HESI Case study Breathing patterns 2

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

Correct Answer: B. Frequent deep cough, producing small amounts of pale yellow sputum. - This is an objective report of the nurse's observations. This documentation provides a thorough description of the cough and the sputum produced.

24. Josh and his mother return to the healthcare provider's office 1 week later, after Josh has completed the course of the antibiotic therapy. In assessing Josh's breath sounds, where should the nurse listen first? A. Lung bases. B. Lung apices. C. Aortic site. D. Pulmonic site.

Correct Answer: B. Lung apices. An accepted method for lung auscultation is to begin at the top of the chest, comparing one side of the chest to the other, moving downward in a systematic method, finishing at the lung base.

20. The patient care technician is planning 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. Place the specimen cup in a biohazard bag for transport. C. Don gloves and a gown for the best protection. D. Wash your hands after carrying the cup to the lab.

Correct Answer: B. Place the specimen cup in a biohazard bag for transport. - This protects the person transporting the specimen, as well as the lab personnel receiving the specimen.

22. The liquid cough syrup is labeled as an antitussive. The nurse explains that his 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.

Correct Answer: B. Reduce the frequency of the cough. - Antitussives are used to reduce the frequency of a cough. This may be desirable for Josh at night, to allow him to sleep.

12. 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 Josh has a latex allergy. B. Clean the sire with an iodine solution. C. "Milk" the capillary blood flow of the site. D. Apply gauze padding to protect the skin.

Correct Answer: A. Determine if Josh has a latex allergy. - 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.

19. Since Josh has a productive cough, the healthcare provider requests that a sputum specimen be obtained and sent to the lab for culture and sensitivity. In assessing Josh to obtain a sputum specimen, what action should the nurse take? A. Instruct Josh 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.

Correct Answer: A. Instruct Josh to cough deeply from the chest and spit into the specimen cup. - 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.

3. Because of Josh's dyspnea, the nurse is concerned that he may need to receive oxygen. To determine the need for the application of a nasal cannula, which assessment is most important for the nurse to perform? A. Measure oxygen saturation. B. Auscultate breath sounds. C. Measure capillary refill. D. Observe chest excursion.

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

25. The nurse auscultates vesicular breath sounds in the peripheral lung fields. What actions should the nurse take? A. Record the presence of clear breath sounds. B. Tell Josh's mother that his lungs are still congested. C. Assist Josh to cough to clear his lungs and listen again. D. Notify the healthcare provider of the abnormal lung sounds.

Correct Answer: A. Record the presence of clear breath sounds. - Vesicular Breath sounds are a normal finding in the peripheral lung fields.

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

Correct Answer: A. Restlessness & fatigue. - Restlessness and fatigue are indications of hypoxia. Restlessness is an early sign of hypoxia that is often missed.

23. The medication label states, "take 2 teaspoonfuls every 4 hours as needed." The nurse gives Josh some medication cups and teaches him and his mother how to pour the medication into the cup. To what level should the medication be poured? A. 5 ml. B. 10 ml. C. 20 ml. D. 30 ml.

Correct Answer: B. 10 ml. - Each teaspoon contains 5 ml. Two teaspoons equals 10 ml. 5 ml x 2 = 10 ml.

5. To measure capillary refill, the nurse must first perform which action? A. Count Josh's radial pulse. B. Compress Josh's nailbed. C. Obtain a healthcare provider's prescription. D. Elevate the extremity to be assessed.

Correct Answer: B. Compress Josh's nailbed. - To measure capullary refill, the nurse should first compress the client's nailbed, and the observe the return of normal color to the nail bed.

7. The nurse measures Josh's oxygen saturation at 88% and capillary refill is at 1 second. Breath sounds are absent in the base and coarse bilaterally throughout the rest of the lung fields. The nurse applies a nasal cannula and administers oxygen at 2 liters per minute. When applying a nasal cannula, it is most important for the nurse to provide which instructions? A. Make sure the cannula tubing stays snugly around the ears and under the chin. B. Remind client and family that oxygen is combustible and must be kept 10 feet away from open flames. C. Make sure the humidifier always contains some water. D. Keep some type a padding around the ears and over the cheekbones.

Correct Answer: B. Remind client and family that oxygen is combustible and must be kept 10 feet away from open flames. - Oxygen supports combustion and is essential to ensure client safety during oxygen administration.

15. After further conversation with Josh'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-cliet relationship? A. Teaching Josh and his mother how to read the oximeter. B. Returning to the room at the time promised. C. Offering the mother reassurance that Josh is stable. D. Providing a phone so that Josh's mother can call home.

Correct Answer: B. Returning to the room at the time promised. - Trust and rapport is important to develop during the orientation stage so the client has the most optimal outcome.

26. Which serum lab value confirms the resolution of Josh's infection? A. Red blood cell count (RBC) 4.5 million/mm^3. B. White blood cell count (WBC) 6,000/mm^3. C. Hemoglobin at 12g/dl. D. Hematocrit at 40%.

