Breathing PatternsJean Flick, RN, MS

Meet the Client: Josh HaskellJosh Haskell, a 9-year-old boy, is brought to the Emergency Department by his mother because he is short of breath and unable to sleep, due to coughing.

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 chest expansion for 15 seconds and multiply by 4.

Since the respirations are rapid and shallow, this technique will probably result in an inaccurate determination of Josh's respiratory rate.

B. Encourage Josh to breathe as deeply and slowly as possible.

This will provide false data about the client's respiratory rate.

C. Watch for nasal flaring and count the air exchanges with each movement.

Observable nasal flaring may not be present consistently; therefore, this technique does not promote an accurate determination of Josh's respiratory rate.

D. Correct Place a hand on Josh's chest and count the hand motion.

This technique allows the nurse to observe and count the chest movement, even when respirations are shallow.

2. Josh's respiratory rate is 36.

How should the nurse describe Josh's respiratory pattern?

A. Eupnea.

A normal respiratory rate.

B. Bradypnea.

A slow respiratory rate.

C. Correct Tachypnea.

A rapid respiratory rate, which is consistent with Josh's rate of 36. Normal respiratory rate for a school-aged child is 16 to 30 breaths per minute. 

D. Orthopnea.

Difficulty breathing while lying flat.

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. Correct Measure oxygen saturation.

Oxygen saturation provides important data about the percentage of hemoglobin that is saturated with oxygen - a valuable reflection of the client's overall oxygenation.

B. Auscultate breath sounds.

This provides valuable assessment data, but it is not the most important assessment.

C. Measure capillary refill.

This provides valuable assessment data, but it is not the most important assessment.

D. Observe chest excursion.

This provides valuable assessment data, but it is not the most important assessment.

4. In assessing Josh's breath sounds, the nurse should ask him to perform which action?

A. Hold his breath for fifteen seconds.

The nurse will not be able to hear air movement if Josh holds his breath.

B. Repeat the phrase, "Ninety-nine."

This technique is used to assess tactile fremitus.

C. Cough deeply after each breath.

This is exhausting for the client and is not necessary.

D. Correct Breathe deeply through the mouth.

Josh should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breath sounds.

5. To measure capillary refill, the nurse must first perform which action?

A. Count Josh's radial pulse.

This is not necessary when measuring capillary refill.

B. Correct-Compress Josh's nailbed.

To measure capillary refill, the nurse should first compress the client's nailbed, and then observe the return of normal color to the nailbed. 

C. Obtain a healthcare provider's prescription.

Measurement of capillary refill is part of the nurse's routine assessment. No prescription is necessary.

D. Elevate the extremity to be assessed.

It is not necessary to elevate the extremity when measuring capillary refill

6. Which response is best for the nurse to provide?

A. "Yes, but the pain will only last a very short time."

It is important to be honest with children who will experience pain. However, the finger clip does not cause pain when applied.

B. "No, you will not even know the clip is on your finger."

While it is correct that the finger clip is not painful, Josh will probably feel it on his finger.

C. Correct "The clip feels like squeezing your finger with your other hand."

This is an honest response to Josh's question regarding pain and one that places the sensation he will feel in a context he can understand

D. "You seem to be worried about experiencing pain."

This is a therapeutic communication technique, but, in this situation, it is most important to directly answer Josh's question, rather than encourage further discussion about the possibility of pain.

7. 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.

The cannula can be secured in this manner, but a snug fit is not the most important consideration.

B. Correct Remind client and family that oxygen is combustible and must be kept 10 feet away from open flames.

Oxygen supports combustion and is essential to ensure client safety during oxygen

administration.  Make sure the humidifier always contains some water.

Adequate humidification reduces the drying effect of the oxygen on the mucus membranes but is not the most important consideration.

C. Keep some type of padding around the ears and over the cheekbones.

Padding reduces the risk of pressure sores, but this is not the most important consideration.

8. Which nursing diagnosis is most relevant to Josh's current status?

A. Excess fluid volume.

Although Josh is producing a large amount of sputum, he is not exhibiting any symptoms of systemic fluid volume overload.

B. Impaired spontaneous ventilation.

Josh's altered respiratory function is not severe enough to be described as respiratory failure.

C. Correct Impaired gas exchange.

Normal saturation is 95-100%. Josh's oxygen saturation is well below normal, indicating that his gas exchange is impaired.

D. Decreased cardiac output.

The assessment information provided does not support this diagnosis.

9. Which assessment finding further supports diagnosis?

A Correct Restlessness & fatigue.

Restlessness and fatigue are indications of hypoxia. Restlessness is an early sign of hypoxia that is often missed.  

B Skin is warm and flushed.

The client with impaired gas exchange will not manifest warm, flushed skin as a result of this problem. However, this may be a manifestation of an infection resulting in impaired gas exchange.

C Complaints of being thirsty.

The client with impaired gas exchange will not manifest thirst as the result of this problem.

