A. A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults. B. A CBC is obtained so that the HCP can rule out the possibility of appendicitis. C. Anemia is suspected, so a CBC is drawn to measure hemoglobin and hematocrit. D. Sickle cell anemia is suspected and must be identified by a CBC to begin treatment

A The HCP is concerned that the child may have pneumonia. White blood cell count increases with infection, inflammation, stress, trauma

To achieve the desired outcome, the nurse has initiated the prescribed oxygen therapy. After applying the nasal cannula, the nurse plans to attach a disposable sensor pad to measure the oxygen saturation continuously. What action should the nurse implement prior to applying the sensor? A. Determine if child has a latex allergy. B. Clean the site with an iodine solution. C. Milk the capillary blood flow of the site. D. Apply gauze padding to protect the skin.

A The disposable sensor pads may be made of latex. If they are, the nurse should confirm that the client does not have a latex sensitivity or allergy.

Since the child has a productive cough, the HCP orders a sputum specimen be obtained and sent to the lab for culture and sensitivity. When assisting the child to obtain a sputum specimen, what action should the nurse take? A. Instruct and demonstrate how to cough deeply from the chest and spit into the specimen cup. B. Gently wipe a sterile, cotton-tipped applicator along the back of the oropharynx. C. Insert a soft-tipped catheter through the nares to suction secretions. D. Use a hard-tipped Yankauer catheter device to remove oral secretions.

A This technique is the least invasive and will provide sputum rather than mucus. A client who is alert, able to follow directions, and has a productive cough can obtain a specimen without the use of an invasive catheter.

After receiving oxygen for a short while, the child is much less dyspneic. The nurse notes that the oxygen saturation reading is 97%. Fifteen minutes later, the oxygen saturation alarm indicates that the reading has changed to 80%. Which actions should the nurse implement immediately? (Select all that apply.) A. Observe the sensor to ensure it is intact and obtain another reading. B. Assess for signs and symptoms of respiratory distress. C. Encourage coughing and deep breathing. D. Increase the oxygen flow to 3 to 4 L/min. E. Notify the HCP immediately.

A, B, C (A) Since the child is not in any distress, the nurse should first reapply the clip and obtain another reading to confirm the sudden drop in oxygenation. (B) Assessment for signs and symptoms of respiratory distress is a priority. (C) Coughing helps to clear mucus from the airway, which will allow for optimal lung expansion.

The nurse measures the child's oxygen saturation at 88% and capillary refill at 1 second. Breath sounds are absent in the bases and coarse bilaterally throughout the rest of the lung fields. The nurse initiates application of a nasal cannula and administers oxygen at 2 L/min per facility protocol. Prior to applying a nasal cannula in the ED, which action is most important for the nurse to implement to ensure client safety? A. Ensure the bed is in low position and the call light is within reach. B. Determine that all electrical equipment in the room is functioning correctly and is properly grounded. C. Use aseptic technique to prevent contamination when applying the cannula. D. Use petroleum gel on the cannula prongs to prevent irritating the nostrils.

B An electrical spark in the presence of oxygen can result in a serious fire.

The mother of the client questions the nurse as to the purpose of an antitussive. The nurse explains that this medication should have what effect? A. Liquefy the respiratory secretions. B. Reduce the frequency of the cough. C. Decrease any pain with coughing. D. Prevent nausea due to the sputum.

B Antitussives are used to reduce the frequency of a cough. This may be desirable for the client at night, to allow him to sleep.

Which is the most important approach for the nurse to use when applying a nasal cannula? A. Ensure the cannula tubing stays snugly around the ears and under the chin. B. Make sure that the tip in the nasal prongs are aimed into the nares. C. Never allow the humidifier to run out of water. D. Keep some type of padding around the ears and over the cheekbones.

B This action directs the flow of oxygen into the client's upper respiratory tract.

After assessing the client and verifying clear lung sounds and no cough, the HCP prescribes a CBC to completed. Which serum lab value confirms the resolution of infection? A. Red blood cell count (RBC) 4.5 x 106/mcL (4.5 x 1012/L). B. White blood cell count (WBC) 6000/mcL (6 x 109/L). C. Hemoglobin at 12 g/dL (120 g/L). D. Hematocrit at 40% (0.4 proportion of 1.0).

B This is a normal value for a child, confirming the resolution of the infection. Infection generally causes an elevation in the WBC.

Which documentation best reflects the nurse's objective assessment? A. The client's mother reports that he has been coughing up large amounts of sputum. B. His deep cough produces a small amount of pale yellow sputum. C. The client seems anxious and short of breath. D. Cough is frequent, and the client produces some yellow sputum when he coughs.

B This is an objective report of the nurse's observations. This documentation provides a thorough description of the cough and the sputum produced.

The client-care technician plans to transport the sputum specimen to the lab. Which instructions should the nurse provide? A. Wear clean gloves to carry the specimen to the lab. B. Wear clean gloves to place the specimen cup in a biohazard bag for transport. C. Wear gloves and a gown for the best protection. D. Wash hands after carrying the cup to the lab.

B This protects the person transporting the specimen, as well as the lab personnel receiving the specimen.

To measure capillary refill, the nurse must first perform which action? A. Count the radial pulse rate. B. Compress the nailbed of one finger until it blanches. C. Place child supine while counting respirations. D. Elevate the extremity to be assessed.

B To measure capillary refill, the nurse should first compress the client's nailbed, then note how many seconds it takes for the return of normal color to the nailbed.

