Respiratory

Part I:
Anatomy + Physiology
Respiratory System Anatomy

Gas exchange
The delivery of oxygen from the lungs to the bloodstream, and the elimination of
carbon dioxide from the bloodstream to the lungs. Occurs in the alveoli through
passive diffusion.
 Terminology
● Ventilation
○ Air movement in and out of the lungs
● Oxygenation
○ Oxygen in the bloodstream
● Perfusion
○ Oxygen in the tissues

Adventitious Breath Sounds

Work of Breathing
● How easy is it for your client to take a deep breath?
● Retractions
○ Note location and severity
○ Location
■ Subcostal
■ Intracostal
■ Supraclavicular
■ Traheal
● Nasal flaring
● Head bobbing
● Grunting
Low-flow Non-rebreather

Nasal Cannula

Simple face mask

High-flow
Venturi mask High flow nasal cannula
 Non-Invasive Ventilation

Invasive Ventilation
● Endotracheal tube
● Tracheostomy
● Mechanical ventilator
Ventilator Alarms
High Pressure Alarms Low Pressure Alarms
Pressure in the circuit is too high. Pressure in the circuit is too low.

Causes: Causes:
Client coughing Tubing is disconnected
Gagging Loose connections
Bronchospasm Leak
Fighting the ventilator Extubation
ETT occlusion Cuffed ETT or trach is deflated
Kink in the tubing Poorly fitting CPAP/BiPAP mask
Increased secretions
Thick secretions
Water in ventilator circuit

Endotracheal
Tube
What is an endotracheal tube (ETT)?
● Invasive, artificial airway used when the client is unable to protect their own
airway.

● Plastic tube inserted into the

tracheal through the mouth or
nose
● Maintains an airway to deliver
oxygen and positive pressure
to the lungs
● “Breathing tube”

Nursing Must Know

● After placement of an ETT, placement should be verified by a chest x-ray
● Assess for equal breath sounds bilaterally
○ The ETT can becomes displaced into the R main stem bronchus
○ Ensure that breath sounds are heard equally bilaterally or the tube may need to be
repositioned.
 Tracheostomy

What is a tracheostomy tube?

● An artificial airway used for
long-term needs.
● Stoma is made in the neck and the
tube inserted into the trachea.
● Breathing is through the
tracheostomy tube, not the nose and
mouth.
● Used for:
○ Tracheal obstruction
○ Slow vent weaning
○ Tracheal damage
○ Neuromuscular damage
Dressing and ties

Trach Care
● Infection prevention is key!
○ The natural defenses of the nose and mouth are bypassed - higher risk for infection
○ Daily trach care - inpatient, this is a sterile procedure.
● Position: Fowler’s or semi-Fowler’s
● Perform hand hygiene, don clean gloves.
● Remove soiled dressing. Don sterile gloves.
● Clean the tracheostomy site
○ Use sterile applicators or gauze dressings moistened with normal saline.
■ 1:1 NS and Hydrogen peroxide is used with some clients
○ Use each applicator/gauze once, then discard.
○ Dry client’s skin
● Apply new sterile dressing
● Change tracheostomy ties
● Check tightness - ensure 1 finger can fit underneath
Suctioning
● Only suction to the pre measured depth
○ Suctioning too deep can cause damage or cause laryngospasm
○ Don’t suction longer than 10 seconds
● Some clients may need pre-oxygenated with 100% FiO2

Safety
● You must keep two back up trachs at the bedside incase of emergency
○ 1 of same size
○ 1 a half size smaller
● If the trach comes out, first try to insert the back up of the same size
● If unsuccessful, try to insert the half size smaller
 Chest Tubes

What is a chest tube?

● Tube inserted into the pleural space
of the lungs.
● Helps to remove air or fluid that has
caused the lung to collapse
● Also placed after cardiac surgery to
help drain blood and fluid from
around the heart.
Why would our client
need a chest tube?
● There is something in the pleural
space….and we need to get it out.
○ Air
○ Fluid
○ Blood
● This allows the lung to fully expand.

