Case Study 2 Questions And Answers
Mr. nW nis nan n83-year-old nman nwho nwas nbrought nto nthe nhospital nfrom na nlong-term ncare nfacility
nby nemergency nmedical nservices nafter nreporting nsevere ndyspnea nand nshortness nof nbreath. nHe
nhas nbeen nexperiencing ncoldlike nsymptoms nfor nthe npast n2 ndays. nHe nhas na nproductive ncough
nwith nthick nyellowish nsputum. nWhen nMr. nW nawoke nin nthe nnursing nhome, nit nwas nfound nthat nhe
nwas nhaving ndifficulty nbreathing neven nafter nusing nhis nalbuterol nmetered-dose ninhaler n(MDI). nHe
nappears nvery nanxious nand nis nin nrespiratory ndistress. nHis nhistory nincludes nchronic nobstructive
npulmonary ndisease n(COPD) nrelated nto nsmoking n2 npacks nof ncigarettes nper nday nsince nhe nwas n15
nyears nold; nhe nquit nsmoking n2 nyears nago nwhen nhe nwas nadmitted nto nthe nlong-term nfacility. nMr.
nW nhas nbeen nincontinent nof nurine nand nstool nfor nthe npast n2 nyears.
In nthe nemergency ndepartment, nMr. nW nundergoes nchest nradiography, nand nadmission nlaboratory
ntests nare nperformed, nincluding nserum nelectrolyte nlev n- nAnswer n- n
Which n*priority* nactions nwill nthe nnurse ntake nwhen nthe npatient nis ninitially nadmitted nto nthe
nemergency ndepartment n(ED)? n*Select nall nthat napply.*
•Place nthe npatient non na ncardiac nmonitor
•Get na nbaseline nset nof nvital nsigns
•Draw nadmission nlabs nand nplace na nsaline nlock
•Change nthe npatient's nadult npad
•Send nthe npatient nfor na nchest nx-ray
•Order nthe npatient na nlunch ntray n- nAnswer n- n•Place nthe npatient non na ncardiac nmonitor
•Get na nbaseline nset nof nvital nsigns
•Draw nadmission nlabs nand nplace na nsaline nlock
•Send nthe npatient nfor na nchest nx-ray
•Baseline ndata nthat nare nessential nto ndecisions nfor nthe ncare nof nthis npatient ntake npriority nat nthis
ntime nincluding nvital nsigns, ncardiac nrhythm, nlab nvalues, nand nchest nx-ray nfindings. nPlacement nof
na nsaline nlock nis nessential nfor nadministration nof nfluids nand nemergency ndrugs. nChanging nthe
, npatient's nincontinence npad nis nimportant nto nprotect nhis nskin nbut nis nnot nurgent. nOrdering na
nlunch ntray nmay nbe npremature nbecause nthe ninterventions nfor nthis npatient's ncare nare nundecided
nwhen nhe nis nfirst nadmitted nto nthe nED.
What nis nthe n*priority* nnursing nconcern nfor nthis npatient?
•Skin ncare ndue nto nincontinence
•Clearance nof nthick nsecretions
•Rapid nheart nrate
•Elevated ntemperature n- nAnswer n- n•Clearance nof nthick nsecretions
•The npatient's nmajor nproblems nat nthis ntime nrelate nto nairway nand nbreathing nincluding nthick
nsputum, ndifficulty nbreathing, nand nrespiratory ndistress. nThe npatient's nskin ncare, nblood npressure,
nand nelevated ntemperature nwill nneed nto nbe nfollowed nup non nsoon nbut nare nnot nas nurgent nat
nthis ntime nas nhis nrespiratory nstatus.
