Uworld Respiratory #5
In the emergency department, a pediatric client is placed on mechanical ventilation by means of an endotracheal tube. Several hours later, the nurse enters the room and finds the client in respiratory distress. It is most important for the nurse to take which of these actions? a. Assess the client for intercostal retractions b. Assess the client's BP in both arms c. Auscultate the client's lung sounds d. Observe the color of the client's fingernail beds
A client experiencing respiratory distress while receiving mechanical ventilation should be assessed for proper ventilation first. The nurse needs to determine if the mechanical ventilation equipment is still properly placed in the trachea. An endotracheal tube (ET) can become displaced with movement. By assessing the client's lung sounds, the nurse can quickly determine if ET placement has been compromised (Option 3). Airway is the priority for this client. By auscultating the client's lung sounds, the nurse can determine if the client has an open airway. (Option 1) This is an assessment of the client's breathing, which is not the priority at this time. (Option 2) This is an assessment of the client's circulation, which is not the priority at this time. (Option 4) This is an assessment of the client's circulation, which is not the priority at this time. Educational objective:Clients with respiratory distress should be assessed for a patent airway first. The nurse should assess the client's airway to determine if it is present or needs to be established.
The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate? Click on the exhibit button for additional information. VS: HR - 132 RR - 40/min O2 sat% - 80% a. Apply a non rebreather face mask with 100% oxygen b. Apply dry, sterile gauze over the stoma and secure with tape c. Insert a new tracheostomy tube using the bedside obturator d. Insert a sterile catheter into the stoma and suction the airway
A tracheostomy tube, an artificial airway inserted into the trachea through the neck, may be secured with sutures or tracheostomy ties. Accidental dislodgment of a tracheostomy tube is a medical emergency often resulting in respiratory distress from closure of the stoma and airway loss. If accidental dislodgment of mature tracheostomies (ie, >7 days after insertion) occurs where the tract is well formed, the nurse should attempt to open the airway by inserting a curved hemostat to maintain stoma patency and insert a new tracheostomy tube with an obturator (Option 3). (Option 1) Application of supplemental oxygen via nonrebreather face mask may not resolve respiratory distress because air can escape from the stoma. (Option 2) Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating the lungs with a bag-valve mask over the nose/mouth may be necessary if the tube cannot be reinserted or the stoma is immature. Dry gauze is porous and does not adequately seal the stoma for ventilation. (Option 4) Tracheal suctioning may be necessary once the airway is resecured. However, suctioning prior to establishing an airway does not improve ventilation and may further reduce the oxygen supply. Educational objective:Accidental dislodgment of a tracheostomy tube is a medical emergency. With a mature tracheostomy, an attempt to insert a new tracheostomy tube with the bedside obturator is indicated. If a tube cannot be reinserted, the stoma is covered with a sterile, occlusive dressing. Ventilation is provided with a bag-valve mask over the nose/mouth.
A client with an asthma exacerbation has been using her albuterol rescue inhaler 10-12 times a day because she cannot take a full breath. What possible side effects of albuterol does the nurse anticipate the client will report? Select all that apply. a. Constipation b. Difficulty sleeping c. Hives with pruritus d. Palpitations e. Tremor
Albuterol is a short-term beta-adrenergic agonist used as a rescue inhaler to treat reversible airway obstruction associated with asthma. Dosing in an acute asthma exacerbation should not exceed 2-4 puffs every 20 minutes x 3. If albuterol is not effective, an inhaled corticosteroid is indicated to treat the inflammatory component of the disease. Albuterol is a sympathomimetic drug. Expected side effects mimic manifestations related to stimulation of the sympathetic nervous system, and commonly include insomnia, nausea and vomiting, palpitations (from tachycardia), and mild tremor. (Option 1) Constipation is not a common side effect of inhaled beta-agonist drugs. (Option 3) Hives can occur as a sign of an allergic reaction and are not a common anticipated side effect of an inhaled beta-agonist drug. Educational objective:Albuterol is a short-term beta-agonist rescue drug used to control symptoms of airway obstruction and promote bronchodilation. It is a sympathomimetic drug; common expected side effects include insomnia, nausea and vomiting, palpitations (tachycardia), and mild tremor.
