Nokea
A nurse is caring for a patient admitted for an acute asthma exacerbation. The patient reports extreme dyspnea, stating, 'Turn up the oxygen, I'm not getting enough air.' Which actions would the nurse take first?
- A. Suction the airway.
- B. Assess the pulse oximetry reading.
- C. Obtain a peak flow meter reading.
- D. Assess for cyanosis of the lips.
Correct Answer: B
Rationale: Using the nursing process, the nurse first assesses the oxygen saturation via pulse oximetry before changing the oxygen flow rate. Suctioning is provided to remove respiratory secretions; the nurse would note adventitious breath sounds or phlegm with cough indicating a need for suction. A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. While cyanosis of the lips is a late sign of hypoxemia, the nurse can quickly begin to alleviate or lessen dyspnea by simply repositioning the patient.
You may also like to solve these questions
A nurse is caring for a patient who has a pleural chest tube attached to a disposable chest drainage system. Which nursing actions are indicated for this patient?
- A. Avoiding turning the patient to prevent disconnections in the tubing
- B. Maintaining an occlusive dressing on the site
- C. Assessing the patient for signs of respiratory distress
- D. Keeping the chest drainage device at the level of the patient's thorax
- E. Ensuring there are no dependent loops or kinks in the tubing
- F. Observing for bubbles indicating air leak in the water seal chamber
Correct Answer: B,C,E,F
Rationale: The chest drainage collection device must be positioned below the tube's insertion site. Maintaining an occlusive dressing helps prevent air leak; assess for crepitus around the chest tube site indicating air leak. Avoid dependent loops or kinks in the tubing, which could impede drainage. Assess for bubbling in the water seal, maintaining the water level at the 2-cm mark. When a chest tube becomes separated from the drainage device, the nurse should submerge the tube's end in water, creating a temporary water seal and allowing air to escape until a new drainage unit can be attached.
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
- A. Assisting with all bathing and hygiene
- B. Telling the patient to avoid speaking during hygiene
- C. Teaching the patient to take short shallow breaths during activity
- D. Taking rest periods between activities
Correct Answer: D
Rationale: To prevent fatigue during activities including hygiene, the nurse should group (personal care) activities into smaller steps and encourage rest periods between activities. The nurse promotes and maintains dignity, independence, and strength by assisting with activities when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits and teach the patient to coordinate pursed-lip or diaphragmatic breathing with the activity.
A student with a history of asthma visits the school nurse reporting difficulty breathing and wheezing. Which tool would the nurse use to assess the severity of airway resistance?
- A. Peak flow meter
- B. End-tidal CO2 monitor
- C. Chest tube
- D. Arterial blood gas
Correct Answer: A
Rationale: A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used by and for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. Capnography or end-tidal CO2 monitoring is used for assessing and monitoring ventilation and placement of artificial airways, predicting patients who are at risk for respiratory compromise, are experiencing partial or complete airway obstruction, or are experiencing hypoventilation. A chest tube is used to remove air or fluid from the pleural space. The arterial blood gas (ABG) is used to assess oxygenation, ventilation, and acid-base status; it is invasive and not performed in the school setting.
A nurse in the emergency department is caring for a patient who had eaten shellfish and is now wheezing. The nurse explains to the patient that the health care provider has prescribed a bronchodilator, which will have what action?
- A. Helping the patient cough up thick mucus
- B. Opening narrowed airways and relieving wheezing
- C. Acting as a cough suppressant
- D. Blocking the effects of histamine
Correct Answer: B
Rationale: A bronchodilator opens narrowed airways which result in wheezing. An expectorant encourages cough to clear secretions. A cough suppressant reduces, treats, or stops a cough. Medications that block histamine (antihistamine) are often used for allergy but are not specific bronchodilators.
Which assessments and interventions should the nurse consider when performing tracheal suctioning?
- A. Closely assessing the patient before, during, and after the procedure
- B. Hyperoxygenating the patient before and after suctioning
- C. Limiting the application of suction to 20 to 30 seconds
- D. Monitoring the pulse to detect effects of hypoxia and stimulation of the vagus nerve
- E. Using an appropriate suction pressure (80 to 150 mm Hg)
- F. Inserting the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
Correct Answer: A,B,D,E,F
Rationale: Close assessment of the patient before, during, and after the procedure is necessary to identify complications such as hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. In addition, monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis caused by excessive negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage.