HESI Case Study: COPD with Pneumonia

Oxygen Saturation and Therapy Continuous monitoring of the client's oxygen saturation indicates readings ranging between 92% and 93%. Normal oxygen saturation for a healthy adult ranges between 98% and 100%. After checking the sensor site to make sure the readings are accurate, the nurse should then initiate which intervention? a. Decrease the oxygen to 4 L/minute per nasal cannula. b. Elevate the head of the bed to high-Fowler position. c. Remove the pulse oximeter to reduce anxiety. d. Assess the client's respiratory rate and rhythm.

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

Assessment: The physical examination reveals the following: Vital signs: temperature 101.6° F (38.6° 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? a. Auscultate breath sounds b. Listen to heart sounds. c. Check for peripheral edema. d. Assess capillary refill.

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

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 IVPB to infuse at how many gtts per min? (Enter numerical value only. If rounding is necessary, round to the whole number.)

33

Therapeutic Communication The next morning, the client is scowling and complains that breakfast is cold, family has not yet been to visit, and it was so noisy during the night that sleep was impossible. The client seems angry, and the nurse recognizes that the client may be using displacement of the anger as a defense mechanism. Which statement by the nurse promotes effective communication with the client? a. Tell the client that the charge nurse will instruct the night staff to keep the door closed at night. b. Acknowledge to the client that they seem upset this morning. c. Ask the client why they are feeling so angry. d. Offer to warm up the client's breakfast tray or order a fresh one. In response to the nurse's therapeutic communication, the client tells the nurse that he blames the cigarette companies for his asthma and COPD. The client does not believe that these companies properly warned people about the dangers of smoking. The client states that if he gets cancer, he will sue the cigarette companies.

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

While taking the client's blood pressure (BP), the nurse observes the reading on the pulse oximeter to be fluctuating from 60% to 80%. Which action should the nurse implement to ensure accurate oxygen saturation readings with the pulse oximeter? a. Place the extremity to which the sensor is attached at heart level. b. Assess capillary refill prior to applying the sensor. c. Lower the lighting in the room. d. Remove the sensor when taking the BP.

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.

Ethical-Legal Considerations As the client's condition improves, a 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? a. Veracity. b. Beneficence. c. Autonomy. d. Nonmaleficence.

Autonomy. Autonomy refers to the individual's right to make their own decisions regarding care. This important principle would be violated if the nurse allowed the family member to play hypnosis tapes without the client's knowledge or consent. An appropriate therapeutic response that will maintain open communication would be "Yes, hypnosis tapes could be played if the client desires to do that." This response validates the client's autonomy and does not discourage communication with the family member.

Which additional discharge instructions should the nurse include in the teaching plan to promote optimal health for the client? Select all that apply a. Decrease physical activity. b. Avoid crowds and people with infections. c. Increase intake of oral fluids. d. It is safe to go outside anytime. e. Notify the healthcare provider (HCP) if symptoms are not relieved. Case Outcome The client responds well to discharge teaching and is able to "teach back" to demonstrate his understanding. The client is successfully discharged home accompanied by family. Three months later, the client visits the nurses on the medical unit. He proudly tells them that he has decreased cigarette use to ½ pack per day.

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 should be encouraged to increase oral fluid intake to maintain adequate hydration and keep respiratory secretions thin. Notify the healthcare provider (HCP) if symptoms are not relieved. If symptoms are not relieved, the client should notify the HCP.

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. The client's evening vital signs are: temperature 99° F (37.2° C), heart rate 84 beats/minute, respirations 22 breaths/minute, and 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 has lowered to 55%. The client's pulse is 110 beats/minute, weak and thready, and blood pressure is 70/40 mmHg. Which intervention should the nurse initiate immediately? a. Call for the rapid response team while getting resuscitation equipment in the room. b. Remove the nasal cannula and place the client on 100% nonrebreather. c. Initiate the cardiac (code) team. d. Set up the cardiac monitor for defibrillation at 200 joules. The client is transferred to the medical intensive care unit where he is treated for acute respiratory distress syndrome (ARDS). The client spends a week in the medical intensive care unit where he is successfully treated with mechanical ventilation support and vasopressor medication for the hypotension. The client is in stable condition when transferred back to the medical-surgical unit.

Call for the rapid response team while getting resuscitation equipment in the room. This is an immediate 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.

Based on the assessment data and medical diagnosis of pneumonia, the nurse develops the client's plan of care and selects several nursing problems and interventions. Which nursing problem has the highest priority when the nurse is planning care for the client? a. Imbalanced nutrition, less than body requirements. b. Impaired physical mobility. c. Deficient fluid volume. d. Ineffective airway clearance.

Ineffective airway clearance. Adventitious breath sounds are present, as well as tachypnea, changes in depth of respirations, fever, and cough, which all support this priority problem. Additional priority problems are impaired gas exchange and ineffective breathing pattern. Impaired gas exchange is reflected in the client's hypercapnia and hypoxia. Ineffective breathing pattern is supported by tachypnea, use of accessory muscles, and changes in the depth of respirations.