A client is brought to the emergency department following a motor vehicle collision. The client's admission vital signs are blood pressure 70/50 mm Hg, pulse 123/min, and respirations 8/min. The nurse anticipates the results of which diagnostic test to best evaluate the client's oxygenation and ventilation status? a. ABGs b. CXR c. Hematocrit and Hgb levels d. Serum lactate level
Arterial blood gas (ABG) assessment parameters provide objective data about the efficiency of gas exchange in the lungs and effectively evaluate the following: Acid-base balance (pH, HCO3) Oxygenation status (PaO2, partial pressure of oxygen in the arterial blood) Tissue oxygenation (SaO2, percentage of available hemoglobin saturated with oxygen) Ventilation (PaCO2, partial pressure of carbon dioxide in the arterial blood) Respiratory failure can occur when oxygenation is inadequate (hypoxemic failure) and/or when ventilation is inadequate (hypercapnic failure). The adequacy of oxygenation and ventilation in a client with respiratory failure is best evaluated through ABG analysis. (Option 2) Chest x-ray is used to determine structural abnormality (eg, enlarged heart, fractured ribs), presence of air, fluid, infiltrates, lesions, and response to treatment. It does not provide objective data about a client's gas exchange, oxygenation, and ventilation status. (Option 3) Decreased serum hematocrit and hemoglobin levels can affect the carrying capacity and delivery of oxygen to the tissues. They do not provide objective data about a client's gas exchange, oxygenation, and ventilation status. (Option 4) The serum lactate level provides information about anaerobic tissue metabolism (perfusion). It does not provide objective data about a client's gas exchange, oxygenation, and ventilation status. Educational objective:Respiratory failure can occur when oxygenation is inadequate (hypoxemic failure) and/or when ventilation is inadequate (hypercapnic failure). Arterial blood gas analysis provides objective data about the efficiency of gas exchange in the lungs.
A client is admitted with an exacerbation of asthma following a respiratory viral illness. Which clinical manifestations characteristic of a severe asthma attack does the nurse expect to assess? Select all that apply. a. Accessory muscle use b. Chest tightness c. High pitched expiratory wheeze d. Prolonged inspiratory phase e. Tachypnea
Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Asthma exacerbations occur due to various triggers (eg, allergens, respiratory infection, exercise, cold air), resulting in edema, hypersecretion of mucus, and bronchospasm. Narrowing of the airways culminates in increased airway resistance, air trapping, and lung hyperinflation. In severe asthma, breath sounds may be diminished due to closure of bronchioles. Absent breath sounds in a client with asthma are a medical emergency. Clinical manifestations of an asthma exacerbation include: Accessory respiratory muscle use related to increased work of breathing and diaphragm fatigue (Option 1) Chest tightness related to air trapping (Option 2) Cough from airway inflammation and increased mucus production Diminished breath sounds related to hyperinflation High-pitched expiratory wheezing caused by narrowing airways (Option 3); wheezing may be heard on both inspiration and expiration as asthma worsens Tachypnea related to inability to take a full, deep breath (Option 5) (Option 4) Clients with obstructive lung disease (eg, asthma, chronic obstructive pulmonary disease) develop prolonged expiratory phase as a physiologic response to hyperinflation and trapped air. Educational objective:Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Clinical manifestations of an asthma exacerbation include accessory respiratory muscle use, chest tightness, diminished breath sounds, high-pitched wheezing on expiration, prolonged expiratory phase, tachypnea, and cough.
