HESI-COPD with Pneumonia
Which assessment is the most important for the nurse to complete next?
Auscultate breath sounds This is the highest priority. The client is exhibiting respiratory distress.
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.)
-Avoid crowds and people with infections -Increase intake of oral fluids -Store prescribed inhalers away from extreme heat and cold
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?
33 V x gtt factor/time (minutes) 100 mL x 20 min/60 min = 33.33
Which statement by the nurse promotes effective communication with the client?
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, 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?
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?
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. If the client is comfortable and not having difficulty breathing, the head of bed does not need to be adjusted. If the client is having difficulty breathing, the head of the bed should be elevated for ease of breathing. Semi- to high-Fowler positions decrease the pressure on the diaphragm and allow for improved lung expansion.
Which ethical principle is most important for the nurse to consider when responding to the family member?
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 intervention should the nurse initiate immediately?
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.
Which nursing diagnosis has the highest priority when the nurse is planning care for the client?
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.
What action should the nurse implement
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.
With a diagnosis of pneumonia, which assessment finding warrants immediate intervention by the nurse?
Oxygen saturation 90% Oxygen should be applied and titrated to keep the oxygen level at 92% or higher.
Which assessment finding warrants immediate intervention by the nurse?
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?
Listen to the client and remain silent
While the client is undergoing nebulizer treatments with salbutamol, it is most important for the nurse to perform which assessment?
Monitor pulse and BP 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 prescribe levofloxacin is administered?
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.
The ABG results indicate that the client is experiencing which acid base imbalance? 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
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 should use the five rights of delegation when working with the UAP. Which one of these rights was violated in this situation?
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.
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 This is the best indicator that the pneumonia is resolved. Levofloxacin peak and trough levels are within normal limits.--This indicates that the client is receiving the correct dose of medication, but it does not indicate resolution of the infection. A clear sputum indicates the resolution of an infectious process.
After observing the client, which instruction by the nurse is most important for client teaching?
Tell the client to wait at least to wait at least 5 minutes between each medication The client should wait 2 to 5 minutes before using the second medication. The albuterol (bronchodilator) should be used first, followed by the beclomethasone (glucocorticoid). The client should wait 20 to 30 seconds between each puff of the same medication. The client should be instructed to wait 5 minutes before using the second medication. Submit
Which instruction should the nurse provide the client for an acute episode of asthma?
Use the salbutamol(albuterol) inhaler for acute asthma attacks Albuterol is a bronchodilator that is used for an acute asthmatic attack.
