HESI: Breathing Patterns
The med label states, "Take 2 tsp every 4hrs as needed." The nurse gives Josh some medication cups and teaches him and his mother how to pour medication into the cup. To what level should the medication be poured? A) 5 ml B) 10 ml C) 20 ml D) 30 ml
10 mL Rationale: 1 tsp = 5 ml
After determining priority nursing diagnoses, what step should the nurse take next in developing 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
Establish goals and expected outcomes- Rationale: after analysis of data to prioritize nursing diagnoses, the nurse should establish nursing care goals and expected outcomes.
After receiving O2 for a short while, Josh is much less dyspneic. The nurse notes that the O2 sat: 97%. 15 min later, O2 sat alarm indicates reading changed to 80%. What immediate action(s) should 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 3-4L/min. E) Notify the healthcare provider immediately.
-Reposition the finger clip and obtain another reading-since he is not in distress (reapply to confirm sudden drop in O2 sat) -Assess Josh for S/S resp distress-priority -Encourage Josh to begin coughing and deep breathing- coughing helps to clear mucous from airway which will allow for max lung expansion Rationale: Since Josh is not in any distress, the nurse should first reapply the clip and obtain another reading to confirm the sudden drop in oxygentation. Assessment for signs and symptoms of respiratory distress is a priority. Coughing helps clear mucous from airway which will allow for optimal lung expansion.
HCP determines Josh has respiratory tract infection and prescribes oral abx and oral liquid cough syrup. Josh's mother obtains meds at pharmacy and shows them to the nurse. The prescription for abx reads, "Take 2 pills for 1st 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) "2 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."
"A large first dose allows the medication to start working faster." Rationale: A large first dose, called a loading dose, is often used to achieve a therapeutic level more rapidly in the bloodstream.
After nurse repositions the finger clip and O2 sat: 97%. Despite normal reading, Josh's mother appears worried/nervous "He's never been sick. I am so scared." To encourage the mother to share more about her feelings, how should 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."
"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. Rationale: This open-ended statement acknowledges the difficult situation the mother is experiencing and encourages further discussion.
The nurse plans to measure Josh's O2 saturation w/spring- tension finger clip. While nurse explains procedure, Josh asks if it will hurt. Which response is best for 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."
"The clip feels like squeezing your finger with your other hand"-- Rationale: 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.
In assessing Josh's breath sounds, the nurse should ask him to perform which action? A) Hold his breath for 15 seconds B) Repeat the phrase, "Ninety-nine" C) cough deeply after each breath D) Breath deeply through the mouth
Breathe deeply through the mouth- Rationale: Josh should be instructed to breath slowly and deeply through a slightly opened mouth to allow best auscultation of breath sounds.
Upon returning to the room, the nurse asseses Josh's cough. Which documentation is subjective data? A) Client's respiration are 36/min. 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.
Client reports that he is coughing a lot Rationale: Subjective data is the information reported by the client
Which outcome statement should nurse use for Josh's plan of care? A) The client will receive O2 at 2L/min per nasal cannula. B) The clients O2 saturation will be monitored continuously. C) the clients O2 saturation will be >95% on room air. D) The clients respiratory function will be stable.
Client's O2 saturation will be >95% on room air- Rationale: the client-cented outcome statement describes the desired outcome in measurable terms
To measure capillary refill, the nurse must 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
Compress Josh's nailbed- Rationale: to measure capillary refill, the nurse should first compress the client's nailbed and then observe the return of normal color to the nailbed.
Upon further observation the nurse describes Josh's sputum as "Tenacious." To what does this refer? A) Color B) Odor C) Frequency D) Consistency
Consistency- Rationale: sputum w/ thick consistency may be described as "tenacious"(sticking together)
To achieve the desired outcome, nurse has initiated the prescribed O2 therapy. After applying nasal cannula, nurse plans to attach a disposal sensor pad to meausure the O2 sat continuously. What action should nurse implement prior to applying the sensor? A) determine is Josh has 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.
Determine if Josh has a latex allergy-disposable pads may be made of latex- Rationale: 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 documentation best reflects 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 anxous and short of breath, as he has a constant productive cough. D) Cough is frequent, and the client produces some yellow sputum when he coughs.
Frequent deep cough, producing SMALL amounts of PALE YELLOW sputum- Rationale: objective report-w/documentation of thorough description of the cough and sputum produced.
