CASE STUDY 2 Dyspnea and Shortness of Breath Flashcards
Mr. W is an 83-year-old man who was brought to the hospital from a long-term care
facility by emergency medical services after reporting severe dyspnea and shortness of
breath. He has been experiencing coldlike symptoms for the past 2 days. He has a
productive cough with thick yellowish sputum. When Mr. W awoke in the nursing
home, it was found that he was having difficulty breathing even after using his
albuterol metered-dose inhaler (MDI). He appears very anxious and is in respiratory
distress. His history includes chronic obstructive pulmonary disease (COPD) related to
smoking 2 packs of cigarettes per day since he was 15 years old; he quit smoking 2
years ago when he was admitted to the long-term facility. Mr. W has been incontinent
of urine and stool for the past 2 years.
In the emergency department, Mr. W undergoes chest radiography, and admission
laboratory tests are performed, including serum electrolyte levels and a complete blood
count. A sputum sample is sent to the laboratory for culture and sensitivity testing and
Gram staining.
Mr. W’s vital sign values are as follows:
Blood pressure 154/92 mm Hg
Heart rate 118 beats/min
O2 saturation 88% on 1 L/min oxygen by nasal cannula
Respiratory rate 38 breaths/min
Temperature 100.9°F (38.3°C) (oral)
Which priority actions will the nurse take when the patient is initially
admitted to the emergency department (ED)? Select all that apply.
1. Place the patient on a cardiac monitor.
2. Get a baseline set of vital signs.
3. Draw admission labs and place a saline lock.
4. Change the patient’s adult pad.
5. Send the patient for a chest x-ray.
6. Order the patient a lunch tray.
Ans: 1, 2, 3, 5 Baseline data that are essential to decisions for the care of this
patient take priority at this time including vital signs, cardiac rhythm, lab
values, and chest x-ray findings. Placement of a saline lock is essential for
administration of fluids and emergency drugs. Changing the patient’s
incontinence pad is important to protect his skin but is not urgent. Ordering a
lunch tray may be premature because the interventions for this patient’s care
are undecided when he is first admitted to the ED. Focus: Prioritization.
Mr. W is an 83-year-old man who was brought to the hospital from a long-term care
facility by emergency medical services after reporting severe dyspnea and shortness of
breath. He has been experiencing coldlike symptoms for the past 2 days. He has a
productive cough with thick yellowish sputum. When Mr. W awoke in the nursing
home, it was found that he was having difficulty breathing even after using his
albuterol metered-dose inhaler (MDI). He appears very anxious and is in respiratory
distress. His history includes chronic obstructive pulmonary disease (COPD) related to
smoking 2 packs of cigarettes per day since he was 15 years old; he quit smoking 2
years ago when he was admitted to the long-term facility. Mr. W has been incontinent
of urine and stool for the past 2 years.
In the emergency department, Mr. W undergoes chest radiography, and admission
laboratory tests are performed, including serum electrolyte levels and a complete blood
count. A sputum sample is sent to the laboratory for culture and sensitivity testing and
Gram staining.
Mr. W’s vital sign values are as follows:
Blood pressure 154/92 mm Hg
Heart rate 118 beats/min
O2 saturation 88% on 1 L/min oxygen by nasal cannula
Respiratory rate 38 breaths/min
Temperature 100.9°F (38.3°C) (oral)
What is the priority nursing concern for this patient?
- Skin care due to incontinence
- Clearance of thick secretions
- Rapid heart rate
- Elevated temperature
Ans: 2 The patient’s major problems at this time relate to airway and
breathing including thick sputum, difficulty breathing, and respiratory
distress. The patient’s skin care, blood pressure, and elevated temperature
will need to be followed up on soon but are not as urgent at this time as his
respiratory status. Focus: Prioritization.
