Breathing Patterns Case Study
Nurse assesses Josh’s vitals signs. His respirations are rapid and shallow.
What is the best technique for the nurse to use to assess josh’s respirations accurately?
Put place hand
How should the nurse describe josh’s respiratory battern
To determine the need for the application of the nasal cannula, which assessment is most important for the nurse to preform?
Measure O2 sat
in assessing josh’s breath sounds, the nurse should ask him to perform which action?
Breathe deeply through the mouth
to measure cap refil
compress josh’s nailbed
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when using the spring-tension finger clip, josh asks if it will hurt. Which response is best?
The clip feels like squeezing your finger with your other hand
Josh’s o2sat is 88% with a cap refill at 1 sec. Breath sounds are absent in the base and coarse bilaterally through the rest of the lung fields. The nurse applies the nasal cannula and admins o2 at 2 L/minuet.
When applying the nasal cannula, it is most important for the nurse to provide which instructions?
Remind client and family that 02 is combustable
which nursing diagnosis is most relevant to josh’s current status?
impaired gas exchange
Which assessment finding further supports diagnosis
restlessness and fatigue
after determining the priority nursing diagnosis, what step should the nurse take next in developing the plan of care?
establish goals and expected outcomes
Which outcome statement should the nurse use for Josh’s plan of care?
The client’s o2 sat will be >95% on room air.
to achieve the desired outcome, the nurse has initiated the prescribed o2 therapy. After applying the nasal cannula, the nurse plants to attach a disposable sensor pad to measure the 02 sat continuously.
Which action should the nurse implement prior to applying the sensor?
Determine if josh has a latex allergy
after receiving 02 for a short while, josh is must less dyspneic. The nurse notes the o2sat reading is 97% Fifteen min later, o2 sat alarm indicates that the reading has changed to 80%
What immediate actions’s should the nurse implement (select all that apply)
reposition the finger clip and obtain another reading
Assess josh for signs and symptoms of respiratory distress.
encourage josh to begin coughing and deep breathing.
After the nurse repositions the finger clip, the oxygen saturation reading returns to 97% despite the normal reading, josh’s mom appears worried and states, “josh has never been sick. I am so scared.”
To encourage the mother to share more about her feelings, how should the nurse respond?
It sounds like this has been a very fighting experience for you
After further conversation with josh’s mom, the nurse needs to leave the room to assess another client.
Which action be the nurse demonstrates the use of trust in the nurse-client relationship?
returning to the room at the time promised
Upon returning to the room, the nurse assesses josh’s cough
Which documentation reflects subjective data?
CLient reports that he is coughing alot
which documentation best reflects the nurse’s objective assessment
Frequent deep cough producing small amounts of pale yellow sputum
Upon further observation, the nurse describes josh sputum as tenacious
To what does this refer?
Since, Josh has a productive cough, the provider requests that the sputum specimen be obtained and sent to the lab for culture and sensitivity.
In assisting josh to obtain a sputum specimen, what action should the nurse take?
Instruct Josh to cough deeply from the chest and spit into the specimen cup
The patient care tech is planning to transport the sputum specimen to the lab
Which instructions should the nurse provide?
place the cup in a bio hazard bag
The provider determines that josh has a respiratory tract infection and prescribes an oral anti-biotic and an oral liquid cough syrup.
Josh’s mom gets the meds from the pharm and shows them to the nurse. The script for the antibiotic reads “take 2 pills for the first dose, followed by 1 pill every 12 hours. ” The mother asks the nurse if this seems right.
How should the nurse respond?
A large first dose allows the medication to start working faster.
The cough syrup is labeled as an antitussive. The nurse explain that this medication should have what effect?
reduce the frequency of the cough
the medication label states “take 2 tspn ever 4 hours as needed. The nurse gives josh some med cups and teaches him and his mother how to put the meds into the cup.
To what level should the meds be poured?
Josh and his mother return to the providers office 1 week later, after josh has completed the course of antibiotic therapy.
In assessing josh’s breath sounds, where should the nurse listen first?
the nurse auscultates vesicular breath sounds in the peripheral lung fields.
What action should the nurse take?
Record the presence of the clear breath sounds
which serum lab value confirms the resolution of josh’s infection?
WBC count 6,000 /mm3