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
Impaired gas exhcange-Normal (95-100%)- Rationale: normal saturation is 95-100%. Joshs O2 saturation is well below normal, indicating that his gas exchange is impaired.
Since Josh has a productive cough, HCP requests sputum specimen be optained and sent to lab for culture and sensitivity. In assisting Josh to obtain a sputum specimen, what action should nurse take? A) Instruct Josh to cough deeply from the chest and spit into the specimen cup. B) Gently wipe a sterile-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.
Instruct Josh to cough deeply from chest and spit into speciment cup- Rationale: this technique is the least invasive and will provide sputum rather than mucus. Client who is alert, able to follow instructions and has productive cough can obtain a specimen without invasive catheter.
Josh and his mother return to HCP office 1 week later, after Josh completed course of abx therapy. In assessing Josh's breath sounds, where should nurse listen first? A) lung bases B) lung apices C) Aortic site D) pulmonic site
Lung apices- Rationale: 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.
Because of Josh's dyspnea, the nurse is concerned he may need to receive O2. To determine the need for application of a nasal cannula, which assessment is most important or the nurse to perform? A) Measure oxygen saturation B) Auscultate breath sounds C) Measure capillary refill D) Observe chest excursion
Measure O2 saturaion- Rationale: Oxygen saturation provides important data about the percentage of hemoglobin that is saturate with oxygen- a valuable reflection for the client's overall oxygenation.
The nurse assesses Josh's vital signs. His respiration are rapid and shallow. What is the best technique for the nurse to use to asses Josh's respirations accurately? A) Observe chest expansion for 15 seconds and multiply by 4. B) Encourage Josh to breath 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.
Place a hand on Josh's chest and count the hand motion- Rationale: This technique allows the nurse to observe and count the chest movement, even when respirations are shallow
After further conversation with Josh's mother, the nurse needs to leave the the room to assess another client. Which action by the nurse demonstrates the use of trust in the nurse-client 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.
Returning to the room time as promised- Rationale: trust and rapport is important to develop during the orientation stage so the client has the most optimal outcome
The patient care technician is planning to transport sputum to the lab. What instructions should 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.
Place specimen cup in biohazard bag for transport Rationale: this protects person transporting specimen, as well as the lab personnel receiving the specimen
Nurse auscultates vesicular breath sounds in the peripheral lung fields. What action should nurse take? A) Record the presence of clear breath sounds B) Tell Josh's mother that his lungs are sill congested C) Assist Josh to cough to clear his lungs and listen again. D) Notify the HCP of the abnormal lung sounds
Record presence of clear breath sounds- Rationale: vesicular breath sounds are a normal finding in peripheral lung fields
The liquid cough syrup is labeles as an antitussive. The nurse explains this 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
Reduce the frequency of the cough- Rationale: antitussives are used to reduce the frequency of a cough. This may be desirable for Josh at night, to allow him to sleep
Nurse measures O2 sat: 88% and capillary refill at 1sec. Breath sounds are absent in base and coarse bilaterally throughout rest of the lung fields. Nurse applies a nasal cannula and administers O2 at 2L/min. When applying nasal cannula, it is most important for nurse to provide what 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 of padding around the ears and over the cheekbones.
Remind client and family that O2 is combustible and must be kept 10ft from open flames- Rationale: Oxygen supports combustion and is essential to ensure client safety during oxygen administration.
Which assessment finding further supports diagnosis? A) Restlessness & fatigue B) skin is warm and flushed C) Complaints of being thirsty D) BP of 102/62
Restlessness and fatigue- Rationale: These are indications of hypoxia. Restlessness is an early sign of hypoxia that is often missed.
Josh's respiratory rate is 36. How should the nurse describe Josh's respiratory pattern? A) Eupnea B) Bradypnea C) Tachypnea D) Orthopnea
Tachypnea- Rationale: rapid respiratory rate, which is consistent with his rate of 36. Normal RR for a school-aged child is 16-30 breaths/min.
Which serum lab value confirms resolution of Josh's infection? A) RBC 4.5 million/mm3 B) WBC 6,000/mm3 C) hemoglobin at 12 g/dl D) Hematocrit at 40%
WBC 6,000/mm3- Rationale: This is a normal value for a child, confirming the resolution of the infection. Infection generally causes an elevation in the WBC's.