Drainage System Chambers

Nursing Considerations
● Always keep the drainage system below the level of the client's chest
● Ensure the tubing is free of kinks and draining freely
● There should be no dependent loops in the tubing
● Monitor the drainage
○ Color - serous - serosanguinous. Know WHY the client has a CT!
○ Odor - none
○ Consistency - thin-thick
○ Amount - no more than 100ml/hr. More? Call the doc!!
■ Mark hourly

What to do if the chest tube comes out

● Cover the site with a
sterile dressing
● Tape on 3 sides
○ Air can escape this way. If
you tape on 4 sides you
might cause a tension
pneumothorax
● Call the provider
● STAY WITH THE CLIENT
What to do if the
tube comes out of the
atrium?
● Still in the client, but becomes
disconnected from the collection
chamber
● Place the end of the chest tube in a
bottle of sterile water

Part II:
Respiratory Pharmacology
Bronchodilators
● Albuterol
● Theophylline
● Terbutaline
● Levosalbutamol
● Ipratropium

Albuterol
Therapeutic class: Bronchodilator; short acting beta 2 agonist

Indication: Asthma, COPD

Action: Binds to Beta2 adrenergic receptors in the airway leading to relaxation of

the smooth muscles in the airways

Nursing Considerations:

● Be very cautious when using in clients with heart disease, diabetes,

glaucoma, or seizures.
● Causes tachycardia
Terbutaline
• Therapeutic class: Selective Beta 2 adrenergic agonist.

• Mechanism of action: Blocks beta 2 adrenergic receptors in the respiratory system to cause
bronchodilation by inhibiting the release of hypersensitivity reaction products from mast cells.

• Indications:
• Rescue/Relief and maintenance drug for wheezing, SOB, and coughing caused by asthma.

• Nursing considerations:
• SE: shakiness, jitteriness, dizziness, drowsiness, sleep disturbances, weakness, headache,
nausea, vomiting tachycardia, hypertension, hyperglycemia. CNS overstimulation.
• Assess HR, BP, EKG, blood glucose
• Can be given orally, SC, or by inhaler. 4-6 hour duration. More SE with oral administration
because it requires higher dosage.
• Teach proper inhaler use

Inhalers
● Hold with mouthpiece down. DO NOT hold
upside down
● Seal lips tightly around mouthpiece.
● Inhale through the mouth slowly
● Press down on inhaler one time. One breath in
= one puff of medication
● Continue inhaling while medication is
dispensed (will likely feel cold) - breathe
slowly and as deeply as possible.
● Shake prior to use
Spacer
● Connects to the mouthpiece
of the inhaler so the
nebulized medication goes
into the spacer first.
● Allows the client to more
easily breathe in the
medication - timing of the
breath is less important
● Wastes less medication
● Common in pediatrics

Practice Question
Which of the following comments by the client reflects an understanding of the proper use of a
metered-dose inhaler?

Select all that apply.

A. “I will be careful not to shake the canister before using it.”

B. “I will hold the canister upside-down when using it.”
C. “I will inhale the medication through my nose.”
D. “I will continue to inhale when the cold propellant is in my throat.”
E. “I will only inhale one spray with one breath.”
F. “I will activate the device while continuing to inhale.”
Answers: D, E, + F
Which of the following comments by the client reflects an understanding of the proper use of a
metered-dose inhaler?

Select all that apply.

A. “I will be careful not to shake the canister before using it.”

B. “I will hold the canister upside-down when using it.”
C. “I will inhale the medication through my nose.”
D. “I will continue to inhale when the cold propellant is in my throat.”
E. “I will only inhale one spray with one breath.”
F. “I will activate the device while continuing to inhale.”

Misc. Respiratory
● Montelukast
○ Leukotriene modifier
● Guaifenesin
○ Expectorant
● Acetylcysteine
○ Mucolytic
● Pseudoephedrine, phenylephrine
○ Decongestant
● Antitussives
○ Dextromethorphan
○ Codeine
Steroids
● Betamethasone
● Dexamethasone
● Cortisone
● Methylprednisolone

Methylprednisolone
Therapeutic class: Corticosteroids

Indication: Inflammation, allergy, autoimmune disorders

Action: Suppress inflammation and normal immune response

Nursing Considerations:

● Monitor for too much steroids

○ Cushing’s symptoms; buffalo hump
● Side effects
○ Immunosuppression
○ Hyperglycemia
○ Osteoporosis
○ Delayed wound healing
Antihistamines
● Histamine-1 blocker → block H1 receptors in CNS - stops allergies!
○ Diphenhydramine

● Histamine-2 blocker → block production of stomach acid!

