Copd case - solved case study PDF

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Which assessment is most important for the nurse to complete next? Auscultate breath sounds. This is the highest priority because Mr. Johnson is clearly exhibiting respiratory distress. Auscultate heart sounds.. Although it is important to auscultate heart sounds, this is not a priority. Assess for peripheral edema. This gives information about fluid volume overload. Mr. Johnson's symptoms of fever, warm skin, and inelastic skin turgor indicate that he is more likely experiencing fluid volume deficit. Assess capillary refill. Although this provides valuable information about over all circulatory function, it is not the highest priority. Question 2 of 19 Which assessment finding supports Mr. Johnson's diagnosis of pneumonia? Pulse rate of 110. Tachycardia is consistent with an infectious process. In addition, Mr. Johnson's fever and rapid respiratory rate are also vital sign findings that indicate a problem, such as an infection. BP of 132/78. This is a normal finding. Increased AP diameter of the chest. This finding is typical in clients with emphysema, but it is not an indicator of pneumonia. Inelastic skin turgor. Inelastic skin turgor is an indicator of dehydration, but it is not an indicator of an acute infectious process, such as pneumonia. Question 3 of 19 These ABG results indicate that Mr. Johnson is experiencing which acid base imbalance? Metabolic acidosis. Although the pH is low, indicating acidosis, metabolic acidosis would be caused by a low HCO3. Metabolic alkalosis. Alkalosis is reflected by a high pH, rather than by the low pH seen in these ABG results. Respiratory acidosis. The low pH indicates that acidosis is present. The 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 Mr. Johnson has a rapid respiratory rate, his underlying COPD causes the retention of CO2. Respiratory alkalosis. Alkalosis is reflected by a high pH, rather than by the low pH seen in these ABG results, although the high CO2 indicates that there is clearly a respiratory problem. Question 4 of 19 Which nursing diagnosis has the highest priority when the nurse is planning care for Mr. Johnson? Imbalanced nutrition, less than body requirements. While it is true that clients with COPD typically exhibit nutritional problems, there is not sufficient data to make this diagnosis.

Impaired physical mobility. Clients with COPD often experience subtle progressive changes in their ability to ambulate without shortness of breath. However, information related to this diagnosis has not yet been obtained from Mr. Johnson. Deficient fluid volume. Mr. Johnson has signs of dehydration, it is not the priority diagnosis. Ineffective airway clearance. There are adventitious breath sounds present, tachypnea, changes in depth of respirations, fever, and cough, which support this as a priority diagnosis. Additional priority diagnoses are impaired gas exchange and ineffective breathing patterns. Impaired gas exchange is reflected in Mr. Johnson's hypercapnia and hypoxia. The diagnosis of ineffective breathing pattern is supported by his tachypnea, use of accessory muscles, and changes in the depth of respiration. Question 5 of 19 Which nursing action should be implemented before the prescribed levofloxacin is administered? Auscultate lung sounds. This is not necessary prior to administration of antibiotics. Assess oral intake. This is not necessary prior to administration of antibiotics. Obtain a sputum culture. The sputum specimen 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 assessment of Mr. Johnson for previous allergic reactions to antibiotics. Assist client to the bathroom. This is not necessary prior to administration of antibiotics. Question 6 of 19 Fill in the blankThe levofloxacin 500 mg IVPB is supplied in 100 mL of D5W 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 IVIVPB to infuse at how many gtts per min? (Enter numerical value only. If rounding is necessary, round to the whole number.) V x gtt factor/time (minutes) 100 mL x 20 min/60 min = 33.33 (33 rounded to whole number)