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 he is not wearing the nasal cannula. The client states that the cannula tubing wouldn't reach the commode, so the UAP removed it. Which action should the nurse implement? a. Report the UAP to the charge nurse for performing an act that was not allowed. b. Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. c. Tell the UAP to obtain assistance in the future from the respiratory therapist. d. Assign the UAP to a different client.

Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. Assisting the client to the commode is an appropriate action for a UAP, but this UAP requires additional instruction and supervision with oxygen equipment.

Which assessment finding warrants immediate intervention by the nurse? a. Kussmaul respirations. b. Blood pressure 90/50 mmHg. c. Onset of drowsiness. d. Anorexia.

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

What is the nurse's best response? a. Tell the client that not everyone who smokes gets cancer. b. Relay your personal struggle with smoking cessation. c. Direct the client to focus on getting better. d. 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 expresses interest nonverbally when silence is used.

While the client is undergoing nebulizer treatments with albuterol, which assessment is it most important for the nurse to perform? a. Monitor pulse oximeter readings. b. Monitor respiratory rate. c. Monitor pulse and blood pressure. d. Monitor temperature.

Monitor pulse and blood pressure. Albuterol 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.

Medication Administration The client is admitted to a room on the medical nursing unit and the healthcare provider (HCP) prescribes the following: Bed rest with bedside commode. O2 at 2 L/minute via nasal cannula. Diet as tolerated. Continuous O2 saturation monitoring via pulse oximeter. 5% Dextrose and sodium chloride 0.45% intravenous infusion at 125 mL/hr. Obtain sputum culture. Medications include: Levofloxacin 500 mg IV every 24 hours. Saline and albuterol nebulizer treatments every 4 hours and PRN. Beclomethasone inhaler 2 puffs twice daily. Salmeterol inhaler 2 puffs every 12 hours. Methylprednisolone 125 mg IV every 8 hours. Which nursing action should be implemented before the prescribed levofloxacin is administered? a. Auscultate lung sounds. b. Assess oral intake. c. Obtain a sputum culture with sensitivity. d. Assist client to the bathroom.

Obtain a sputum culture with sensitivity The sputum culture 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 to assess the client for previous allergic reactions to antibiotics.

With a diagnosis of pneumonia, which assessment finding warrants immediate intervention by the nurse? a. Oxygen saturation 90%. b. Blood pressure (BP) 132/78 mmHg. c. Heart rate 120 beats/minute. d. Inelastic skin turgor. The nurse auscultates crackles bilaterally in the lower posterior lung fields with diminished breath sounds noted throughout all lung fields. The client's chest x-ray shows infiltrates in the lung bases bilaterally. The client is admitted to the acute care facility with a medical diagnosis of pneumonia and is transported to the nursing unit.

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

Arterial Blood Gas (ABG) Analysis ABGs were obtained with the following results:Normal Conventional ValueNormal SI Unit Value pH 7.25 7.35 to 7.45 7.35 to 7.45 pCO2 58 35 to 45 mmHg 35 to 45 mmHg HCO3 26 21 to 28 mEq/L 21 to 28 mmol/L pO2 87 80 to 100 mmHg 80 to 100 mmHg The ABG results indicate that the client is experiencing which acid-base imbalance? a. Metabolic acidosis. b. Metabolic alkalosis. c. Respiratory acidosis. d. Respiratory alkalosis.

Respiratory acidosis. Low pH indicates that acidosis is present. 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, the 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? a. Right task. b. Right circumstance. c. Right person. d. 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 in place at all times, especially during any activity. The fifth right, right supervision, includes direction/guidance, evaluation/monitoring, and follow-up.

Discharge Teaching The remainder of the client's hospital stay is uneventful. Which outcome statement is the best indicator that the client's pneumonia is resolved and he is ready to be discharged? a. Sputum culture is negative. b. Levofloxacin peak and trough levels are within normal limits. c. Oxygen saturation level is 92%. d. Clear sputum. The client, his family, and the nurse discuss the use of anti-smoking hypnosis tapes along with other measures to promote good health upon discharge. The client agrees to follow all of the discharge instructions and expresses understanding of the use of prescribed medications, including the proper use of the metered dose inhaler.

Sputum culture is negative. This is the best indicator that the pneumonia is resolved.

Client Teaching: Metered Dose Inhaler (MDI) The nurse observes the client using the MDI. Using a spacer, the client takes 2 puffs of albuterol, followed one minute later by 2 puffs of beclomethasone. After observing the client, which instruction by the nurse is most important for client teaching? (Select all that apply.) a. Instruct the client to use the beclomethasone first, followed by the albuterol. b. Explain that using a spacer reduces medication absorption. c. Tell the client to wait at least 5 minutes between each medication. d. Teach the client to wait at least 2 minutes between each puff of the same medication.

Tell the client to wait at least 5 minutes between each medication. The client should wait 2 to 5 minutes before using the second medication.

Which instruction should the nurse provide the client for an acute episode of asthma? a. Administer the beclomethasone as soon as possible. b. Use the albuterol inhaler for an acute asthma attack. c. Call the healthcare provider before taking any medication. d. Take an extra dose of salmeterol.

Use the albuterol inhaler for an acute asthma attack. Albuterol is a bronchodilator that is used for an acute asthmatic attack.