HESI Breathing Patterns Flashcards
Mother brings her nine-year-old to the emergency department because she’s short of breath and unable to sleep, due to coughing.
The nurse assesses the clients vital signs. His respirations are rapid in shallow. What technique should the nurse use to accurately assess the respirations?
Place a hand on the client upper abdomen and observe the rise and involve the chest.
Rationale: this technique allows the nurse to observe and count each ventilatory cycle, even when respirations are shallow.
Because of the clients dyspnea, the nurse is concerned that he may need to to receive oxygen. Which assessment should the nurse perform that would be the most indicative of the need for supplemental oxygen?
Measure oxygen saturation
Rationale: Oxygen saturation provides important data about the percentage of hemoglobin that is saturated with oxygen – – value reflection of the clients overall oxygenation.
When assessing breath sounds, the nurse to demonstrate and ask the nine-year-old to perform, which action.
Breathe deeply through the mouth.
Rationale: the child should be instructed to breathe slowly and deeply through a slightly open mouth to allow best auscultation of breath sounds.
The clients mother states that this is the third time in the recent months she has brought him to the ED with a cough and shortness of breath. The nurse asked the mother how many respiratory or other indications he had within the past year. What is the nurses purpose for this question?
To assess for a possible immune deficiency disorder.
Rationale: Preschool and school aged children may have 6 to 12 infections per year. The clinical hallmark of immune physicians attend to develop an unusual occurrence, severe infections.
To measure capillary refill, the nurse must first perform which action?
Compress the nail bed of one finger until blanched.
Rationale: To measure cap refill, the nurse should first compress, the clients, nail bed, then note how many seconds it takes for the return of normal color to the nail bed.
Pulse oximetry
The nurse plans to measure the child’s oxygen saturation with the spring tension finger clip.
Well, the nurse is explaining this procedure, the client asks if it will hurt. Which response by the nurse is best?
The clip feels like a clothes pain, squeezing your finger
Rationale: this is an honest response to the child’s question regarding pain, and one that places the sensation he will feel in a context he can understand.
The nurse measures the child’s oxygen saturation at 88% and capillary refill at one second. Birthstones are absent in the bases and course bilaterally through the rest of of the lung field. The nurse initiates application of nasal cannula and administer oxygen at 2 L/minute per facility protocol.
Prior to applying a nasal cannula in the ED, which action is most important for the nurse to implement to ensure client safety?
Determine that all electrical equipment in the room is functioning correctly and is properly grounded.
Rationale: An electrical spark in the presence of oxygen can result in a serious fire.
Which is the most important approach for the nurse to use when applying in nasal cannula?
Make sure that the tip in the nasal prongs are aimed into the nares.
Rationale: This section directs the flow of action into the clients upper respiratory tract.
Nursing plan of care
Which nursing diagnosis is the most relevant to the clients current status?
Impaired gas exchange.
Rationale: Normal saturation is 95 to 100%. The child’s oxygen saturation as well below normal, indicating that the gas exchange is impaired.
Which assessment finding further support diagnosis?
Restlessness and dyspnea.
Rationale: restlessness, and Dheepa are indications of hypoxia. Restlessness is an early sign of hypoxia that is often missed.
After determining the priority, nursing diagnosis, what step should the nurse take next in developing the plan of care?
Establish goals and expected outcomes.
Rationale: After an analysis of the data to prioritize nursing diagnosis, the nurse should establish nursing care goals, and expected outcomes.
Which outcome statement should the nurse use for the plan of care?
The child’s oxygen saturation will be greater than 95% on room air.
Rationale: the client sent it outcome statement describes the desired outcome in measurable terms.
Morning oxygen saturation
To achieve the desired outcome, the nurse has initiated the prescribed oxygen therapy. After applying the nasal cannula, the nurse plans to attach a disposable sensor pad to measure the oxygen saturation continuously.
What action should the nurse implement prior to applying the sensor?
Determine if the child has a latex allergy.
Rationale: the disposable sensor pads may be made of latex. If they are, the nurse should confirm that the client does not have a latex sensitivity or allergy.
After receiving oxygen, for a short while, the child is much less dyspneic. The nurse notes for the oxygen saturation reading is 97%. 15 minutes later, the saturation alarm indicates that the reading has changed to 80%.
Which actions should the nurse implement immediately? (SATA)
Reposition the clip, and obtain another reading
Rationale: Since the child is not in any distress, the nurse should first reapply the clip, and obtain another reading to confirm the sudden drop in oxygenation.
Assess for signs and symptoms of respiratory distress
Rationale: Assessment for signs and symptoms of respiratory distress is a priority.
Encourage deep breathing
Rationale: Coughing helps to clear mucus from the airway, which will allow for optimal lung expansion.
Therapeutic communication
After the nurse repositions the finger clip, the oxygen saturation reading returns to 97%. Despite the normal reading, the client mother appears worried and nervous and states, he 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 frightening experience for you.
Rationale: This open ended statement acknowledges the difficult situation. The mother is experiencing and encourages for the discussion.
The child’s mother further states that she’s worried her two-year-old daughter at home may become ill. What is an appropriate and therapeutic response to the mother’s concern concerned about her daughter?
There’s a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms.
Rationale: Viral infections can spread from person to person by droplets from sneezing or coughing and by direct contact. Colds are most contagious in the first 2 to 3 days after symptoms appear, so the sibling is at risk and the mother should be informed.
Ethical considerations
Have further conversation with a client, mother, the nurse needs to leave the room to assess another client.
What action by the nurse demonstrates the use of trust in the nurse client relationship
Returning to the room at the time promised.
Rationale: Trust and report is important to develop during the orientation stage of the client has the most optimal outcome.
Documentation skills
Upon returning to the room, the nurse hears and sees the child coughing. She assesses the cough further.
Which documentation reflects subjective data?
The client and his mother states he has a cough.
Rationale: this is subjective as it is the client and his mothers reported symptom.
Which documentation best reflects the nurses objective assessment?
His deep cough produces a small amount of pale yellow sputum.
Rationale: This is an objective report of the nurses observation. The documentation provides a thorough description of the cough and sputum produced.
Upon further observation, the nurse describes the child sputum as tenacious. To what does tenacious refer?
Consistency.
Rationale: speed him with a thick consistency may be described as tenacious (sticking together).
Laboratory specimen, collection
Since the child has a productive cough, the HCP orders, a sputum specimen be obtained, and sent to the lab for culture and sensitivity.
When assisting the child to obtain a speed of specimen, what action should the nurse take?
Insert demonstrate how to coffee deeply from the chest and spit into the specimen cup.
Rationale: This technique is the least invasive, and will provide speed rather than mucus. A client who is alert, able to follow directions, and has a productive cough, can obtain a specimen without the use of an invasive catheter.
The client care technician plans to transport the sputum specimen to the lab. Which instructions should the nurse provide?
Wear clean gloves to place the specimen cup in hazard bag for transport.
Rationale: This protects the person, transporting the specimen, as well as the lab personnel, receiving the specimen.
DCPA prescribes, a complete blood count (CBC) as part of the diagnostic work up. Which is the best explanation for the HPC prescription?
A CBC is obtained to assess for an elevated WBC count, which is a common finding pneumonia except an older adults.
Rationale: The HPS is concerned that the child may have pneumonia.