D Blood pressure of 102/62.

This is a normal blood pressure for a 9-year-old child. Normal BP ranges for children aged 6 to 12 years are 80 to 120 systolic and 45 to 70 diastolic

10. After determining the priority nursing diagnoses, what step should the nurse take next in developing the plan of care?

A. Determine the need for client teaching.

The nurse should determine the need for client teaching while gathering data and establishing the priority diagnoses.

B. Reassess Josh for any changes.

This is not the correct step in the nursing process that is used following data analysis.

C. Implement the priority nursing actions.

The nurse must first use another step of the nursing process before the implementation of nursing actions.

D. Correct Establish goals and expected outcomes.

After analysis of the data to prioritize nursing diagnoses, the nurse should establish nursing care goals and expected outcomes.

11. Which outcome statement should the nurse use for Josh's plan of care?

A Incorrect The client will receive oxygen at 2 L/minute per nasal cannula.

This is a nursing intervention, rather than an outcome statement.

B The client's oxygen saturation will be monitored continuously.

This is a nursing intervention, rather than an outcome statement.

C Correct The client's oxygen saturation will be >95% on room air.

This client-centered outcome statement describes the desired outcome in measurable terms.

D The client's respiratory function will be stable.

This statement is broad and vague, and it does not provide a measurable outcome.

Monitoring 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.

12. What action should the nurse implement prior to applying the sensor?

A. Correct Determine if Josh has a latex allergy.

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. 

B. Clean the site with an iodine solution.

This is a non-invasive procedure. Cleansing the site with an antiseptic solution is not necessary.

C. "Milk" the capillary blood flow of the site.

This technique is sometimes used to obtain a capillary blood sample for glucose measurement. However, it is not used to obtain oxygen saturation readings.

D. Apply gauze padding to protect the skin.

Padding is not necessary to protect the skin, and it may interfere with measurement of the oxygen saturation.

After receiving oxygen for a short while, Josh is much less dyspneic. The nurse notes that the oxygen saturation reading is 97%. Fifteen minutes later, the oxygen saturation alarm indicates that the reading has changed to 80%.

13. What immediate action(s) should the nurse implement? (Select all that apply.)

A Correct Reposition the finger clip and obtain another reading.

Since Josh is not in any distress, the nurse should first reapply the clip and obtain another reading to confirm the sudden drop in oxygenation.

B Correct Assess Josh for signs and symptoms of respiratory distress.

Assessment for signs and symptoms of respiratory distress is a priority.

C Correct Encourage Josh to begin coughing and deep breathing.

Coughing helps to clear mucous from airway which will allow for optimal lung expansion.

D Increase the oxygen flow to 3–4 liters/minute.

This might be an important action to take, but only after another action is taken.

E Notify the healthcare provider immediately.

This will be important if the immediate actions taken by the nurse do not change the reading of the O2 saturation monitor.

14. 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."

This is patronizing and offers false reassurance.

B. "I worried just like you when my son was sick."

This moves the conversation away from being client-centered and toward being nurse-centered.

C. "Perhaps you would rather wait outside."

This will not encourage further communication.

D. Correct "It sounds like this has been a very frightening experience for you."

This open-ended statement acknowledges the difficult situation the mother is experiencing and encourages further discussion.

After further conversation with Josh's mother, the nurse needs to leave the room to assess another client.

15. Which action by the nurse demonstrates the use of trust in the nurse-client relationship?

A. Teaching Josh and his mother how to read the oximeter.

This demonstrates caring by the nurse and promotes client autonomy but is not an example of the concept of trust.

B. Correct Returning to the room at the time promised.

Trust and rapport is important to develop during the orientation stage so the client has the most optimal outcome.

C. Offering the mother reassurance that Josh is stable.

This action demonstrates caring and beneficence and promotes good but is not an example of the concept of trust.

D. Providing a phone so that Josh's mother can call home.

This action demonstrates caring and beneficence and promotes good but is not an example of the concept of trust.

16. Which documentation reflects subjective data?

A. Client's respirations are 36/minute.

This is objective data observed by the nurse.

B. Client appears to be very anxious.

This is objective data observed by the nurse. Better documentation would be to describe the data that has resulted in the nurse's analysis that the client appears to be very anxious.

C. Client's mother is present in the room.

This is objective data observed by the nurse.

D. Correct Client reports that he is coughing a lot.

Subjective data is the information reported by the client.

17. Which documentation best reflects the nurse's objective assessment?

A. Client reports that he has been coughing up large amounts of sputum.

This is subjective data based on Josh's reported information.

B. Correct Frequent deep cough, producing small amounts of pale yellow sputum.

This is an objective report of the nurse's observations. This documentation provides a thorough description of the cough and the sputum produced.

C. Client seems anxious and short of breath, and he has a constant productive cough.

This documentation provides some objective data, but it is incomplete.

D. Cough is frequent, and the client produces some yellow sputum when he coughs.

This provides some objective data, but it is incomplete.

