HESI Case Study - Week 1: COPD

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? -Relay to the client that the charge nurse will instruct the night staff to keep the door closed at night. -Acknowledge to the client that they seem upset this morning. -Ask the client why they are feeling so angry. -Offer to warm up the client's breakfast tray or order a fresh one.

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

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? -Place the extremity to which the sensor is attached at heart level. -Assess capillary refill prior to applying the sensor. -Lower the lighting in the room. -Remove the sensor when taking the B/P.

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? -Decrease the oxygen to 4 L/minute per nasal cannula. -Elevate the head of the bed to a high-Fowler's position. -Remove the pulse oximeter to reduce anxiety. -Assess the client's respiratory rate and rhythm. Submit

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

Section 1: Assessment The physical examination reveals the following: Vital signs: temperature 101.6° F (38.6o C), heart rate 110 beats/minute, respirations 32 breaths/minute, blood pressure 132/78 mmHg. Respirations shallow and labored, with use of respiratory accessory muscles. Increased anteroposterior (AP) diameter of the chest. Skin dry and warm to touch, with inelastic skin turgor, and fingernail clubbing present. Which assessment is most important for the nurse to complete next? - Auscultate breath sounds. - Listen to heart sounds.. - Check for peripheral edema. - Assess capillary refill.

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

Ethical-Legal Considerations As the client's condition improves, family member expresses concern that the client will continue to smoke. The family member asks the nurse if anti-smoking hypnosis tapes could be played during the night while the client is asleep. Which ethical principle is most important for the nurse to consider when responding to the family member? Veracity. Beneficence. Autonomy. Nonmaleficence.

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 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.) Decrease physical activity. Avoid crowds and people with infections. Increase intake of oral fluids. It is all right to go outside anytime. Instruct on effective breathing techniques.

Avoid crowds and people with infections. This is an important measure to avoid future infections. The client should also be encouraged to get an annual pneumonia vaccine. Increase intake of oral fluids. The client needs to increase their oral fluid intake to maintain adequate hydration and keep respiratory secretions thin. Instruct on effective breathing techniques. Client and family need to understand effective pursed lip breathing which provides internal stability to the airways.

A Complication Occurs The client's oxygen saturation level returns to 91% after the nurse reapplies the nasal cannula. The remainder of the day is uneventful, and the client's evening vital signs are temperature 99° F (37.2o C), heart rate 84 beats/minute, respirations 22 breaths/minute, blood pressure 130/78 mmHg. Lung sounds remain diminished, but the crackles are less audible, and the client is producing only minimal clear sputum.During the night, the client calls the nurse to report a sudden inability to catch his breath. Upon assessment, the nurse notes that the client's respiratory rate has increased to 40 breaths/minute with obvious dyspnea, and O2 saturation reading of 55%. The client's pulse is 110 beats/minute, weak and thready, and blood pressure is 70/40 mmHg. Which intervention should the nurse immediately initiate? -Call for the rapid response team while getting resuscitation equipment in the room. -Remove the nasal cannula and place the client on 100% non-rebreather. -Initiate the cardiac resuscitative responsive team. -Set up the cardiac monitor for defibrillation at 200 joules if directed by the RN rapid response team leader.

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.

Which nursing problem has the highest priority when the PN is assisting the RN in planning care for the client? Nutritional deficit. Altered mobility. Decreased fluid volume. Inability to clear the airway.

Inability to clear the airway. There are adventitious breath sounds present, tachypnea, changes in depth of respirations, fever, and cough, which supports this as a priority problem. Additional priority problems are altered gas exchange and change in normal breathing patterns. Altered gas exchange is reflected in the client's hypercapnia and hypoxia. The problem of change in normal breathing pattern is supported by his tachypnea, use of accessory muscles, and changes in the depth of respiration.

Delegation and Supervision Later that morning, the unlicensed assistive personnel (UAP) helps the client transfer to the bedside commode. After the client is back in bed, the nurse enters the room and observes that the client's oxygen saturation level is 85% and that they are not wearing the nasal cannula. The client states that the cannula tubing wouldn't reach all the way to the commode, so the UAP removed it. What action should the nurse implement? -Report the UAP to the charge nurse for performing an act that was not allowed. -Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. -Tell the UAP to obtain assistance next time from the respiratory therapist. -Assign the UAP to a different client.

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 focused assessment finding warrants immediate intervention by the nurse? Kussmaul respirations Blood pressure 90/50 mmHg Onset of drowsiness Anorexia

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

In response to the nurse's effective communication, the client tells the nurse he blames the cigarette companies for his COPD. The client does not believe that these companies properly warned people about the dangers of smoking. The client states that if they get cancer they will sue the cigarette companies. What is the nurse's best response? -Tell the client that not everyone who smokes gets cancer. -Relay your personal struggle with smoking cessation. -Direct the client to focus on getting better. -Listen to the client and remain silent.

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 albuterol/salbutamol, it is most important for the nurse to perform which focused assessment? Monitor pulse oximeter readings. Monitor respiratory rate. Monitor pulse and BP. Monitor temperature.

Monitor pulse and BP. Albuterol/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? Auscultate lung sounds. Assess oral intake. Obtain a sputum culture. Assist client to the bathroom.

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 focused assessment finding warrants immediate intervention by the nurse? - Oxygen saturation 90%. - BP of 132/78 mm/Hg. - Heart rate 120 beats/minute. - Inelastic skin turgor.

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

Arterial Blood Gas (ABG) Analysis Arterial Blood Gases were obtained with the following results: Normal Conventional Value Normal SI Unit Value 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

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.

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 Task. Right Circumstance. Right Person. Right Direction/Communication.

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. Levafloxacin peak and trough levels are within normal limits. Oxygen saturation level is 92%. Clear sputum.

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? Select all that apply Instruct to do the beclomethasone first, followed by the salmeterol. Explain that using a spacer reduces medication absorption. Tell the client to wait at least 2-5 minutes between each medication. Teach the client to wait at least 2 minutes between each puff of the same medication.

Tell the client to wait at least 2-5 minutes between each medication.

Which instruction should the nurse provide the client for an acute episode of asthma? -Administer the beclomethasone as soon as possible. -Use the albuterol/salbutamol inhaler for acute asthma attacks. -Call healthcare provider before taking any medication. -Take an extra dose of salmeterol.

Use the albuterol/salbutamol inhaler for acute asthma attacks. Albuterol/salbutamol is a short-acting bronchodilator that is used for acute asthmatic attacks.