After further conversation with the client's mother, the nurse needs to leave the room to assess another client. Which action by the nurse demonstrates the use of trust in the nurse-client relationship? A. Teaching the child and his mother how to read the oximeter. B. Returning to the room at the time promised. C. Offering the mother reassurance that the child is stable. D. Providing a phone so that the child's mother can call home.

B Trust and rapport is important to develop during the orientation stage so the client has the most optimal outcome.

The client's mother states that this is the third time in recent months she has brought her child to the ED with a cough and shortness of breath. The nurse asks the mother how many respiratory or other infections the child has had within the past year. What is the nurse's purpose for this question? A. To assess for suspected child neglect or abuse. B. To explore the possibility of antibiotic resistance developing. C. To assess for a possible immune deficiency disorder. D. To explore the need for a primary care provider to avoid ED visits.

C By 5 years of age a child should have developed immunity to many types of infections. It they continue to have recurrent infections it may be a sign of immune deficiency which will need further investigation.

The nurse assists with the creation of a plan of care. Which nursing diagnosis is most relevant to the client's current status? A. Excess fluid volume. B. Inability to sustain spontaneous breathing. C. Impaired gas exchange. D. Decreased cardiac output.

C Normal saturation is 95 to 100%. The child's oxygen saturation is well below normal, indicating that his gas exchange is impaired.

When assisting with the planning of care for this client, the nurse's priority is focused toward what client goal? A. To maintain oxygen at 2 L/minute per nasal cannula. B. To monitor the child's oxygen saturation continuously. C. To maintain the child's oxygen saturation greater than 95% on room air. D. To ensure the child's respiratory function is stable.

C This client-centered outcome statement describes the desired outcome in measurable terms.

The nurse plans to measure the child's oxygen saturation with a spring-tension finger clip. While the nurse is explaining this procedure, the client asks if it will hurt. Which response by the nurse is best? A. Yes, but the pain will only last a very short time. B. No, you will not even know the clip is on your finger. C. The clip feels like a clothespin squeezing your finger. D. You seem to be worried about experiencing pain.

C This is an honest response to the child's question regarding pain and one that places the sensation they will feel in a context he can understand.

The child's mother further states that she is worried her 2-year-old daughter at home may also become ill. What is an appropriate and therapeutic response to the mother's concern about her daughter? A. If you breastfed your daughter, she will have natural immunity. B. She will be protected from illness if she has had all her scheduled vaccinations. C. There is a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms. D. She is young enough that she will not be as ill as her brother. There is nothing serious to worry about.

C Viral infections can spread from person to person by droplets from sneezing or coughing and by direct contact. Colds are most contagious in the first two to three days after symptoms appear, so the sibling is at risk and the mother should be informed.

The HCP determines that the client has a respiratory tract infection and prescribes an oral antibiotic and an oral liquid antitussive. The client's mother questions the prescription for the antibiotic. The HCP states that the child should "Take 2 pills for the first dose, followed by 1 pill every 12 hours." The mother asks the nurse if this seems right. How should the nurse respond? A. This sounds like a mistake. Take 1 pill with each dose. B. Two pills every 12 hours is the usual dose. C. Let me contact the pharmacist to clarify these directions. D. A large first dose allows the medication to start working faster.

D A large first dose, called a loading dose, is often used to achieve a therapeutic level more rapidly in the bloodstream.

After determining the priority nursing diagnoses, what step should the nurse take next in developing the plan of care? A. Determine the need for client teaching. B. Reassess for any changes. C. Implement the priority nursing actions. D. Establish goals and expected outcomes.

D After analysis of the data to prioritize nursing diagnoses, the nurse should establish nursing care goals and expected outcomes.

Upon further observation, the nurse describes the child's sputum as tenacious. To what does tenacious refer? A. Color. B. Odor. C. Frequency. D. Consistency.

D Sputum with a thick consistency may be described as tenacious (sticking together).

When auscultating breath sounds, the nurse should demonstrate and ask the child to perform which action? A. Hold their breath for fifteen seconds while auscultating. B. Extend their arm to observe the color of the nailbeds. C. Cough deeply after each breath. D. Breathe deeply through the mouth.

D The child should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breath sounds.

Upon returning to the room, the nurse hears and sees the child coughing. She assesses the cough further. Which documentation reflects subjective data? A. Respirations are 36 breaths/min. B. The client appears anxious by repeatedly reaching for his mother's hand and asking, if he is okay. C. The client's mother is present in the room. D. The client and his mother state he has a cough.

D This is subjective as it is the client and his mother's reported symptom.

After the nurse repositions the finger clip, the oxygen saturation reading returns to 97%. Despite the normal reading, the client's mother appears worried and nervous and states that her child has never been sick and this scares her. To encourage the mother to share more about her feelings, how should the nurse respond? A. Your child will be just fine. You don't need to worry. B. I worried just like you when my child was sick. C. Perhaps you would rather wait outside. D. It sounds like this has been a very frightening experience for you.

D This open-ended statement acknowledges the difficult situation the mother is experiencing and encourages further discussion.

The practical nurse (PN) evaluates the client's vital signs. Respirations are rapid and shallow. What technique should the nurse use to accurately evaluate the child's respirations? A. Observe chest expansion for 15 seconds and multiply by 4. B. Encourage the client to breathe as deeply and slowly as possible. C. Watch for nasal flaring and count the air exchanges with each movement. D. Place hands flat against the back or chest and observe the rise and fall of the chest.

D This technique allows the nurse to observe and count each ventilatory cycle, even when respirations are shallow.