Elsevier Case studies

Which documentation reflects subjective data? A. James appears anxious by repeatedly reaching for his mother's hand and asks, "Am I going to be okay?" B. James' mother is present in the room. C. James reports that he is coughing a lot. D. James' respirations are 36 breaths/min.

C. James reports that he is coughing a lot. Subjective data is the information reported by the client.

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 capillary refill B. Auscultate breath sounds C. Measure oxygen saturation D. Observe chest excursion

C. 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.

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

To encourage the mother to share more about her feelings, how should the nurse respond? A. "It sounds like this has been a very frightening experience for you." B. "James will be just fine. You don't need to worry." C. "I worried just like you when my son was sick." D. "Perhaps you would rather wait outside."

A. "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.

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

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

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

A. Breathe deeply through the mouth. James should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breath sounds.

Which is the most important approach for the nurse to use when applying a nasal cannula? A. Check that the openings in the nasal prongs are aimed into the nose to prevent t skin breakdown. B. Never allow the humidifier to run out of water. C. Ensure the cannula tubing stays snugly around the ears and under the chin. D. Keep some type of padding around the ears and over the cheekbones.

A. Check that the openings in the nasal prongs are aimed into the nose to prevent t skin breakdown. This is the most important action to take when applying a nasal cannula.

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

A. Consistency. Sputum with a thick consistency may be described as "tenacious" (sticking together).

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. Apply gauze padding to protect the skin. D. "Milk" the capillary blood flow of the site.

A. Determine if James 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.

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

B. Impaired gas exchange. Normal saturation is 95 to 100%. James's oxygen saturation is well below normal, indicating that his gas exchange is impaired.

When applying a nasal cannula in the Ed, what actions most important for the nurse to implement to ensure client safety? A. Determine that all electrical equipment in the room is functioning correctly and is properly grounded. B. Use aseptic technique to prevent contamination when applying the cannula. C. Use petroleum gel on the cannula prongs to prevent irritating the nostrils. D. ensure the bed is in low position and the call light is within reach.

A. Determine that all electrical equipment in the room is functioning correctly and is properly grounded. An electrical sparking the presence of oxygen can result in a serious fire.

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

A. 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.

The 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. Place a hand on James' upper abdomen and observe the rise and fall of the chest. 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. Observe chest expansion for 15 seconds and multiply by 4.

A. Place a hand on James' upper abdomen and observe the rise and fall of the chest. This technique allows the nurse to observe and count each ventilatory cycle, even when respirations are shallow.

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

A. Restlessness and fatigue. Restlessness and fatigue are indications of hypoxia. restlessness is an early sign of hypoxia that is often missed.

James' mother states that this is the third time in recent months she has brought him to the ED with a cough and SOB. The nurse asks the mother how many respiratory infections James has had w/ in the past year/. Why does the nurse ask this? A. To assess for a possible immune deficiency disorder. B. To explore the need for a primary care provider to avoid ED visits. C. To explore the possibility of antibiotic resistance developing. D. To assess for suspected child neglect or abuse.

A. To assess for a possible immune deficiency disorder. Preschool and school-aged children may have 6 to 12 infections per year. The clinical hallmark of immune deficiency is a tendency to develop unusual or recurrent, severe infections.

When assisting James obtain a sputum specimen, what action should the nurse take? A. Gently wipe a sterile, cotton-tipped applicator along the back of the oropharynx. B. Instruct James to cough deeply from the chest and spit into the specimen cup. C. Insert a soft-tipped catheter through the nares to suction secretions. D. Use a hard-tipped Yankauer catheter device to remove oral secretions.

B. Instruct James 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.

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

B. James' oxygen saturation will be greater than 95% on room air. This client-centered outcome statement describes the desired outcome in measurable terms.

Which action be the nurse demonstrates the use of trust in the nurse-client relationship? A. Offering he mother reassurance that James is stable. B. Returning to the room at the time promised. C. Teaching James and his mother how to read the oximeter. D. Providing a phone so that James' mother can call home.

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

The client-care technician plans to transport the sputum specimen to the lab. Which instructions should the nurse provide? A. Wash hands after carrying the cup to the lab. B. Wear clean gloves to place the specimen cup in a biohazard bag for transport. C. Wear gloves and a gown for the best protection. D. Wear clean gloves to carry the specimen to the lab.

B. Wear clean gloves to 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.

To measure capillary refill, the nurse must first perform which action? A. Elevate the extremity to be assessed. B. Obtain a healthcare provider's prescription. C. Compress the nailed of one finger until it blanches. d. Count the radial pulse rate.

C. Compress the nailbed of one finger until it blanches. To measure capillary refill, the nurse should first compress the client's nailbed, then note how many seconds it takes for the return of normal color to the naibled.

James' mother further states that she is worried her 2 year old daughter at home may also become ill. What is an appropriate and therapeutic response to the mother's concern about her daughter? A. "She is young enough that she will not be as ill as her brother. There is nothing serious to worry about." B. "She will be protected from illness if she has had allergy her scheduled vaccinations." C. "There is a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms." D. "If you breastfed your daughter, she will have natural immunity."

C. "There is a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms." viral infections can spread form person to person by droplets form sneezing or coughing and by direct contact. Colds are most contagious in the first 2 to 3 days after symptoms appear, so the sibling is at risk and the mother should be informed.

Which response is best for the nurse to provide? A. "You seem to be worried about experiencing pain." B. "Yes, but the pain will only last a very short time." C. "No, you will not even know the clip is on your finger." D. "The clip feels like squeezing your finger with your other hand."

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

The HCP prescribes a complete blood count (CBC) as a part of the diagnostic workup on James. Which is the best explanation of the HCP's prescriptions? A. Sickle cell anemia is suspected and must be identified by a CBC to begin treatment. B. A CBC is obtained so that the HCP can rule out the possibility of appendicitis. C. Anemia is suspected, so a CBC is drawn to measure hemoglobin and hematocrit. D. A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults.

D. A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults. The HCP is concerned that James may have pneumonia.

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

D. Tachypnea A rapid respiratory rate, which is consistent with James's rate of 36 breaths/min. Normal respiratory rate for a school-aged child is 16-30 breaths/min.

Meet the Client: James Harrison

James Harrison, a 9-yr old male, is brought to the Emergency Department (ED) by his mother because he is short of breath and unable to sleep, due to coughing.

Pulse Oximetry

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.