The nurse takes the admission history of a 70-year-old client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following statements by the client does the nurse recognize as contributing to the development of COPD? Select all that apply. a. I have been drinking alcohol almost daily since age 20 b. I have been overweight for as long as I can remember c. I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year d. I know I eat too much fast food e. I was a car mechanic for about 40 years and had my own garage
Chronic obstructive pulmonary disease (COPD) generally refers to two conditions: emphysema and chronic bronchitis. A combination of the two is common. COPD affects approximately 12 million people and is the third leading cause of death in the United States, occurring most commonly in the seventh decade of life. It is characterized by slowly progressive, persistent airflow obstruction, and its etiology is closely associated with chronic airway inflammation. The major risk factor for COPD is current or former tobacco smoking (eg, cigarette, pipe, cigar). An additional contributing factor is prolonged exposure to respiratory irritants (eg, chemical fumes, smoke, dust) related to the client's occupation (eg, car mechanic, firefighter, coal miner). Risk for COPD is even higher if the client both smokes tobacco and has occupational exposure to respiratory irritants (Options 3 and 5). Chronic exposure to air pollution and genetic predisposition (eg, alpha1-antitrypsin deficiency) also contribute. (Option 1) Alcohol consumption is not associated with the development of COPD. (Options 2 and 4) Although obesity can worsen COPD symptoms by contributing to dyspnea, obesity and poor nutrition are not factors that directly contribute to the development of COPD. Educational objective:Chronic airway inflammation is closely associated with the development of chronic obstructive pulmonary disease. Specific etiologic factors include current or former tobacco smoking, prolonged exposure to occupational respiratory irritants, chronic exposure to air pollution, and genetic predisposition.
A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply. a. Inhaled albuterol nebulizer every 20 minutes b. Inhaled ipratopium nebulizer every 20 minutes c. Methyprednisolone IV d. Montelukast 10 mg PO STAT e. Salmetrol MDI every 20 minutes
Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia (>120/min), tachypnea (>30/min), saturation <90% on room air, use of accessory muscles to breathe, and peak expiratory flow (PEF) <40% of predicted or best (<150 L/min). Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol) (Option 4) Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti-inflammatory effects; it is used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma. (Option 5) A long-acting beta agonist (Salmeterol) is administered with an inhaled corticosteroid for long-term control of moderate to severe asthma; it is not used as an emergency rescue drug in asthma. Educational objective:Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia, tachypnea, saturation <90% on room air, use of accessory muscles of respiration, and PEF <40% predicted. Management includes the administration of high-dose inhaled SABA and ipratropium nebulizer, systemic corticosteroids, and oxygen to maintain saturation >90%.
A nurse has received new medication prescriptions for a client admitted with hypertension and an exacerbation of chronic obstructive pulmonary disease. Which prescription should the nurse question? a. Amlodipine b. Codeine c. Ipratropium d. Methyprenisolone
Codeine is a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (eg, asthma, COPD). (Option 1) Calcium channel blockers (eg, amlodipine, nifedipine) are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (eg, metoprolol, atenolol). (Option 3) Ipratropium (Atrovent) is a short-acting inhaled anticholinergic often used in combination with a short-acting beta-agonist (eg, albuterol) to promote bronchodilation and reduce bronchospasm. (Option 4) Methylprednisolone (Solu-Medrol) is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD. Educational objective:Codeine is a narcotic medication with antitussive properties that can cause an accumulation of secretions in clients with chronic obstructive pulmonary disease and lead to respiratory distress. Caution is advised when sedatives are prescribed for clients with respiratory diseases.
The nurse is caring for a client with advanced heart failure on an inpatient hospice unit. The client is having trouble breathing. Which comfort intervention should the nurse implement first? a. Administer PRN albuterol by nebulizer b. Administer prn IV furosemide c. Elevate the HOB d. Give prn sublingual morphine
Dyspnea, difficulty breathing, is a common symptom in the client with advanced heart failure who is on hospice. The most common cause of dyspnea is fluid overload, and elevating the head of the bed is often an effective intervention that can be implemented quickly and easily. (Option 1) Albuterol is a bronchodilator and is unlikely to relieve feelings of dyspnea caused by fluid overload. (Options 2 and 4) Additional interventions for dyspnea in heart failure include the use of IV furosemide to promote diuresis to treat the fluid overload. The use of prn morphine can alleviate the sensation of dyspnea, but this would not be the first intervention; it should be used in combination with diuresis if the dyspnea is associated with fluid overload. Educational objective:The client with advanced heart failure on hospice is likely to have dyspnea associated with fluid overload. The first intervention should be to elevate the head of the bed and then assess for fluid overload, which would be treated with IV diuretics. Morphine can alleviate dyspnea associated with heart failure, but it should be used in combination with other nonpharmacologic and pharmacologic interventions.
