HESI Case study MODULE 1 Breathing patterns – Flashcards

1. The nurse assesses Josh's vital signs. His respirations are rapid and shallow. What is the best technique for the nurse to use to assess Josh's respirations accurately? A. Observe the chest expansions for 15 seconds and multiply by 4. B. Encourage Josh to breathe as deeply and slowly as possible. C. Watch for nasal flaring and count the air exchanges with each movement. D. Place a hand on Josh's chest and count the hand motion.

2. Josh's respiratory rate is 36. How should the nurse describe Josh's respiratory pattern? A. Eupnea. B. Bradypnea. C. Tachypnea. D. Orthopnea.

3. Because of Josh's dyspnea, the nurse is concerned that he may need to receive oxygen. To determine the need for the application of a nasal cannula, which assessment is most important for the nurse to perform? A. Measure oxygen saturation. B. Auscultate breath sounds. C. Measure capillary refill. D. Observe chest excursion.

4. In assessing Josh's breath sounds, the nurse should ask him to perform which action? A. Hold his breath for fifteen seconds. B. Repeat the phrase "Ninety-nine." C. Cough deeply after each breath. D. Breathe deeply through the mouth.

5. To measure capillary refill, the nurse must first perform which action? A. Count Josh's radial pulse. B. Compress Josh's nailbed. C. Obtain a healthcare provider's prescription. D. Elevate the extremity to be assessed.

6. The nurse plans to measure Josh's oxygen saturation with a spring-tension finger clip. While the nurse is explaining this procedure, Josh asks if it will hurt. Which response is best for the nurse to provide? A. "Yes, but the pain will only last a very short time." B. "No, you will not even know the clip is on your finger." C. "The clip feels like squeezing your finger with your other hand." D. "You seem to be worried about experiencing pain."

7. The nurse measures Josh's oxygen saturation at 88% and capillary refill is at 1 second. Breath sounds are absent in the base and coarse bilaterally throughout the rest of the lung fields. The nurse applies a nasal cannula and administers oxygen at 2 liters per minute. When applying a nasal cannula, it is most important for the nurse to provide which instructions? A. Make sure the cannula tubing stays snugly around the ears and under the chin. B. Remind client and family that oxygen is combustible and must be kept 10 feet away from open flames. C. Make sure the humidifier always contains some water. D. Keep some type a padding around the ears and over the cheekbones.

8. Which nursing diagnosis is most relevant to Josh's current status? A. Excess fluid volume. B. Impaired spontaneous ventilation. C. Impaired gas exchange. D. Decreased cardiac output.

9. Which assessment finding further supports diagnosis? A. Restlessness & fatigue. B. Skin is warm and flushed. C. Complaints of being thirsty. D. Blood pressure of 102/62.

10. After determining the priority nursing diagnosis, what step should the nurse take next in developing the plan of care? A. Determine the need for client teaching. B. Reassess Josh for any changes. C. implement the priority nursing actions. D. Establish goals and expected outcomes.

11. Which outcome statement should the nurse use for Josh's plan of care? A. The client will receive oxygen at 2 L/minute per nasal cannula. B. The client's oxygen saturation will be monitored continuously. C. The client's oxygen saturation will be > 95% on room air. D. The client's respiratory function will be stable.

12. 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? A. Determine if Josh has a latex allergy. B. Clean the sire with an iodine solution. C. "Milk" the capillary blood flow of the site. D. Apply gauze padding to protect the skin.

13. After receiving oxygen for a short while, Josh is much less dyspneic. The nurse notes that the oxygen saturation is reading 97%. Fifteen minutes later, the oxygen saturation alarm indicates that the reading has changed to 80%. What immediate action(s) should the nurse implement? (Select all that apply.) A. Reposition the finger clip and obtain another reading. B. Assess Josh for signs and symptoms of respiratory distress. C. Encourage Josh to begin coughing and deep breathing. D. Increase the oxygen flow to 3-4 liters/minute. E. Notify the healthcare provider immediately.

