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N136 Week 3 - COPD with Pneumonia
Meet the Client A client comes to the Emergency Department (ED) with a 4-day history of increased sputum production, a change in the sputum color from clear to yellow, increased shortness of breath, and a fever of 101° F (38.3oC). The client has smoked cigarettes for the past 38 years and smoking 2 packs a day for the past 20 years. The client reports that he had asthma as a child and was treated with albuterol inhalers from time to time as an adult. The client has been hospitalized twice with pneumonia; the most recent pneumonia-related hospitalization was 2 years ago. - well answered Important to Know
- Your first answer is the one that counts towards your score, but you'll be prompted to try again if you get the wrong answer. When you get the right answer, you'll go to the next section.
- If you choose to re-take a Case Study, you will no longer be able to see your previous score. - well answered Section 1 Assessment The physical examination reveals the following: Vital signs: temperature 101.6° F (38.6o 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. - well answered Question 1 of 20 Which assessment is most important for the nurse to complete next? Auscultate breath sounds. Listen to heart sounds.. Check for peripheral edema. Assess capillary refill. - well answered Auscultate breath sounds.
Auscultate breath sounds. This is the highest priority. The client is exhibiting respiratory distress. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 510, 512, 513, 515, Listen to heart sounds.. Although it is important to auscultate heart sounds, this is not a priority. Check for peripheral edema. This gives information about fluid volume overload. The client's symptoms of fever, warm skin, and inelastic skin turgor indicate that they are 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 20 With a diagnosis of pneumonia, which focused assessment finding warrants immediate intervention by the nurse? Oxygen saturation 90%. BP of 132/78 mm/Hg. Heart rate 120 beats/minute. Inelastic skin turgor. - well answered Oxygen saturation 90%. Oxygen saturation 90%. Oxygen should be applied and titrated to keep the oxygen level at 92% or higher. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg.
BP of 132/78 mm/Hg. This is a normal finding. Heart rate 120 beats/minute. Signs of the body compensating is tachycardia. Tachycardia is consistent with an infectious process. In addition, The client's fever and rapid respiratory rate are also vital sign findings that indicate a problem, such as an infection.
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 the client has a rapid respiratory rate, his underlying COPD causes the retention of CO2. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg.
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. Section 3 Nursing Diagnoses - well answered Question 4 of 20 Which nursing problem has the highest priority when the PN is assisting the RN in planning care for the client? Nutritional deficit. Altered mobility. Decreased fluid volume. Inability to clear the airway. - well answered Inability to clear the airway. Nutritional deficit. While it is true that clients with COPD typically exhibit nutritional problems, there is not sufficient data to make this a priority problem. Altered mobility. Clients with COPD often experience subtle progressive changes in their ability to ambulate without shortness of breath. However, information related to this problem has not yet been obtained from the client. Decreased fluid volume. The client has signs of dehydration, it is not the priority problem.
Inability to clear the airway. There are adventitious breath sounds present, tachypnea, changes in depth of respirations, fever, and cough, which supports this as a priority problem. Additional priority problems are altered gas exchange and change in normal breathing patterns. Altered gas exchange is reflected in the client's hypercapnia and hypoxia. The problem of change in normal breathing pattern is supported by his tachypnea, use of accessory muscles, and changes in the depth of respiration. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 414,
Question 5 of 20 Which focused assessment finding warrants immediate intervention by the nurse? Kussmaul respirations Blood pressure 90/50 mmHg Onset of drowsiness Anorexia - well answered Kussmaul respirations Kussmaul respirations Kussmaul respirations are a deep, rapid respirations that occurs when the lungs are trying to compensate for the acidosis. If not corrected, the respiratory status will worsen until an acute intervention is necessary to maintain the respirations. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg.
Blood pressure 90/50 mmHg Hypotension is a symptom of respiratory acidosis but not life threatening at this time. Onset of drowsiness Change of level of consciousness is a symptom of respiratory acidosis but drowsiness is not life threatening at this time. Anorexia Anorexia is not a life threatening symptom of respiratory acidosis. Section 4 Medication Administration
necessary. Another important nursing intervention is assessment of the client for previous allergic reactions to antibiotics. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 751. Assist client to the bathroom. This is not necessary prior to administration of antibiotics. Question 7 of 20 Fill in the blank 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? (Enter numerical value only. If rounding is necessary, round to the whole number.) - well answered 33 Question 8 of 20 While the client is undergoing nebulizer treatments with albuterol/salbutamol, it is most important for the nurse to perform which focused assessment? Monitor pulse oximeter readings. Monitor respiratory rate. Monitor pulse and BP. Monitor temperature. - well answered Monitor pulse and BP. Monitor pulse oximeter readings. Monitoring the client's pulse oximeter readings are important, but that is not the most important assessment related to the albuterol/salbutamol. Monitor respiratory rate. Monitoring respiratory rate is important, but it is not the most important assessment related to the albuterol/salbutamol. Monitor pulse and BP. Albuterol/salbutamol 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.