The nRN nassesses nMr. nW nin nthe nemergency ndepartment. nWhich nassessment nfindings nare
nconsistent nwith na ndiagnosis nof nCOPD? n*Select nall nthat napply.*
•Enlarged nneck nmuscles
•Forward nbent nposture
•Respiratory nrate n15 nto n25 nbreaths/min
•Inspiratory nand nexpiratory nwheezes
•Blue-tinged ndusky nappearance
•Symmetrical nlung nexpansion n- nAnswer n- n•Enlarged nneck nmuscles
•Forward nbent nposture
•Inspiratory nand nexpiratory nwheezes
•Blue-tinged ndusky nappearance
•The npresence nof nwheezes, nenlarged nneck nmuscles, nbluish ndusky nappearance, nand nforward nbent
nposture nare nall nclassic nmanifestations nin na npatient nwith nCOPD. nThe nrespiratory nrate nis nusually
Mr. nW nis nan n83-year-old nman nwho nwas nbrought nto nthe nhospital nfrom na nlong-term ncare nfacility
nby nemergency nmedical nservices nafter nreporting nsevere ndyspnea nand nshortness nof nbreath. nHe
nhas nbeen nexperiencing ncoldlike nsymptoms nfor nthe npast n2 ndays. nHe nhas na nproductive ncough
nwith nthick nyellowish nsputum. nWhen nMr. nW nawoke nin nthe nnursing nhome, nit nwas nfound nthat nhe
nwas nhaving ndifficulty nbreathing neven nafter nusing nhis nalbuterol nmetered-dose ninhaler n(MDI). nHe
nappears nvery nanxious nand nis nin nrespiratory ndistress. nHis nhistory nincludes nchronic nobstructive
npulmonary ndisease n(COPD) nrelated nto nsmoking n2 npacks nof ncigarettes nper nday nsince nhe nwas n15
nyears nold; nhe nquit nsmoking n2 nyears nago nwhen nhe nwas nadmitted nto nthe nlong-term nfacility. nMr.
nW nhas nbeen nincontinent nof nurine nand nstool nfor nthe npast n2 nyears.
In nthe nemergency ndepartment, nMr. nW nundergoes nchest nradiography, nand nadmission nlaboratory
ntests nare nperformed, nincluding nserum nelectrolyte nlev n- nAnswer n- n
Which n*priority* nactions nwill nthe nnurse ntake nwhen nthe npatient nis ninitially nadmitted nto nthe
nemergency ndepartment n(ED)? n*Select nall nthat napply.*
•Place nthe npatient non na ncardiac nmonitor
•Get na nbaseline nset nof nvital nsigns
•Draw nadmission nlabs nand nplace na nsaline nlock
•Change nthe npatient's nadult npad
•Send nthe npatient nfor na nchest nx-ray
•Order nthe npatient na nlunch ntray n- nAnswer n- n•Place nthe npatient non na ncardiac nmonitor
•Get na nbaseline nset nof nvital nsigns
•Draw nadmission nlabs nand nplace na nsaline nlock
•Send nthe npatient nfor na nchest nx-ray
•Baseline ndata nthat nare nessential nto ndecisions nfor nthe ncare nof nthis npatient ntake npriority nat nthis
ntime nincluding nvital nsigns, ncardiac nrhythm, nlab nvalues, nand nchest nx-ray nfindings. nPlacement nof
na nsaline nlock nis nessential nfor nadministration nof nfluids nand nemergency ndrugs. nChanging nthe
, npatient's nincontinence npad nis nimportant nto nprotect nhis nskin nbut nis nnot nurgent. nOrdering na
nlunch ntray nmay nbe npremature nbecause nthe ninterventions nfor nthis npatient's ncare nare nundecided
nwhen nhe nis nfirst nadmitted nto nthe nED.
What nis nthe n*priority* nnursing nconcern nfor nthis npatient?
•Skin ncare ndue nto nincontinence
•Clearance nof nthick nsecretions
•Rapid nheart nrate
•Elevated ntemperature n- nAnswer n- n•Clearance nof nthick nsecretions
•The npatient's nmajor nproblems nat nthis ntime nrelate nto nairway nand nbreathing nincluding nthick
nsputum, ndifficulty nbreathing, nand nrespiratory ndistress. nThe npatient's nskin ncare, nblood npressure,
nand nelevated ntemperature nwill nneed nto nbe nfollowed nup non nsoon nbut nare nnot nas nurgent nat
nthis ntime nas nhis nrespiratory nstatus.
The nRN nassesses nMr. nW nin nthe nemergency ndepartment. nWhich nassessment nfindings nare
nconsistent nwith na ndiagnosis nof nCOPD? n*Select nall nthat napply.*
•Enlarged nneck nmuscles
•Forward nbent nposture
•Respiratory nrate n15 nto n25 nbreaths/min
•Inspiratory nand nexpiratory nwheezes
•Blue-tinged ndusky nappearance
•Symmetrical nlung nexpansion n- nAnswer n- n•Enlarged nneck nmuscles
•Forward nbent nposture
•Inspiratory nand nexpiratory nwheezes
•Blue-tinged ndusky nappearance
•The npresence nof nwheezes, nenlarged nneck nmuscles, nbluish ndusky nappearance, nand nforward nbent
nposture nare nall nclassic nmanifestations nin na npatient nwith nCOPD. nThe nrespiratory nrate nis nusually