Mr. W is an 83-year-old man who was brought to the hospital from a long-term care
facility by emergency medical services after reporting severe dyspnea and shortness of
breath. He has been experiencing coldlike symptoms for the past 2 days. He has a
productive cough with thick yellowish sputum. When Mr. W awoke in the nursing
home, it was found that he was having difficulty breathing even after using his
albuterol metered-dose inhaler (MDI). He appears very anxious and is in respiratory
distress. His history includes chronic obstructive pulmonary disease (COPD) related to
smoking 2 packs of cigarettes per day since he was 15 years old; he quit smoking 2
years ago when he was admitted to the long-term facility. Mr. W has been incontinent
of urine and stool for the past 2 years.
In the emergency department, Mr. W undergoes chest radiography, and admission
laboratory tests are performed, including serum electrolyte levels and a complete blood
count. A sputum sample is sent to the laboratory for culture and sensitivity testing and
Gram staining.
Mr. W’s vital sign values are as follows:
Blood pressure 154/92 mm Hg
Heart rate 118 beats/min
O2 saturation 88% on 1 L/min oxygen by nasal cannula
Respiratory rate 38 breaths/min
Temperature 100.9°F (38.3°C) (oral)
The RN assesses Mr. W in the emergency department. Which assessment findings are consistent with a diagnosis of COPD? Select all that apply. 1. Enlarged neck muscles 4492. Forward bent posture 3. Respiratory rate 15 to 25 breaths/min 4. Inspiratory and expiratory wheezes 5. Blue-tinged dusky appearance 6. Symmetrical lung expansion
Ans: 1, 2, 4, 5 The presence of wheezes, enlarged neck muscles, bluish dusky
appearance, and forward bent posture are all classic manifestations in a
patient with COPD. The respiratory rate is usually higher than normal and
during an exacerbation can be as high as 30 to 40 breaths/min. Lung
expansion in patients with COPD is usually asymmetrical. Focus:
Prioritization.
The health care provider’s (HCP’s) prescribed actions for this patient include
all of the following. Which intervention should the nurse complete first?
1. Send an arterial blood gas (ABG) sample to the laboratory.
2. Schedule pulmonary function tests.
3. Repeat chest radiography each morning.
4. Administer albuterol via MDI 2 puffs every 4 hours.
Ans: 1 Baseline ABG results are important in planning the care of this patient.
The unit clerk can schedule the pulmonary function tests and chest
radiography. The albuterol therapy is a routine order. Focus: Prioritization.
Mr. W’s ABG results include the following: pH, 7.37; arterial partial pressure of
carbon dioxide (Pa co 2 ), 55.4 mm Hg; arterial partial pressure of oxygen (Pa o 2 ), 51.2 mm
Hg; bicarbonate (HCO 3− ) level, 38 mEq/L (38 mmol/L).
What is the nurse’s interpretation of these results?
1. Compensated metabolic acidosis with hypoxemia
2. Compensated metabolic alkalosis with hypoxemia
3. Compensated respiratory acidosis with hypoxemia
4. Compensated respiratory alkalosis with hypoxemia
Ans: 3 The pH is on the low side of normal, and the Paco 2 is elevated, which
indicates an underlying respiratory acidosis. The HCO 3− level is elevated,
which indicates compensation. Both the Pao 2 and the oxygen saturation levels
are low, which points to hypoxemia. These blood gas results are typically
expected when a patient has a chronic respiratory problem such as COPD.
Focus: Prioritization; Test Taking Tip: The nurse must remember and apply
physiologic concepts learned in school to patient care (e.g., normal ABG
values).
Mr. W’s ABG results include the following: pH, 7.37; arterial partial pressure of
carbon dioxide (Pa co 2 ), 55.4 mm Hg; arterial partial pressure of oxygen (Pa o 2 ), 51.2 mm
Hg; bicarbonate (HCO 3− ) level, 38 mEq/L (38 mmol/L).
Based on the patient’s ABG results, what are the nurse’s priority actions at
this time? Select all that apply.
1. Administer oxygen at 2 L/min via nasal cannula.
2. Initiate a rapid response.
3. Teach the patient how to cough and deep breathe.
4. Begin IV normal saline at 100 mL/hr.
5. Arrange a transfer to the intensive care unit (ICU).
6. Remind the patient to practice incentive spirometry every hour while
awake.