Question 7 of 19 While Mr. Johnson is undergoing nebulizer treatments with albuterol, it is most important for the nurse to perform which assessment? Monitor pulse oximeter readings. Monitoring Mr. Johnson's pulse oximeter readings are important, but that is not the most important assessment related to the albuterol (Ventolin). Monitor respiratory rate. Monitoring respiratory rate is important, but it is not the most important assessment related to the albuterol (Ventolin). Monitor pulse and BP. Albuterol (Ventolin) is a beta-adrenergic agonist with a bronchodilating effect. Because adrenergic agonists mimic sympathetic stimulation, Mr. Johnson must be monitored carefully for cardiac arrhythmias, hypertension, nervousness, and restlessness. Monitor temperature. Monitoring temperature is important for the client with pneumonia, but it is not needed for a client receiving albuterol (Ventolin). Question 8 of 19 After observing Mr. Johnson, which instruction by the nurse is most important for client teaching? Sel ectal l t hatappl y "Administer the beclomethasone first, followed by the salmeterol." The salmeterol (bronchodilator) should be used first, followed by the beclomethasone (glucocorticoid). "Using a spacer reduces medication absorption." A spacer is an effective tool that helps to improve the amount of the medication that is absorbed when MDIs are used. ”Wait at least 5 minutes between each medication.” Mr. Johnson should wait at least 5 minutes before using the second medication. "Wait at least 1 minute between each puff of the same medication." Mr. Johnson should wait 1 to 2 minutes between each puff of the same medication. In addition, he should be instructed to wait 5 minutes before using the second medication. Question 9 of 19 Which instruction should the nurse provide Mr. Johnson for an acute episode of asthma? "Administer the Vanceril as soon as possible." Beclomethasone is a glucocorticoid with an antiinflammatory effect. It is used for long-term prevention in asthma, but it is not useful during acute episodes. "Use the albuterol inhaler for acute asthma attacks." Albuterol is a bronchodilator that is used for acute asthmatic attacks. "Call your healthcare provider before administering any medication." Mr. Johnson has access to an effective method of self-care, so that should be initiated first. "Take an extra dose of salmeterol for an acute attack." Salmeterol is a long-acting bronchodilator that cannot be used more than 2 puffs every 12 hours and is not used for acute episodes. Question 10 of 19

After checking the sensor site to make sure the readings are accurate, the nurse should then initiate which intervention? Decrease the oxygen to 4 L/minute per nasal cannula. Mr. Johnson has chronic lung disease, so it is not surprising that his saturation level is lower than someone without lung disease. The current reading is an acceptable level for the client and the rate should not be changed. Clients with COPD should be maintained on low doses of oxygen because the drive to breathe is based on hypoxia, rather than hypercapnia. Elevate the head of the bed to a high-Fowler's position. If the client is comfortable and not having difficulty breathing, then the head of bed does not need to be adjusted. If the client is having difficulty breathing, then the head of the bed should be elevated for ease of breathing. Semi to high-Fowler's positions decrease the pressure on the diaphragm and allow for improved lung expansion. Some clients with COPD prefer to lean forward and rest their upper bodies on an overbed table (tripod position). Remove the pulse oximeter to reduce anxiety. Continuous O2 saturation monitoring has been prescribed by the healthcare provider, and it should not be removed. This provides important ongoing monitoring of Mr. Johnson's oxygenation. Assess the client’s respiratory rate and rhythm. This is an acceptable oxygen saturation level for a client with COPD. The first action by the nurse is to assess the client’s respiratory status and observe his effort of breathing. Question 11 of 19 While taking the client’s blood pressure, 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? Place the extremity to which the sensor is attached at heart level. This is not necessary. Assess the adequacy of circulation 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. Lower the lighting in the room. Lighting does not make a difference in the function of the pulse oximeter. To prevent inaccurate readings, at times the sensor may need to be protected from too much sunlight by placing the extremity under the bedcovers. Remove the sensor when taking the B/P. Blood pressure monitoring will disrupt pulsatile blood flow and affect the oximeter reading. However, a better intervention would be to take the B/P on the opposite extremity so as not to disrupt O2 monitoring. Question 12 of 19 Which statement by the nurse promotes effective communication with Mr. Johnson? "I will inform the charge nurse of this and she will instruct the night staff to keep your door closed at night." This statement does not allow Mr. Johnson an opportunity to communicate his feelings. "You seem pretty upset this morning." This statement allows an opportunity for Mr. Johnson to clarify his feelings.