Upon further observation the nurse describes Josh's sputum as "Tenacious."

18. To what does this refer?

A. Color.

"Tenacious" does not refer to color.

B Odor.

"Tenacious" does not refer to odor.

C Frequency.

"Tenacious" does not refer to frequency.

D Correct Consistency.

Sputum with a thick consistency may be described as "Tenacious" (sticking together).

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.

19. In assisting Josh to obtain a sputum specimen, what action should the nurse take?

A. Correct Instruct Josh to cough deeply from the chest and spit into the specimen cup.

This technique is the least invasive and will provide sputum 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. 

B. Gently wipe a sterile cotton-tipped applicator along the back of the oropharynx.

This technique is used to obtain a throat culture rather than a sputum specimen.

C. Insert a soft-tipped catheter through the nares to suction secretions.

This invasive technique may be used for a client who is unable to cough up a sputum specimen.

D. Use a hard-tipped Yankauer catheter device to remove oral secretions.

This technique is primarily used to clear mucus secretions from the mouth of a client who is unable to cough to remove these secretions.

.

The patient care technician is planning to transport the sputum specimen to the lab.

20.: Which instructions should the nurse provide?

E. Wear clean gloves to carry the specimen to the lab.

This is not the best protection for transporting body fluids.

F. Correct Place the specimen cup in a biohazard bag for transport.

This protects the person transporting the specimen, as well as the lab personnel receiving the specimen. 

G. Don gloves and a gown for the best protection.

This is more protection than is needed.

H. Wash your hands after carrying the cup to the lab.

This does not provide adequate protection during specimen transport.

Medication Administration

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."

21. How should the nurse respond?

A. "This sounds like a mistake. Take 1 pill with each dose."

This will lead to the administration of an inaccurate dose.

B. "Two pills every 12 hours is the usual dose."

This will lead to the administration of an inaccurate dose.

C. "Let me contact the pharmacist to clarify these directions."

This is not necessary.

D. Correct "A large first dose allows the medication to start working faster."

A large first dose, called a loading dose, is often used to achieve a therapeutic level more rapidly in the bloodstream.

The liquid cough syrup is labeled as an antitussive.

22. The nurse explains that this medication should have what effect?

A Liquefy the respiratory secretions.

The class of medication used to liquefy respiratory secretions is expectorant.

B Correct Reduce the frequency of the cough.

Antitussives are used to reduce the frequency of a cough. This may be desirable for Josh at night, to allow him to sleep.

C Decrease any pain with coughing.

Medications that reduce pain are analgesics.

D Prevent nausea due to the sputum.

Medications that prevent nausea are antiemetics.

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.

23. To what level should the medication be poured?

A. 5 ml.

Review dosage conversion and recalculate!

B. Correct 10 ml.

Each teaspoon contains 5 ml. Two teaspoons equals 10 ml. 5 ml × 2 = 10 ml

C. 20 ml.

Review dosage conversion and recalculate!

D. 30 ml.

Review dosage conversion and recalculate!

Breath Sounds

Josh and his mother return to the healthcare provider's office 1 week later, after Josh has completed the course of antibiotic therapy.

24. In assessing Josh's breath sounds, where should the nurse listen first?

A. Lung bases.

Thorough and systematic auscultation of breath sounds generally begins at another location and ends at the bases of the lungs.

B. Correct Lung apices.

An accepted method for lung auscultation is to begin at the top of the chest, comparing one side of the chest to the other, moving downward in a systematic method, finishing at the lung base.

C. Aortic site.

This is the location where the nurse will begin assessment of heart sounds.

D. Pulmonic site.

This is one of the sites where the nurse will auscultate heart sounds.

The nurse auscultates vesicular breath sounds in the peripheral lung fields.

25. What action should the nurse take?

A. Correct Record the presence of clear breath sounds.

Vesicular breath sounds are a normal finding in the peripheral lung fields. 

B. Tell Josh's mother that his lungs are still congested.

Review the characteristics of vesicular lung sounds and try again.

C. Assist Josh to cough to clear his lungs and listen again.

Review the characteristics of vesicular lung sounds and try again.

D. Notify the healthcare provider of the abnormal lung sounds.

Review the characteristics of vesicular lung sounds and try again.

26. Which serum lab value confirms the resolution of Josh's infection?

A. Red blood cell count (RBC) 4.5 million/mm3.

This is a normal value for a child, but it does not confirm the resolution of the infection.

B. Correct White blood cell count (WBC) 6,000/mm3.

This is a normal value for a child, confirming the resolution of the infection. Infection generally causes an elevation in the WBC

C. Hemoglobin at 12 g/dl.

This is a normal value for a child, but it does not confirm the resolution of the infection.

D. Hematocrit at 40%.

This is a normal value for a child, but it does not confirm the resolution of the infection.

Case Outcome- Josh is discharged from his healthcare provider's care and is happy to resume his normal activities with no further cough or dyspnea.