Ans: 1, 2, 3, 6 The patient’s major problem at this time is impaired gas
exchange with hypoxemia. Strategies to compensate include administration
of low-flow oxygen as well as interventions to improve gas exchange, such as
having the patient cough and deep breathe and perform incentive
spirometry. These strategies may improve the patient’s condition and prevent
the need to initiate a code, transfer to the ICU, or both. A saline lock is a good
idea, but giving the patient too much fluid may worsen his condition by
producing a fluid overload. The patient’s symptoms call for initiation of a
rapid response to treat him now and prevent the need for a code. Focus:
Prioritization.
Which intervention would the RN assign to an experienced LPN/LVN?
- Drawing a sample for ABG determination
- Administering albuterol by hand-held nebulizer
- Measuring vital signs every 2 hours
- Increasing oxygen delivery to 2 L/min via nasal cannula
Ans: 4 Increasing oxygen flow for a patient based on an HCP’s prescription is
454within the scope of practice of LPN/LVNs. UAPs may measure vital signs.
Arterial draws for laboratory tests are not within the LPN/LVN’s scope of
practice unless they have had additional special training. The RN would need
to assess the LPN/LVN’s skill before assigning this task. Hand-held
nebulizers are usually operated by respiratory therapists. Focus: Assignment,
Supervision.
After the rapid response, the respiratory therapist provides the patient with a hand-held
nebulizer treatment, and Mr. W is stable enough to be admitted to the acute care unit.
Which interventions would the acute care RN delegate to an experienced
unlicensed assistive personnel (UAP)? Select all that apply.
1. Changing the patient’s incontinence pad as needed
2. Performing pulse oximetry every shift
3. Teaching the patient to cough and deep breathe
4. Reminding the patient to use incentive spirometry every hour while awake
5. Assessing the patient’s breath sounds every shift
6. Encouraging the patient to drink adequate oral fluids
Ans: 1, 2, 4, 6 Assisting patients with activities of daily living such as toileting
are within the scope of practice of UAPs. After licensed nurses or respiratory
therapists have taught the patient to use incentive spirometry, the UAP can
play a role in reminding the patient to perform it. UAPs can participate in
encouraging patients to drink adequate fluids. Assessing and teaching are not
within the scope of practice of UAPs. Performing pulse oximetry is
appropriate for experienced UAPs after they have been taught how to use the
pulse oximetry device to gather additional data. Focus: Delegation,
Supervision.
Mr. W’s emergency department lab values include a serum potassium of
- 8 mg/dL (2.8 mmol/L). What is the priority nursing action at this time?
- Teach the patient about potassium-rich foods.
- Provide the patient with oxygen at 2 L per nasal cannula.
- Contact and notify the HCP immediately.
- Initiate 0.9% saline at 20 mL/hr.
Ans: 3 A low serum potassium places the patient at risk for cardiac
dysrhythmias, which can be life threatening. The HCP should be notified
immediately and will likely order IV or oral potassium supplements to move
the patient’s level back into the normal range. Later, before discharge, the
nurse would certainly want to teach the patient about potassium-rich foods,
but this is not urgent. Oxygen is essential for the patient’s respiratory
problem but will not correct the low potassium, nor will IV normal saline.
Focus: Prioritization.
Mr. W is receiving an IV dose of potassium 10 mEq/100 mL
(10 mmol/100 mL) normal saline to run over 1 hour. The UAP asks the nurse
why it takes so long to infuse such a small amount of fluid. What should the
nurse explain to the UAP? Select all that apply.
1. “IV potassium is very irritating to the veins and can cause phlebitis.”
2. “Tissue damaged by potassium can become necrotic.”
3. “Oral potassium can cause nausea, so IV potassium is preferred.”
4. “The maximum recommended infusion rate for IV potassium is 5 to
10 mEq/hr (5 to 10 mmol/hr).”
5. “That’s a good question, and I will ask the HCP if I can give the drug IV
push.”