○ Famotidine
○ Ranitidine

Diphenhydramine
Therapeutic class: Antihistamine

Indication: Allergy, anaphylaxis, sedation

Action: Antagonizes effects of histamine, CNS depression

Nursing Considerations:

● Monitor for drowsiness

● Anticholinergic effects
 Part III:
Respiratory Disorders

Chronic Obstructive Pulmonary Disease

● A group of lung diseases

that block airflow and make
it difficult to breathe.
● Includes:
○ Emphysema
○ Chronic bronchitis
● Damage is not reversible.
Assessment
● Barrel chest
● Accessory muscle use
○ Retractions
○ Nasal flaring
○ Tracheal tug
● Congestion
● Lung sounds
○ Diminished
○ Crackles
○ Wheezes
● Acidotic
● Hypercarbic
● Hypoxic
Treatment
● Be very careful with oxygen administration!
○ In the normal client, hypercarbia stimulates the body to breathe.
○ This client has been hypercarbic for an extended period of time
○ For them, hypoxia has become the driving factor to stimulate breathing
● Bronchodilators
● Chest physiotherapy
● Increased fluid intake
● Encourage pursed lip breathing to help expire completely.
● Eat small frequent meals to avoid overdistention of the stomach which
impedes the diaphragm.

Asthma
● A respiratory condition marked by spasms in the bronchi of the lungs, causing
difficulty in breathing.
● Chronic inflammation of bronchi and bronchioles.
● Excess mucus.
● Result of an allergic reaction or hypersensitivity.
Pathophysiology
1. Airway is abnormally reactive - heightened sensitivity
2. Trigger causes a response
3. Inflammation and excess mucus production occur
4. Bronchospasm decreases the airway diameter
5. Airflow becomes obstructed

After many asthma reactions, airway remodeling occurs which causes scarring
and changes to lung tissue.

Triggers
A - Allergens

S - Sport / Smoking

T - Temperature change

H - Hazards

M - Microbes

A - Anxiety
Assessment
● Shortness of breath
● Unable to speak
○ Evaluate how many words they can say before taking a breath
● Cough
● Increased work of breathing
○ Retractions
○ Tracheal tug
○ Head bobbing
● Wheeze
● Prolonged expiration
● Can’t hear any breath sounds? Complete obstruction.

Treatment - acute exacerbation

● Airway, breathing, circulation!!
● Airway
○ Intubate?
○ Adrenergic agonists
● Open up airway
● Albuterol
● Breathing
○ Oxygen administration
○ Theophylline - Bronchodilator
○ Ipratropium - Anticholinergic
○ Dexamethasone - Steroid
● Circulation
○ IV fluids
Complication - Status Asthmaticus
● Asthma attack that is refractory to
treatment
● Leads to severe respiratory failure
● Can progress to death if untreated

Treatment - long-term control

● Inhaled Corticosteroids
○ Budesonide & Fluticasone
○ Take daily
● Leukotriene modifiers
○ Montelukast sodium
○ Blocks leukotrienes from over responding to triggers
● Theophylline
○ Bronchodilator
○ Helps keep bronchioles open and prevent wheezing, but must be used regularly.
● Allergen control
○ Clean environment
○ Minimize dust, pet dander, and mold
○ No secondhand smoke
Pneumonia
● Inflammation of the lung affecting the alveoli
● Alveoli
○ Tiny air sacs of the lungs which allow for gas exchange
● Alveoli become filled with pus and liquid

Classifications
● Viral
○ Caused by viruses such as RSV, adenovirus, and influenza
● Bacteria
● Fungal
● Chemical irritation
● Aspiration
○ When foreign bodies such as food and secretions enter the lungs
○ Cause inflammation and infection leading to pneumonia
Diagnosis
● Chest x-ray
○ “Patchy infiltrates”
● Sputum culture
○ Will identify a bacterial source

Assessment
● High fever
● Cough
● Tachypnea
● Crackles
● Chest pain
● Work of breathing
○ Retractions
○ Tracheal tug
○ Nasal Flaring
○ Grunting
○ Head bobbing
Treatment
● Maintain airway ● Chest physiotherapy
○ Suction
● Antipyretics
○ Monitor SpO2
● Monitor breathing ● Analgesia
○ Assess for increased work of breathing ● Cough suppressant
○ Provide support as needed ● Expectorants
○ Humidified oxygen ● Antibiotics if bacterial
● Maintain circulation ● Isolation
○ Monitor for dehydration
○ IVF if unable to tolerate PO

