Week 1 Breathing Pattern Case Studies

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

A Restlessness and fatigue are signs of hypoxia. And restlessness is an early sign of hypoxia that's usually missed. Hypoxia is absence of oxygen.

Which nursing diagnosis is most relevant to James' current status? A. Excess fluid volume. B. Inability to sustain spontaneous breathing. C. Impaired gas exchange. D. Decreased cardiac output.

C because Jame's oxygen was below the normal (95-100%)

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

C because it's an outcome STATEMENT and is MEASUREABLE

The nurse plans to measure James' oxygen saturation with a spring-tension finger clip. While the nurse is explaining this procedure, James 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."

C because you're being honest, but realistic, but also not worrying Jame's too much.

James' respiratory rate is 36 breaths/min. How should the nurse describe James' respiratory pattern? A. Eupnea. B. Bradypnea. C. Tachypnea. D. Orthopnea.

C Bradypnea = low respiratory rate Tachypnea = high respiratory rate Eupnea (normal respiratory rate) = 12-16 breaths/min Orthopnea = Difficulty breathing while lying flat. Jame's is high with a 36 breaths/min.

After the nurse repositions the finger clip, the oxygen saturation reading returns to 97%. Despite the normal reading, James' mother appears worried and nervous and states, "James has never been sick. I am so scared." To encourage the mother to share more about her feelings, how should the nurse respond? A. "James 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."

D You're being considerate

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 James for any changes. C. Implement the priority nursing actions. D. Establish goals and expected outcomes.

D because ADPIE! after diagnosis is planning so that means make goals and have outcomes!

In assessing James' breath sounds, the nurse should ask him to perform which action? A. Hold his breath for fifteen seconds. B. Observe the color of the nailbeds and lips. C. Cough deeply after each breath. D. Breathe deeply through the mouth.

D because you when Jame's to do an ACTION! Coughing won't work because that's to find something with the spirometer, and nailbeds is not an action.

*When applying a nasal cannula in the ED, what 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 Because electrical park leads to fire, and a fire decreases oxygen, and for a patient who needs air needs to breath

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. Obtain a healthcare provider's prescription. D. Elevate the extremity to be assessed.

B From class, ya know

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 James 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 because you don't want Jame's to have MORE problems with an allergy that could be worst. (like Dua) NOT B because this is a "non-invasive" procedure so there's no break in the skin or cuts that need to be cleaned. NOT C because milking capillary blood flow is use to measure capillary blood sample for glucose, NOT oxygen saturation stuff.

Because of James' dyspnea, the nurse is concerned that he may need to receive oxygen. To determine the need for supplemental oxygen, 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.

A - because it's a valid way of measuring! It measures the percentage of hemoglobin that's saturated in the oxygen. NOT B because auscultating is hearing the sound- and that's not very accurate. NOT C because that's to see if you can put that machine on your finger. NOT D because that's a basic measurement, and we can do better.

After receiving oxygen for a short while, James 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%. What immediate actions should the nurse implement? Select all that apply A. Reposition the finger clip and obtain another reading. B. Assess James for signs and symptoms of respiratory distress. C. Encourage James to begin coughing and deep breathing. D. Increase the oxygen flow to 3 to 4 L/min. E. Notify the HCP immediately.

A, B, & C A & B are both needed assessments before doing anything. C is coughing that encouraged things to come out so Jame's has a clear airway and can breathe better.

The nurse measures James' 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 applies a nasal cannula and administers oxygen at 2 liters per minute. 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. Check that the openings in the nasal prongs are aimed into the nose to prevent skin breakdown. C. Never allow the humidifier to run out of water. D. Keep some type of padding around the ears and over the cheekbones.

B

James' mother states that this is the third time in recent months she has brought him to the ED with a cough and shortness of breath. The nurse asks the mother how many respiratory or other infections James has had within the past year. Why does the nurse ask this? 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

Assessment SkillsThe nurse assesses James' vital signs. His respirations are rapid and shallow. Which is the best technique for the nurse to use to assess James' respirations accurately? A. Observe chest expansion for 15 seconds and multiply by 4. B. Encourage James 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 James' upper abdomen and observe the rise and fall of the ches

D