6. “The goal is to prevent infiltration into the tissue.”
Ans: 1, 2, 4, 6 A dilution no greater than 1 mEq (1 mmol) of potassium to
10 mL of solution is recommended for IV administration. The maximum
recommended infusion rate is 5 to 10 mEq/hr (5 to 10 mmol/hr); this rate is
never to exceed 20 mEq/hr (20 mmol/hr) under any circumstances. In
accordance with National Patient Safety Goals, potassium is not given by IV
push to avoid causing cardiac arrest. Oral potassium can cause nausea, and
vomiting (give it with food to prevent this), but this does not answer the
UAP’s question. Focus: Prioritization, Supervision.
During morning rounds, the nurse notes all of these assessment findings for
Mr. W. Which finding indicates a worsening of the patient’s condition?
1. Barrel-shaped chest
2. Clubbed fingers on both hands
3. Crackles bilaterally
4. Frequent productive cough
Ans: 3 Barrel chest and clubbed fingers are signs of COPD. The patient had a
productive cough on admission to the hospital. Bilateral crackles are a new
finding and indicate fluid-filled alveoli and pulmonary edema. Fluid in the
alveoli affects gas exchange and can result in worsening ABG concentrations.
Focus: Prioritization.
The nurse reports the morning assessment findings (see question 11) to the
HCP. Which prescribed intervention is most directly related to the nurse’s
assessment findings?
1. Administer furosemide 20 mg IV push now.
4512. Keep accurate records of intake and output.
3. Administer potassium 20 mEq (20 mmol) orally every morning.
4. Weigh the patient every morning.
Ans: 1 Furosemide is a loop diuretic. The uses of this drug include treatment
of pulmonary edema, which is most directly related to the new finding.
Intake and output records and daily weights are important in documenting
the effectiveness of the medication. A side effect of this drug is hypokalemia,
and some patients are also prescribed a potassium supplement when taking
this medication. Focus: Prioritization.
Which assessment finding would the nurse instruct the UAP to report
immediately?
1. Incontinence of urine and stool
2. 1-lb (0.45-kg) weight loss since admission
3. Patient cough productive of greenish-yellow sputum
4. Eating only half of breakfast and lunch
Ans: 3 The patient’s temperature was elevated on admission, and his cough
455was productive. The changes in Mr. W’s sputum could indicate an ongoing
infection. The HCP needs to be notified and an appropriate treatment plan
started. All of the other pieces of information are important but are not
urgent. The patient’s incontinence is not new. Focus: Supervision,
Prioritization.
The UAP checks morning vital signs and immediately reports the following
values to the nurse. Which takes priority when notifying the HCP?
1. Heart rate of 96 beats/min
2. Blood pressure of 160/90 mm Hg
3. Respiratory rate of 34 breaths/min
4. Oral temperature of 103.5°F (39.7°C)
Ans: 4 The heart rate and blood pressure are slightly increased from
admission, and the respiratory rate is slightly decreased. The continued
elevation in temperature indicates a probable respiratory tract infection that
needs to be recognized and treated. Focus: Prioritization.
An LPN/LVN tells the RN that the patient is now receiving oxygen at
2 L/min via nasal cannula and his pulse oximetry reading is now 91%, but he
still has crackles in the bases of his lungs. What intervention should the RN
assign to the LPN/LVN?
1. Begin creating a plan for discharging the patient.
2. Administer furosemide 20 mg orally each morning.
3. Get a baseline weight for the patient now.
4. Administer cefotaxime IV piggyback every 6 hours.
Ans: 2 Discharge planning and IV administration of antibiotics are more
appropriate to the scope of practice of the RN. However, in some states,
LPN/LVNs with special training may administer IV antibiotics. (Be aware of
state regulations and nursing practice laws in your state.) Administering oral
medications is appropriate to assign to LPN/LVNs, and in this case,
furosemide may help clear up the crackles. Although the LPN/LVN could
weigh the patient, this intervention is also appropriate to the scope of practice
of the UAP. Focus: Assignment, Supervision.