NCLEX Question
The nurse is reviewing the discharge teaching with a family who will be taking their
12 year old diagnosed with pneumonia home today. Which of the following points
should they review? Select all that apply.

a. Encourage your child to drink lots of water.

b. Administer the full course of antibiotics, even if your child starts to feel
better.
c. Call your pediatrician if there is tan sputum when when child coughs
d. Administer ibuprofen if your child has a temperature greater than 100
degrees F.
e. If your child is breathing harder or faster, call your PHCP immediately
 Answer: A, B and E
A is correct. It is appropriate teaching to have the parents encourage their child to drink lots of water. Pneumonia can
frequently cause dehydration, due to tachypnea and increased insensible fluid losses. Parents should encourage adequate
hydration to promote fluid and electrolyte balance while their child is recovering from pneumonia.

B is correct. It is very important to teach parents to administer the full course of antibiotics, even if their child starts to feel
better. If the parents stop administering antibiotics part of the way through the course, they will be promoting antibiotic
resistance and the chance that the infection could return.

C is incorrect. The parents do not need to call the pediatrician if there is tan sputum when the child coughs. This is a
normal finding of pneumonia and should be expected. If there is a new onset of green sputum, this could indicate the
development of a bacterial pneumonia and the need to call the pediatrician.

D is incorrect. While Ibuprofen does have some antipyretic properties, it is not the best choice of medication to treat a
fever. If the child has a temperature of 100 F, the parents should be educated to administer acetaminophen, which is the
first choice for an antipyretic medication.

E is correct. Any signs of increased work of breathing (tachypnea, retractions, accessory muscle use, grunting, etc.) need
to be reported and assessed by a provider immediately

NCSBN Client Need:

Topic: Health promotion and maintenance Subtopic:-

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatric
Lesson: Respiratory

Acute Respiratory Distress Syndrome

● “an acute condition
characterized by bilateral
pulmonary infiltrates and
severe hypoxemia in the
absence of evidence for
cardiogenic pulmonary
edema”
● Fluid collects in alveoli
● Deprives body of oxygen
Causes
Anything that causes an inflammatory reaction in the lungs!!

● Sepsis
● Trauma
● Burns
● Aspiration pneumonia
● Overdose
● Near drowning

Source: Creative Commons: Altaf Gauhar Haji, Shekhar Sharma, DK Vijaykumar and Jerry Paul., Transfusion-related acute lung injury chest X-ray, CC BY 2.0

Assessment
● Chest x-ray
○ Diffuse bilateral infiltrates
○ “Whited-out”
● Hypoxemia
○ Pale
○ Cool
○ Dusky
○ Mottled
○ Low SpO2
Treatment
TREAT THE UNDERLYING CONDITION

● Intubation and mechanical ventilation

○ High pressures
● Prone
● Prevent infection
○ VAP
● Prevent barotrauma

Pneumothorax
● Air or fluid collects in the
pleural space
● Presses down on the lung.
Causes
● Spontaneous
○ Occurs due to a disease process
● Traumatic
○ Blunt
○ Penetrating
○ Complication of a procedure

Assessment
● Shortness of breath
● Chest pain
● Desaturation
● Hypotension
● Tachycardia
● Check that the trachea is midline…
Treatment
● Needle decompression
● Chest tube

**Complication** - TENSION pneumothorax!

→ When air continues to enter the lungs, leak into the pleural space, and then
can’t leave!

→ It pushes on the lungs, trachea, and heart and starts shifting them to one side.

→Tracheal shift (check that the trachea is midline!)

Pulmonary Embolism
What is a Pulmonary Embolism?
● Life threatening blood clot in the lungs
● Can be caused by an embolism from a vein entering the lung, or a clot during
surgery.
● The clot decreases perfusion causing hypoxemia
● Can lead to right heart failure if untreated.