"Why are you feeling so angry?" Using "why" is considered a block to effective communication, and it should be avoided. "I can warm up your breakfast tray or order a fresh one for you." This statement does not allow Mr. Johnson an opportunity to communicate his feelings. Question 13 of 19 What is the nurse's best response? "You may be one of the lucky ones and not get cancer." This is false reassurance, which should be avoided. It blocks Mr. Johnson from further exploring feelings. "I understand that. I have been trying to quit smoking for a few years but have not been successful." This self-disclosure has no therapeutic purpose and takes the focus away from Mr. Johnson. "You should focus on getting better and try not to worry about that now." This answer disregards Mr. Johnson's concerns and will block further communication. Remain silent. This is the best choice. Silence can be a very effective communication technique. The nurse should express interest nonverbally when silence is used. Question 14 of 19 What is the best nursing action? Report the UAP to the charge nurse for performing an act that was not allowed. Trained UAPs may provide care for clients with oxygen if given clear directions. UAPs can be given tasks that fall within the intervention component of the nursing process, but they must receive adequate supervision. Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. Helping Mr. Johnson to the commode is an appropriate action for a UAP to perform, but this UAP requires some additional instruction and individual supervision with oxygen equipment.. Request that a second UAP assist the UAP the respiratory therapist to assist with Mr. Johnson's activities. This action is not necessary because the UAP should be able to perform this responsibility with additional instruction and supervision. Assign the UAP to a different client. This assignment is not necessary because the UAP should be able to provide care for Mr. Johnson with additional instruction and supervision. Question 15 of 19 The National Council of State Boards of Nursing has defined five rights of delegation. Which one of these rights was violated in this situation? Right Task. This was an appropriate task to assign to a UAP. Responsibilities should fall within the intervention component of the nursing process. Right Circumstance. Since Mr. Johnson was in stable condition, the circumstances for delegation were appropriate. Right Person. This is a task that could be delegated by an RN to a UAP.

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 on the client at all times, especially during any activity. The fifth right, Right Supervision includes direction/guidance, evaluation/monitoring, and follow-up. Question 16 of 19 Which intervention should the nurse initiate immediately? Place resuscitation equipment in the room. This is a high priority because Mr. Johnson's O2 saturation is dangerously low. The nurse should also prepare to transfer Mr. Johnson to the critical care unit for close monitoring. Increase the O2 to 6 L/min. This is not initiated with a client with COPD. Initiate CPR. Mr. Johnson still has a pulse, BP, and respirations, so CPR should not be initiated. The nurse should attach ECG leads to determine if a cardiac arrhythmia is occurring and call for the Rapid Response Team if available. Set defibrillator at 200 joules. This may be necessary if ventricular fibrillation develops, but it is not warranted in this situation. Question 17 of 19 Which ethical principle is most important for the nurse to consider when responding to the son? Veracity. This ethical concept refers to telling the truth, which is always an important ethical consideration. However, there is a more relevant principle for this situation. Beneficence. This ethical concept refers to doing good; however, there is a more relevant principle for this situation.doing good; however, there is a more relevant principle for this situation. Autonomy. This ethical principle refers to the individual's right to make his own decisions regarding his care. It is an important principle, which would be violated if the nurse allowed the son to play hypnosis tapes without his father's knowledge or consent. Nonmaleficence. This ethical concept refers to doing harm; however there is a more relevant principle for this situation. Question 18 of 19 Which outcome statement is the best indicator that Mr. Johnson's pneumonia is resolved and he is ready to be discharged? Sputum culture is negative. This is a significant indicator that the pneumonia is resolved. Levafloxacin peak and trough levels are within normal limits. This indicates that Mr. Johnson is receiving the correct dose of medication, but it does not indicate resolution of the infection. Oxygen saturation level is 92%. This low oxygen saturation level probably reflects Mr. Johnson's chronic pulmonary problems, rather than the pneumonia.

Clear sputum. This is one indicator of the resolution of an infectious process. However, it is important to make sure that Mr. Johnson's sputum is clear because of the resolution of the infection. There is a better choice. Question 19 of 19 Which additional discharge instructions should the nurse include in the teaching plan to promote optimal health for Mr. Johnson? Sel ectal l t hatappl y Decrease physical activity. Regular exercise in moderation is an important factor in overall health. Mr. Johnson should be instructed in methods that will enable him to exercise safely, rather than instructed to decrease physical activity. Avoid crowds and people with infections. This is an important measure to avoid future infections. Mr. Johnson should also be encouraged to get an annual pneumonia vaccine. Increase intake of oral fluids. Mr. Johnson needs to increase his oral fluid intake to maintain adequate hydration and keep respiratory secretions thin. It is all right to go outside anytime. Mr. Johnson should be instructed to avoid being outdoors during high ozone alerts, or any other times when there are high levels of respiratory irritants in the air. Store prescribed inhalers away from extreme heat and cold. Extreme heat and cold can alter the composition of the inhaler medication and render it ineffective. Pr evi ousSect i on...