COPD with PNA

Which additional discharge instructions should the nurse include in the teaching plan to promote optimal health for the client? (Select all that apply. One, some, or all options may be correct.)

-Avoid crowds and people with infections.This is an important measure to avoid future infections. Mr. Johnson should also be encouraged to get an annual pneumonia vaccine. -Increase intake of oral fluids.Mr. Johnson needs to increase his oral fluid intake to maintain adequate hydration and keep respiratory secretions thin. -Store prescribed inhalers away from extreme heat and cold.Extreme heat and cold can alter the composition of the inhaler medication and render it ineffective

The levofloxacin 500 mg IVPB is supplied in 100 mL of 5% Dextrose to be delivered over 60 minutes. There is no IV pump available so the nurse will infuse the antibiotic by gravity. The drop factor on the tubing is 20 gtts/mL. The nurse should set the IV IVPB to infuse at how many gtts per min? (Enter numerical value only. If rounding is necessary, round to the whole number.)

33

Which statement by the nurse promotes effective communication with the client?

Acknowledge to the client that they seem upset this morning. This statement allows an opportunity for the client to clarify his feelings.

Which ethical principle is most important for the nurse to consider when responding to the family member?

Autonomy. This ethical principle refers to the individual's right to make his own decisions regarding his care. It is an important principle, which would be violated if the nurse allowed the son to play hypnosis tapes without the client's knowledge or consent.

Which intervention should the nurse initiate immediately?

Call for the rapid response team while getting resuscitation equipment in the room. This is a high priority because the client's O2 saturation is dangerously low. The rapid response team can assist with emergent interventions. The nurse should also prepare to transfer the client to the critical care unit for close monitoring.

While taking the client's blood pressure, the nurse observes the reading on the pulse oximeter to be fluctuating from 60 to 80 percent. Which action should the nurse implement to ensure accurate oxygen saturation readings with the pulse oximeter?

Assess capillary refill prior to applying the sensor. The sensor will provide the most accurate reading if circulation is adequate. At regular intervals, the nurse should assess circulation and move the sensor to a new site.

After checking the sensor site to make sure the readings are accurate, the nurse should then initiate which intervention?

Assess the client's respiratory rate and rhythm. This is an acceptable oxygen saturation level for a client with asthma. The nurse should continue a problem focused assessment which a respiratory assessessment to include the client's respiratory status and effort of breathing.

Which assessment is most important for the nurse to complete next?

Auscultate breath sounds. This is the highest priority. The client is exhibiting respiratory distress.

Which nursing diagnosis has the highest priority when the nurse is planning care for the client?

Ineffective airway clearance. There are adventitious breath sounds present, tachypnea, changes in depth of respirations, fever, and cough, which support this as a priority diagnosis. Additional priority diagnoses are impaired gas exchange and ineffective breathing patterns. Impaired gas exchange is reflected in the client's hypercapnia and hypoxia. The diagnosis of ineffective breathing pattern is supported by his tachypnea, use of accessory muscles, and changes in the depth of respiration.

What action should the nurse implement?

Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. Helping the client to the commode is an appropriate action for a UAP to perform, but this UAP requires some additional instruction and individual supervision with oxygen equipment.

Which assessment finding warrants immediate intervention by the nurse?

Kussmaul respirations Kussmaul respirations are a deep, rapid repiration that occurs when the lungs are trying to compensate for the respiratory acidosis. If not corrected, the respiratory status will worsen until an acute intervention is necessary to maintain the respirations.

What is the nurse's best response?

Listen to the client and remain silent. This is the best choice. Silence can be a very effective communication technique. The nurse should express interest nonverbally when silence is used.

While the client is undergoing nebulizer treatments with salbutamol, it is most important for the nurse to perform which assessment?

Monitor pulse and BP. Salbutamol is a beta-adrenergic agonist with a bronchodilating effect. Because adrenergic agonists mimic sympathetic stimulation, the client must be monitored carefully for cardiac arrhythmias, hypertension, nervousness, and restlessness.

Which nursing action should be implemented before the prescribed levofloxacin is administered?

Obtain a sputum culture. The sputum specimen should be obtained prior to initiation of the first dose of antibiotics. Since levofloxacin is a broad-spectrum bactericidal antibiotic, it is likely to be effective against the causative organism. Once the culture and sensitivity results are obtained, a different antibiotic may be used if necessary. Another important nursing intervention is assessment of the client for previous allergic reactions to antibiotics.

With a diagnosis of pneumonia, which assessment finding warrants immediate intervention by the nurse?

Oxygen saturation 90%. Oxygen should be applied and titrated to keep the oxygen level at 92% or higher.

These ABG results indicate that the client is experiencing which acid base imbalance?

Respiratory acidosis. The low pH indicates that acidosis is present. The elevated pCO2 indicates that the problem is respiratory in nature. Clients with any condition that depresses respirations are prone to the development of respiratory acidosis. Even though the client has a rapid respiratory rate, his underlying COPD causes the retention of CO2. pH 7.25 7.35 - 7.45 7.35 - 7.45 pCO2 58 35 - 45 mmHg 35 - 45 mmHg HCO3 26 21 - 28 mEq/L 21 - 28 mmol/L pO2 87 80 - 100 mmHg 80 - 100 mmHg

The nurse should use the five rights of delegation when working with the UAP. Which one of these rights was violated in this situation?

Right Direction/Communication. Since continuous oxygenation was a high priority for this client, the nurse's directions to the UAP should have emphasized the need for the nasal cannula to be left on the client at all times, especially during any activity. The fifth right, Right Supervision includes direction/guidance, evaluation/monitoring, and follow-up.

Which outcome statement is the best indicator that the client's pneumonia is resolved and they are ready to be discharged?

Sputum culture is negative. This is a significant indicator that the pneumonia is resolved.

After observing the client, which instruction by the nurse is most important for client teaching?

Tell the client to wait at least 5 minutes between each medication. The client should wait at least 2-5 minutes before using the second medication.

Which instruction should the nurse provide the client for an acute episode of asthma?

Use the salbutamol inhaler for acute asthma attacks. Salbutamol is a bronchodilator that is used for acute asthmatic attacks.