Assessment
● Anxiety
● Dyspnea
● Chest pain
● Hypoxemia
● Rales
● Diaphoresis
● Hemoptysis
Treatment and Nursing Interventions
● Oxygen administration
● Positioning
○ High fowler’s
○ Promotes maximum lung expansion and assists with breathing
● Anticoagulants
● Thrombolytics

Air embolism Pulmonary

Pulmonary
● Positioning: embolism
embolism
○ Durant’s maneuver: Left lateral
trendelenburg ● Positioning
○ High fowler’s
NCLEX Question
The client had just given birth and is resting in the postpartum unit when
suddenly she feels a sharp pain in the chest and is having difficulty breathing.
Upon assessment by the nurse, she has a heart rate of 120 and a respiratory rate
of 24. She is suspected of having a pulmonary embolism. What should be the
initial action of the nurse?
A. Start an IV line.

B. Monitor the client’s blood pressure.

C. Draw up morphine sulfate.

D. Administer a sedative medication to the client

E. Give oxygen via face mask at 8-10 liters per minute.

Answer: E
Choice E is correct. During a pulmonary embolism, circulation in the pulmonary bed is altered,
thus affecting the oxygenation of the client. Oxygen should be started immediately at 8-10 liters
per minute to decrease hypoxia.

Choice A is incorrect. Starting an IV line is necessary but it is not the priority.

Choice B is incorrect. Checking the client’s blood pressure is a necessary action, but it should not
be the first action for the nurse to take.

Choice C is incorrect. Morphine sulfate may be given for pain management; however, the nurse’s
initial action would be to provide oxygen.

Choice D is incorrect. Administering a sedative medication would be an incorrect choice in this

scenario. The client is experiencing a sharp pain in the chest, difficulty breathing, and is suspected
of having a pulmonary embolism. These symptoms suggest a potential life-threatening condition
that requires immediate intervention.
 NGN Practice

The 12-year-old child with a history of asthma is brought to urgent care.

Nurses’ Notes

1700 – 12-year-old male arrives with his parents after playing outside
with friends and suddenly developing shortness of breath. The client’s
mother believes he is having an asthma attack. He has a medical history
of asthma, insulin dependent diabetes mellitus, and is current on all
immunizations. No known allergies.
 Vital Signs

Oral Temperature 99 o F (37.2o C)

Pulse 114/minute
Respirations 26/minute
Blood pressure 107/76 mm Hg
Oxygen saturation 89%

Assessment

Client is alert and fully oriented. Anxious and unable to respond in full sentences.
Appears in significant distress. Peripheral pulses were palpable. Skin was cool and
dry to touch. Respirations were labored with audible wheezes and expiratory
stridor. Tachypnea and use of accessory muscles. Frequent, non-productive cough.
Active bowel sounds in all quadrants. Client reported no pain.
The nurse reviews the assessment information and
identifies that which two (2) pieces of assessment
data require follow-up?

a. The client being anxious

b. Non-productive cough
c. Audible expiratory stridor
d. History of diabetes mellitus
e. Temperature of 99 o F (37.2o C)
f. Oxygen saturation of 89%

The nurse reviews the assessment information and identifies which two
(2) pieces of assessment data requires follow-up?
a. The client being anxious
b. Non-productive cough
c. Audible expiratory stridor
d. History of diabetes mellitus
e. Temperature of 99 o F (37.2o C)
f. Oxygen saturation of 89%

A cough and the client being anxious are common findings associated with asthma. The
most concerning finding that requires follow-up is the audible stridor and the oxygen
saturation of 89%. Stridor signifies that the upper airways are closing, which indicates that
the asthma attack is advancing. The low oxygen saturation further supports the
seriousness of this asthma attack.
The nurse understands which pathological process best
explains the client assessment findings?

a. Increased forced expiratory volume

b. Ventilation perfusion match
c. Decreased lactic acid production
d. Airway hyperresponsiveness

The nurse understands which pathological process best explains the client findings?

a. Increased forced expiratory volume

b. Ventilation perfusion match
c. Decreased lactic acid production
d. Airway hyperresponsiveness

Airway hyperresponsiveness and inflammation explain asthma's disease process as both result
in bronchoconstriction, thereby decreasing gas exchange. A client with asthma would have a
decrease in forced expiratory volume, ventilation perfusion mismatch, and an increase in lactic
acid as asthma decreases oxygen causing anaerobic processes leading to the accumulation of
lactic acid.
Complete the sentences from the list of options.