The nurse is providing care for a client with cancer of the left lung who will undergo video-assisted thoracic surgery in the morning. The client is nervous, jumpy, and short of breath. Pulse is 120/min, respirations are 30/min and shallow, and expiratory wheezing is auscultated in the left upper and lower lung posteriorly. Which of the following is the priority nursing action? a. Administered prescribed intravenous morphine 2 mg to relieve anxiety b. Page RT to administer inhaled bronchodilator nebulizer treatment c. Place HOB in Fowler's or high Fowler's position d. Stay with client and encourage client to discuss feelings about the surgery.
Elevating the head of the bed to Fowler's or high Fowler's position is the priority nursing action to help relieve shortness of breath, facilitate oxygenation (breathing), and promote lung expansion (airway). Alternate positions to high Fowler's include the following: Orthopneic position: Sitting in a chair, on the side, or in bed leaning over the bedside table, with one or more pillows under the arms or elbows for support Tripod position: Sitting in a chair leaning forward with hands or elbows resting on the knees. Sitting upright and leaning forward pulls the scapulae apart, promotes lung expansion, and decreases the diaphragmatic pressure produced by the viscera. (Option 1) Morphine is effective in relieving anxiety and decreasing the work of breathing by slowing respirations. It can cause hypoventilation and decrease gas exchange in the lungs and is not the priority action, especially as the client's respirations are shallow. (Option 2) The cause of the wheezing could be from lung tumor or true bronchoconstriction. Paging the respiratory therapist to administer a bronchodilator nebulizer treatment to relieve wheezing is an appropriate intervention, but it is not the priority action. (Option 4) Encouraging the client to talk about the diagnosis and upcoming surgery is an appropriate intervention to help alleviate anxiety and address self-actualization needs, but is not the priority action. Educational objective:Elevating the head and chest in the Fowler's, high Fowler's, orthopneic, and tripod positions allows for maximum lung expansion and promotes oxygenation, especially in clients with dyspnea.
The nurse is assessing a 3-year-old client in the emergency department and finds dyspnea, high fever, irritability, and open-mouthed drooling with leaning forward. The parents report that the symptoms started rather abruptly. The client has not received age-appropriate vaccinations. Which set of actions should the nurse anticipate? a. 20 gauge needle insertion at the mid axillary line for pleural aspiration b. 4 L oxygen at 100% n/c with BPAP ventilation standing by c. Intubation in the operating room with prepared tracheotomy kit standing by d. Nebulized racemic epinephrine with pediatric anesthesiologist standing by
Epiglottitis should be considered first in a 3-7-year-old child with acute respiratory distress, toxic appearance (eg, sitting up, leaning forward, drooling), stridor, and high-grade fever. Tachycardia and tachypnea are also present. This is a pediatric emergency and should be managed with endotracheal intubation; however, intubation of such clients is difficult, and preparation for possible tracheostomy is also standard. The complications of epiglottitis are serious and include sudden airway obstruction. (Option 1) This is a recommended therapy for spontaneous tension pneumothorax, which is demonstrated by tracheal deviation; absent lung sounds; and severe, abrupt hypotension and dyspnea. (Option 2) Neither oxygenation nor BPAP is acceptable in acute epiglottitis as the trachea can close completely from edema. (Option 4) This is the appropriate therapy for croup, not epiglottitis. Croup is notably distinct for the hacking cough, which does not occur in epiglottitis. Educational objective:When assessing a client with symptoms suggestive of epiglottitis (eg, acutely ill, drooling, leaning forward, dyspnea), the nurse should prepare for an emergency airway.