14. After the nurse repositions the finger clip, the oxygen saturation reading returns to 97%. Despite the normal reading, Josh's mother appears worried and nervous 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? A. "Josh will be just fine. You don't need to worry." B. "I worried just like you when my son was sick." C. "Perhaps you would rather wait outside." D. "It sounds like this has been a very frightening experience for you."

15. After further conversation with Josh's mother, the nurse needs to leave the room to assess another client. Which action by the nurse demonstrates the use of trust in the nurse-cliet relationship? A. Teaching Josh and his mother how to read the oximeter. B. Returning to the room at the time promised. C. Offering the mother reassurance that Josh is stable. D. Providing a phone so that Josh's mother can call home.

16. Upon returning to the room, the nurse assesses Josh's cough. Which documentation reflects subjective data? A. Client's respirations are 36/minute. B. Client appears to be very anxious. C. Client's mother is present in the room. D. Client reports that he is coughing a lot.

17. Which documentation best reflects the nurse's objective assessment? A. Client reports that he has been coughing up large amounts of sputum. B. Frequent deep cough, producing small amounts of pale yellow sputum. C. Client seems anxious and short of breath, and he has a constant productive cough. D. Cough is frequent, and the client produces some yellow sputum when he coughs.

18. Upon further observation the nurse describes Josh's sputum as "Tenacious." To what does this refer? A. Color. B. Odor. C. Frequency. D. Consistency.

19. Since Josh has a productive cough, the healthcare provider requests that a sputum specimen be obtained and sent to the lab for culture and sensitivity. In assessing Josh to obtain a sputum specimen, what action should the nurse take? A. Instruct Josh to cough deeply from the chest and spit into the specimen cup. B. Gently wipe a sterile cotton-tipped applicator along the back of the oropharynx. C. Insert a soft-tipped catheter through the nares to suction secretions. D. Use a hard-tipped Yankauer catheter device to remove oral secretions.

20. The patient care technician is planning to transport the sputum specimen to the lab. Which instructions should the nurse provide? A. Wear clean gloves to carry the specimen to the lab. B. Place the specimen cup in a biohazard bag for transport. C. Don gloves and a gown for the best protection. D. Wash your hands after carrying the cup to the lab.

21. The healthcare provider determines that Josh has a respiratory tract infection and prescribes an oral antibiotic and an oral liquid cough syrup. Josh's mother obtains the medications at the pharmacy and shows them to the nurse. The prescription 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. "This sounds like a mistake. Take 1 pill with each dose." B. "Two pills every 12 hours is the usual dose." C. "Let me contact the pharmacist to clarify these directions." D. "A large first dose allows the medication to start working faster."

22. The liquid cough syrup is labeled as an antitussive. The nurse explains that his medication should have what effect? A. Liquefy the respiratory secretions. B. Reduce the frequency of the cough. C. Decrease any pain with coughing. D. Prevent nausea due to the sputum.

23. The medication label states, "take 2 teaspoonfuls every 4 hours as needed." The nurse gives Josh some medication cups and teaches him and his mother how to pour the medication into the cup. To what level should the medication be poured? A. 5 ml. B. 10 ml. C. 20 ml. D. 30 ml.

24. Josh and his mother return to the healthcare provider's office 1 week later, after Josh has completed the course of the antibiotic therapy. In assessing Josh's breath sounds, where should the nurse listen first? A. Lung bases. B. Lung apices. C. Aortic site. D. Pulmonic site.

25. The nurse auscultates vesicular breath sounds in the peripheral lung fields. What actions should the nurse take? A. Record the presence of clear breath sounds. B. Tell Josh's mother that his lungs are still congested. C. Assist Josh to cough to clear his lungs and listen again. D. Notify the healthcare provider of the abnormal lung sounds.

26. Which serum lab value confirms the resolution of Josh's infection? A. Red blood cell count (RBC) 4.5 million/mm^3. B. White blood cell count (WBC) 6,000/mm^3. C. Hemoglobin at 12g/dl. D. Hematocrit at 40%.

Case outcome