After change of shift, the nurse has the following patients on her assignment. Which one should she see first?
A 50-year-old with COPD and a Spo2 of 90%
A 72-year-old with pneumonia who needs his antibiotic
A 37-year-old with asthma who reported that he is still having shortness of breath after using his inhaler
A68-year-old on a CPAP who needs a sputum specimen sent to the lab
The Correct Answer is C
C. Persistent shortness of breath after using an inhaler could indicate an inadequate response to treatment or worsening asthma exacerbation. The nurse should therefore see this patient first.
A. In COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable. In the treatment of exacerbations of chronic obstructive pulmonary disease (COPD), oxygen should be titrated to achieve a target oxygen saturation range of 88-92%. This results in a greater than twofold reduction in mortality, compared with the routine administration of high-concentration oxygen therapy.
B. Administering antibiotics can be prioritized, but it may not require immediate attention compared to addressing acute respiratory distress or hypoxemia.
D. Collecting a sputum specimen for laboratory analysis is important for diagnosing and managing respiratory infections, but it may not be as time-sensitive as addressing acute respiratory distress or hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Holding the breath for at least 10 seconds after inhaling the medication allows the medication to settle in the lungs and increases its effectiveness. This ensures maximum delivery of the drug to the respiratory tract.
B. The recommended time to wait between inhalations is typically around 1 to 2 minutes, not 10 minutes. Waiting too long between puffs may reduce the effectiveness of the medication and is not necessary.
C. There is no specific recommendation that the inhaler must be held with the non-dominant hand. The inhaler should be held in the hand that feels most comfortable and provides the best control, which is usually the dominant hand for most people.
D. The correct technique involves tilting the head slightly back to open the airway, making it easier for the medication to reach the lungs. Tilting the head forward could restrict the airflow and reduce the effectiveness of the inhalation.
Correct Answer is C
Explanation
C. Pursed lip breathing is a technique that can help patients with acute dyspnea by improving ventilation, prolonging exhalation, and reducing the work of breathing. It helps to keep the airways open longer and makes it easier to get rid of excess carbon dioxide, which can provide quick relief from acute shortness of breath.
A. Teaching the patient about using accessory muscles for breathing can be beneficial in managing chronic respiratory issues, but it is not an immediate intervention.
B. Understanding the cause of dyspnea is important for treatment planning but it is not the first action to take when the patient is experiencing acute shortness of breath.
D. The Sims position, where the patient lies on their side with the lower arm behind the back and the upper leg flexed, is not typically used for relieving acute respiratory distress.
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