Morris, D. (2017). Calculate with Confidence. (7thedition). St. Louis, Missouri. Elsevier. Pg. 179. Monitor temperature. Monitoring temperature is important for the client with pneumonia, but it is not needed for a client receiving albuterol/salbutamol. Section 5 Client Teaching: Metered Dose Inhaler (MDI) The nurse observes the client as they use their inhalers. Using a spacer, the client takes 2 puffs of the salmeterol, followed one minute later by 2 puffs of the beclomethasone. - well answered Question 9 of 20 After observing the client, which instruction by the nurse is most important for client teaching? Select all that apply Instruct to do the beclomethasone first, followed by the salmeterol. Explain that using a spacer reduces medication absorption. Tell the client to wait at least 2-5 minutes between each medication. Teach the client to wait at least 2 minutes between each puff of the same medication. - well answered Tell the client to wait at least 2-5 minutes between each medication. Instruct to do the beclomethasone first, followed by the salmeterol. The salmeterol (bronchodilator) should be used first, followed by the beclomethasone (glucocorticoid). Explain that 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. Tell the client to wait at least 2-5 minutes between each medication. The client should wait at least 2-5 minutes before using the second medication.Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 460. Teach the client to wait at least 2 minutes between each puff of the same medication. The client should wait 20-30 seconds between each puff of the same medication. In addition, the client should be instructed to wait 2-5 minutes before using the second medication. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 460.
Decrease the oxygen to 4 L/minute per nasal cannula. Elevate the head of the bed to a high-Fowler's position. Remove the pulse oximeter to reduce anxiety. Assess the client's respiratory rate and rhythm. - well answered Assess the client's respiratory rate and rhythm. Decrease the oxygen to 4 L/minute per nasal cannula. The client has COPD, 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. 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. 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 the client's oxygenation. Assess the client's respiratory rate and rhythm. This is an acceptable oxygen saturation level for a client with COPD. The nurse should continue a problem focused assessment which a respiratory assessessment to include the client's respiratory status and effort of breathing. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 417,
Question 12 of 20 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? Place the extremity to which the sensor is attached at heart level. Assess capillary refill prior to applying the sensor. Lower the lighting in the room. Remove the sensor when taking the B/P. - well answered Assess capillary refill prior to applying the sensor.
Place the extremity to which the sensor is attached at heart level. This is not necessary. 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. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 378. 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 O monitoring. Section 7 Therapeutic Communication The next morning, the client is scowling and complains that their breakfast is cold, their family has not yet been to visit him, and it was so noisy during the night that they were unable to sleep. The client seems angry, and the nurse recognizes that they may be using displacement of their anger as a coping defense mechanism. - well answered Question 13 of 20 Which statement by the nurse promotes effective communication with the client? Relay to the client that the charge nurse will instruct the night staff to keep the door closed at night. Acknowledge to the client that they seem upset this morning. Ask the client why they are feeling so angry. Offer to warm up the client's breakfast tray or order a fresh one. - well answered Acknowledge to the client that they seem upset this morning. Relay to the client that the charge nurse will instruct the night staff to keep the door closed at night.
Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 68. Section 8 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 they are not wearing the nasal cannula. The client states that the cannula tubing wouldn't reach all the way to the commode, so the UAP removed it. - well answered Question 15 of 20 What action should the nurse implement? Report the UAP to the charge nurse for performing an act that was not allowed. Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. Tell the UAP to obtain assistance next time from the respiratory therapist. Assign the UAP to a different client. - well answered Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. Report the UAP to the charge nurse for performing an act that was not allowed. Trained UAP's may provide care for clients with oxygen if given clear directions. UAP's 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 the client 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. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 886,
Tell the UAP to obtain assistance next time from the respiratory therapist. 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 the client with additional instruction and supervision.
Question 16 of 20 The nurse should use the five rights of delegation when working with the UAP. Which one of these rights was violated in this situation? Right Task. Right Circumstance. Right Person. Right Direction/Communication. - well answered Right Direction/Communication. 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 the client was in stable condition, the circumstances for delegation were appropriate. Right Person. This is a task that could be delegated by an PN 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. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 886,
Section 9 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, and the client's evening vital signs are temperature 99° F (37.2o C), heart rate 84 beats/minute, respirations 22 breaths/minute, 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
Section 10 Ethical-Legal Considerations As the client's condition improves, 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. - well answered Question 18 of 20 Which ethical principle is most important for the nurse to consider when responding to the family member? Veracity. Beneficence. Autonomy. Nonmaleficence. - well answered Autonomy. 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 the client's knowledge or consent. Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 74. Nonmaleficence. This ethical concept refers to doing harm; however there is a more relevant principle for this situation. Section 11 Discharge Teaching
The remainder of the client's hospital stay is uneventful. - well answered Question 19 of 20 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. Levafloxacin peak and trough levels are within normal limits. Oxygen saturation level is 92%. Clear sputum. - well answered Sputum culture is negative. Sputum culture is negative. This is a significant indicator that the pneumonia is resolved. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 375,
Levafloxacin 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. Oxygen saturation level is 92%. This low oxygen saturation level probably reflects the client'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 the client's sputum is clear because of the resolution of the infection. There is a better choice. The client, his family, and the nurse discuss the use of anti-smoking hypnosis tapes, along with other measures to promote good health upon their discharge. The client agrees to follow all of the discharge instructions and states that they understand the use of the prescribed medications, including the proper use of the metered dose inhaler. - well answered Question 20 of 20 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.)
The client responds appropriately to the discharge teaching using "teach back" validation and is successfully discharged home, accompanied by family. Three months later, the client visits the nurses on the medical unit, and he proudly tells them that they have decreased cigarette use to ½ pack per day. - well answered