Correct Answer: B. White blood cell count (WBC) 6,000/mm^3. - This is a normal value for a child, confirming the resolution of the infection. Infection generally causes an elevation in the WBC.

6. The nurse plans to measure Josh's oxygen saturation with a spring-tension finger clip. While the nurse is explaining this procedure, Josh asks if it will hurt. Which response is best for the nurse to provide? 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 squeezing your finger with your other hand." D. "You seem to be worried about experiencing pain."

Correct Answer: C. "The clip feels like squeezing your finger with your other hand." - This is an honest response to Josh's question regarding pain and one that places the sensation he will feel in a context he can understand.

8. Which nursing diagnosis is most relevant to Josh's current status? A. Excess fluid volume. B. Impaired spontaneous ventilation. C. Impaired gas exchange. D. Decreased cardiac output.

Correct Answer: C. Impaired gas exchange. - Normal saturation is 95-100%. Josh's oxygen saturation is well below normal, indicating that his gas exchange is impaired.

2. Josh's respiratory rate is 36. How should the nurse describe Josh's respiratory pattern? A. Eupnea. B. Bradypnea. C. Tachypnea. D. Orthopnea.

Correct Answer: C. Tachypnea. - A rapid respiratory rate, which is consistent with Josh's rate of 36. Normal respiratory rate for a school-aged child is 16 to 30 breaths per minute.

11. Which outcome statement should the nurse use for Josh's plan of care? A. The client will receive oxygen at 2 L/minute per nasal cannula. B. The client's oxygen saturation will be monitored continuously. C. The client's oxygen saturation will be > 95% on room air. D. The client's respiratory function will be stable.

Correct Answer: C. The client's oxygen saturation will be > 95% on room air. - This client-centered outcome statement describes the desired outcome in measurable terms.

21. The healthcare provider determines that Josh has a respiratory tract infection and prescribes an oral antibiotic and an oral liquid cough syrup. Josh's mother obtains the medications at the pharmacy and shows them to the nurse. The prescription for the antibiotic reads, "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."

Correct Answer: D. "A large first dose allows the medication to start working faster." - A large first dose, called a loading dose, is often used to achieve a therapeutic level more rapidly in the blood stream.

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

Correct Answer: D. "It sounds like this has been a very frightening experience for you." - This open-ended statement acknowledges the difficult situation the mother is experiencing and encourages further discussion.

4. In assessing Josh's breath sounds, the nurse should ask him to perform which action? A. Hold his breath for fifteen seconds. B. Repeat the phrase "Ninety-nine." C. Cough deeply after each breath. D. Breathe deeply through the mouth.

Correct Answer: D. Breathe deeply through the mouth. - Josh should be instructed to breathe slowly and deeply through a slightly opened mouth to allow the best auscultation of breath sounds.

16. Upon returning to the room, the nurse assesses Josh's cough. Which documentation reflects subjective data? A. Client's respirations are 36/minute. B. Client appears to be very anxious. C. Client's mother is present in the room. D. Client reports that he is coughing a lot.

Correct Answer: D. Client reports that he is coughing a lot. Subjective data is the information reported by the client.

18. Upon further observation the nurse describes Josh's sputum as "Tenacious." To what does this refer? A. Color. B. Odor. C. Frequency. D. Consistency.

Correct Answer: D. Consistency. - Sputum with a thick consistency may be described as "Tenacious" (sticking together).

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

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

1. The nurse assesses Josh's vital signs. His respirations are rapid and shallow. What is the best technique for the nurse to use to assess Josh's respirations accurately? A. Observe the chest expansions for 15 seconds and multiply by 4. B. Encourage Josh to breathe as deeply and slowly as possible. C. Watch for nasal flaring and count the air exchanges with each movement. D. Place a hand on Josh's chest and count the hand motion.

Correct Answer: D. Place a hand on Josh's chest and count the hand motion. - This technique allows the nurse to observe and count the chest movement, even when respirations are shallow.

13. After receiving oxygen for a short while, Josh is much less dyspneic. The nurse notes that the oxygen saturation is reading 97%. Fifteen minutes later, the oxygen saturation alarm indicates that the reading has changed to 80%. What immediate action(s) should the nurse implement? (Select all that apply.) A. Reposition the finger clip and obtain another reading. B. Assess Josh for signs and symptoms of respiratory distress. C. Encourage Josh to begin coughing and deep breathing. D. Increase the oxygen flow to 3-4 liters/minute. E. Notify the healthcare provider immediately.

Correct Answers: A. Reposition the finger clip and obtain another reading. - Since Josh is not in any distress, the nurse should first reapply the clip and obtain another reading to confirm the sudden drop in oxygenation. B. Assess Josh for signs and symptoms of respiratory distress. - Assessment for signs and symptoms of respiratory distress is a priority. C. Encourage Josh to begin coughing and deep breathing. - Coughing helps to clear mucous from airway which will allow for optimal lung expansion.

Case outcome

Josh is discharged from his healthcare provider's care and is happy to resume his normal activities with no further cough or dyspnea.