A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full face mask with continuous positive airway pressure (CPAP). Oxygen saturation drops to 85% during the night. What is the nurse's first action? a. Assess level of consciousness and lung sounds b. Check the tightness of the straps and mask c. Notify the HCP d. Remove the mask and administer supplemental oxygen
Obstructive sleep apnea (OSA) is a chronic condition that involves the relaxation of pharyngeal muscles during sleep. The resulting upper airway obstruction with multiple events of apnea and shallow breathing (hypopnea) leads to hypoxemia and hypercapnia. CPAP is an effective treatment for OSA; it involves using a nasal or full face mask that delivers positive pressure to the upper airway to keep it open during sleep. In this case, the nurse's first action should be to check the tightness of the straps that hold the mask in place. The full face mask must fit snugly over the client's nose and mouth without air leakage to maintain the positive airway pressure and prevent obstruction of upper airway airflow. Readjustment of the head straps may be necessary (Option 2). (Option 1) Underlying OSA is the most likely reason for this client's drop in oxygen saturation during sleep. If CPAP is not effective, then the characteristic OSA signs (eg, hypoxia, hypercapnia) will occur. In addition, decreased level of consciousness and lung sounds are expected when there is no airflow to the lungs. Although the nurse should assess these parameters, this should not be the first action. (Option 3) If the attempt to readjust the straps and mask seal does not reverse the client's hypoxemia quickly, the nurse should notify the health care provider and respiratory therapist (per institution policy). However, this should not be the nurse's first action. (Option 4) Supplemental oxygen may be indicated if readjustment of the straps and mask seal does not reverse the client's hypoxemia quickly. This should not be the nurse's first action. Educational objective:CPAP is prescribed for clients with obstructive sleep apnea in the home and clinical settings. The mask is secured with adjustable head straps to maintain a snug fit over the face to prevent air leakage and loss of positive pressure.
A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first? a. Administer prescribed analgesic medication for incisional pain b. Encourage use of IS every 2 hours while awake c. Offer an additional pillow to splint the incision while coughing d. Promote increased oral fluid intake
Postoperative clients are at risk for atelectasis and possibly for pneumonia following surgery as a result of retained secretions. Effective coughing is essential to prevent these complications. The nurse can promote many client actions that will facilitate effective coughing. These include splinting the incision while coughing, changing position every 1-2 hours, ambulating early, using an incentive spirometer, and hydrating adequately to thin the secretions. However, all of these interventions are less effective if the client is in pain. The nurse should instruct the client to request pain medication before the pain becomes intense. Pain relief should be addressed prior to implementing coughing exercises and ambulation. (Options 2, 3, and 4) These are appropriate interventions but will be more effective if pain is managed first. Educational objective:The nurse should ensure that the postoperative client has effective pain relief before performing coughing exercises.
The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply. a. Bradycardia b. Chest pain c. Dyspnea d. Hypoxemia e. Tachypnea f. Tracheal deviation
Pulmonary embolism (PE) is a potentially life-threatening medical emergency occurring when a blood clot, fat or air embolus, or tissue (eg, tumor) travels via the venous system into the pulmonary circulation and obstructs blood flow into the lung. This prevents deoxygenated blood from reaching the alveoli, which leads to hypoxemia due to impaired gas exchange and cardiac strain due to congested blood flow in the pulmonary arteries. Clinical manifestations of PE range from mild (eg, anxiety, cough) to severe (eg, heart failure, sudden death). However, many clients initially have mild, nonspecific symptoms that are often misdiagnosed and inadequately managed, greatly increasing the likelihood of progression to shock and/or cardiac arrest. Clinical manifestations of PE include: Pleuritic chest pain (ie, sharp lung pain while inhaling) (Option 2) Dyspnea and hypoxemia (Options 3 and 4) Tachypnea and cough (eg, dry or productive cough with bloody sputum) (Option 5) Tachycardia Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis (Option 1) Tachycardia, rather than bradycardia, is expected with PE because the heart attempts to compensate for hypoxemia, right ventricular overfilling, and decreased left ventricular cardiac output. (Option 6) Tracheal deviation is a sign of tension pneumothorax (not PE), which occurs when pressure on the side of the collapsed lung pushes organs toward the unaffected lung. Educational objective:Pulmonary embolism is a potentially life-threatening medical emergency occurring when a pulmonary artery is obstructed. Common clinical manifestations include pleuritic chest pain, dyspnea, hypoxemia, tachypnea, cough, tachycardia, and unilateral leg swelling.
The school nurse assesses an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first? a. Assess the client's peak expiratory flow b. Call the HCP c. Educate the client about avoiding triggers d. Notify the client's parents
Symptoms of an asthma exacerbation include wheezing, chest tightness, dyspnea, cough (may be nocturnal, dry, or productive), and retractions. A cough is often the earliest sign of an asthma exacerbation in children. Bronchospasm leads to CO2 trapping and retention. The bronchospasm forces the client to work harder to exhale and the expiratory phase becomes prolonged. The nurse needs to further assess this client to validate the severity of the exacerbation before implementing an intervention. By assessing the client's peak expiratory flow, the nurse can determine the severity of the symptoms. The nurse will also need to assess the client's respiratory rate and lung sounds. (Option 2) Additional information is needed before notifying the HCP to determine the severity of the client's current condition. (Options 3 and 4) The client's parents do need to be notified and discuss asthma triggers with the nurse. However, these are not a priority as the client is currently symptomatic. Educational objective:The nurse must determine the severity of a client's condition before implementing an intervention. By assessing this client's peak expiratory flow, the nurse can determine the severity of the asthma symptoms.
A client's arterial blood gases (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs? Click on the exhibit button for additional information. Laboratory results pH 7.25 PO2 79 mm Hg (10.5 kPa) PaCO2 35 mm Hg (4.66 kPa) HCO3. 12 mEq/L (12 mmol/L) a. Decrease in bicarbonate reabsorption b. Decrease in RR c. Increase in bicarbonate reabsorption d. Increase in RR
The client's ABGs have low pH consistent with acidosis. If it is a primary respiratory acidosis, pCO2 would be higher. If it is metabolic acidosis, bicarbonate would be lower. Because this client has low pH coupled with low bicarbonate, the most likely diagnosis is primary metabolic acidosis. Respiratory alkalosis is the body's natural compensation for metabolic acidosis. Respiratory alkalosis is achieved by blowing more CO2 off from the system through rapid breathing. (Option 1) Decreased bicarbonate reabsorption would produce metabolic acidosis; this would occur as a compensation for primary respiratory alkalosis (decreased pCO2 and high pH). (Option 2) When the respiratory rate is decreased, pCO2 would increase, creating a respiratory acidosis; this would occur in response to a primary metabolic alkalosis. (Option 3) Increased bicarbonate reabsorption would produce metabolic alkalosis; this would occur as a compensation for primary respiratory acidosis (increased pCO2 and low pH). Educational objective:Respiratory alkalosis is the body's natural compensation for metabolic acidosis. It is achieved by blowing more CO2 off from the system through rapid breathing.
The triage nurse is assessing an unvaccinated 4-month-old infant for fever, irritability, and open-mouthed drooling. After the infant is successfully treated for epiglottitis, the parents wonder how this could have been avoided. Which response by the nurse would be most appropriate? a. It's impossible to know for sure what could have caused this episode b. Most cases of epiglottitis are preventable by standard immunizations c. We are still waiting for the formal report from the microbioligy laboratory d. There is nothing you could have done; the important thing is that your child is safe now.
The majority of cases of epiglottitis are caused by Haemophilus influenza type B (HiB), which is covered under the standard vaccinations given during the 2- and 4-month visits. Epiglottitis is rarely seen in vaccinated children. (Option 1) This statement is technically true, but it is not helpful to the parents and misses a critical teaching moment for them. (Option 3) It is reasonable to attribute the cause of the infant's epiglottitis to missing the vaccinations for Haemophilus influenza type B. (Option 4) This statement is both unhelpful and inaccurate as the child is still at risk for further preventable illness. Educational objective:Cases of epiglottitis are preventable, and parents should always be educated on the risks of foregoing vaccinations for their children.
A client was medicated with intravenous morphine 2 mg 2 hours ago to relieve moderate abdominal pain after appendectomy. The client becomes lethargic but arouses easily to verbal and tactile stimuli, and is oriented to time, place, and person. The pulse oximeter reading has dropped from 99% to 89% on room air. Which oxygen delivery device is the most appropriate for the nurse to apply? a. Nasal cannula b. Non-rebreather mask c. Simple face mask d. Venturi mask
The nasal cannula is the most appropriate oxygen delivery device to apply at this time because it is comfortable, used for the short term, inexpensive, and permits the client to eat and drink fluids. It can supply adequate oxygen concentrations of up to 44%. This client is most likely hypoventilating as a result of the opioid medication. The client is alert and oriented and able to follow directions. Because pain relief is effective according to the pain scale, the client should be able to breathe deeply through the nose, and the hypoxemia should reverse rapidly. (Option 2) The non-rebreather mask is used in emergencies, delivers high concentrations of oxygen (up to 90%-95%), requires a tight face seal, and is restrictive and uncomfortable. (Option 3) The simple face mask delivers a higher concentration of oxygen (40%-60%), is more uncomfortable and restrictive, must be removed to eat or drink, and is not appropriate at this time. It can be used if hypoxemia does not resolve. (Option 4) The Venturi mask is a more expensive device used to deliver a guaranteed oxygen concentration to clients with unstable chronic obstructive pulmonary disease. These clients cannot tolerate changes in oxygen concentration. Educational objective:The nasal cannula is an inexpensive, comfortable, low-flow oxygen delivery device capable of delivering oxygen concentrations of up to 44%. It can be used in the short term in responsive postoperative clients to treat hypoventilation and reverse hypoxemia effectively.
A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse's priority action? a. Administer 5 mg inhaled albuterol treatment to decrease inflammatory bronchoconstriction b. Administer 100% oxygen using a nonrebreather mask with flow rate of 15L/min c. Administer methyprednisolone to decrease lung inflammation from toxic inhalant d. Titrate oxygen to maintain pulse oximeter saturation of >95%
The purpose of hemoglobin (Hgb) is to pick up oxygen in the lungs and deliver it to the tissues. It must be able to pick up oxygen and release it in the right places. Carbon monoxide (CO) has a much stronger bond to Hgb than oxygen does. Consequently, CO displaces oxygen from Hgb, causing hypoxia that is not reflected by a pulse oximeter reading. The nurse's primary action is to administer highly concentrated (100%) oxygen using a nonrebreather mask at 15 L/min in order to reverse this displacement of oxygen. (Option 1) Albuterol is not a priority action as bronchoconstriction is not a consequence of CO poisoning. (Option 3) Administration of corticosteroids is not a priority/primary action as direct inflammation of the lungs is not an underlying cause for hypoxemia and hypoxia associated with CO poisoning. (Option 4) When all available Hgb binding sites are occupied (oxyhemoglobin or carboxyhemoglobin), saturation (SaO2) is 100%. The conventional pulse oximeter cannot differentiate carboxyhemoglobin from oxyhemoglobin as both absorb the oximeter's red and infrared light wavelengths. Consequently, the pulse oximeter reading may be adequate (>90%), but severe hypoxemia and hypoxia may be present. Alternate methods of CO saturation measurement (eg, multiple wavelength CO pulse oximeter, spectrographic blood gas analysis) are recommended. Educational objective:The conventional pulse oximeter is not effective in identifying hypoxia in CO poisoning; diagnosis requires co-oximetry of a blood gas sample. The priority action is to administer 100% oxygen using a nonrebreather mask to treat hypoxia and help eliminate CO.
An elderly client is admitted with chronic obstructive pulmonary disease (COPD) exacerbation. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using his accessory muscles to breathe. Which prescription should the nurse question? a. Albuterol 2.5 mg by nebulizer b. Methylprednisolone 125 mg IV now and every 6 hours c. Morphine 2 mg IV now and may repeat every 2 hours d. Oxygen at 2L/min via n/c
This client has exacerbation (wheezing) of chronic obstructive pulmonary disease (COPD). Restlessness is an early, subtle sign of hypoxemia. Although morphine can be used to decrease restlessness and slow the respiratory rate to decrease oxygen demand, it can depress respirations. Morphine and other medications (eg, benzodiazepines) that can depress the respiratory center should not be used in clients with COPD exacerbation as they can further worsen CO2 retention. The oxygen and medications should increase saturation and decrease restlessness, pulse, and respiratory rate. (Option 1) Albuterol is a beta agonist and is appropriate for the immediate relief of bronchoconstriction because of its rapid, short action. (Option 2) Methylprednisolone (Solu-Medrol) is a corticosteroid and is appropriate for decreasing inflammation of the lungs during an acute exacerbation of COPD. (Option 4) The initiation of low flow, low concentration oxygen at 2 L/min by nasal cannula is appropriate in a client with COPD. It is best to start oxygen at a lower concentration and titrate upward if the saturation does not reach 90% within 20-30 minutes as many clients with COPD rely on their hypoxemic drive to breathe. Educational objective:Morphine and other medications (eg, benzodiazepines) that can depress the respiratory center should not be used in clients with COPD exacerbation as they can further worsen CO2 retention.