Select
The client is most likely experiencing
pneumonia.
bronchospasm.
pleurisy.

The nurse should take immediate action and Select

administer supplemental oxygen
administer an inhaled corticosteroid
prepare an injection of epinephrine

to prevent the most serious complication of Select

distributive shock.
respiratory arrest.
pulmonary hypertension.

Complete the sentences from the list of options.

Select
The client is most likely experiencing
pneumonia.
bronchospasm.
pleurisy.

The nurse should take immediate action and Select

administer supplemental oxygen
administer an inhaled corticosteroid
prepare an injection of epinephrine

to prevent the most serious complication of Select

distributive shock.
respiratory arrest.
pulmonary hypertension.
Rationale:
This client’s history and symptoms coincide with a classic asthma attack. This
bronchospasm is serious because of the client’s hypoxia. An immediate intervention the
nurse should take is to raise the client’s head-of-bed to ease their respirations and to
provide supplemental oxygen because of the client’s low oxygen saturation. If nurse fails to
act, the client may develop respiratory arrest.

The nurse notifies the physician of the client’s condition and

prepares to act.
When collaborating with the physician, the nurse should
anticipate or not anticipate which physician order?
Physician Order Anticipated Not Anticipated

Albuterol via nebulizer

Blood cultures

Broad spectrum antibiotics

Intravenous corticosteroids
The nurse notifies the physician of the client’s condition and
prepares to act.
When collaborating with the physician, the nurse should
anticipate or not anticipate which physician order?
Physician Order Anticipated Not Anticipated

Albuterol via nebulizer X

Blood cultures X

Broad spectrum antibiotics X

Intravenous corticosteroids X

Rationale:
Albuterol via nebulizer and intravenous corticosteroids are necessary
to help alleviate this client’s symptoms. This coupled with
supplemental oxygen should provide the client with immediate relief.
Asthma exacerbations are not infectious and the collection of blood
cultures and the administration of antibiotics are not necessary.
 Orders

▪ Albuterol via nebulizer

▪ 4 liters of nasal cannula oxygen
▪ 40 mg of solumedrol intravenous (IV) push
▪ Establish peripheral vascular access
▪ Continuous cardiac monitoring

The nurse received and implemented the physician orders.

Upon reassessment, the client’s respiratory status has not changed.
The nurse anticipates that the physician will prescribe which
medication?

a. Dextromethorphan
b. Magnesium sulfate
c. Vasopressin
d. Diphenhydramine
The nurse received and implemented the physician orders.
Upon reassessment, the client’s respiratory status has not changed.
The nurse anticipates that the physician will prescribe which
medication?

a. Dextromethorphan
b. Magnesium sulfate
c. Vasopressin
d. Diphenhydramine
Magnesium sulfate is third line therapy in the treatment of refractory asthma. Magnesium sulfate
relaxes bronchioles and may further alleviate the client’s symptoms. While diphenhydramine
may be used for allergies that trigger an asthma exacerbation, it would not facilitate
bronchodilation. Dextromethorphan is a cough suppressant not indicated in asthma
exacerbations.

After four hours of treatment and monitoring, the client improves

and is ordered discharge home with a prescription of prednisone.
Which statements by the client’s mother, would require follow-up
regarding the prescribed prednisone?

a. “I should give this medication to my child with food.”

b. “This medication may cause my child’s blood glucose to increase.”
c. “This medication should be taken at nighttime.”
d. “The steroids may make my child have mood fluctuations.”
After four hours of treatment and monitoring, the client improves
and is ordered discharge home with a prescription of prednisone.
Which statements by the client’s mother, would require follow-up
regarding the prescribed prednisone?

a. “I should give this medication to my child with food.”

b. “This medication may cause my child’s blood glucose to increase.”
c. “This medication should be taken at nighttime.”
d. “The steroids may make my child have mood fluctuations.”

Corticosteroids are activating and may trigger insomnia, if possible, the medications should be taken
earlier in the day. All of the other statements are true, as steroids may cause gastrointestinal upset,
raise blood glucose, and fluctuating mood.

COPD
Nurses’ Note

1530 – 71-year-old male arrives with his daughter reporting increased dyspnea with activity,
productive cough, lethargy, and according to his family, ‘is just not acting right.’ The symptoms
started two days ago, and despite over-the-counter cough medicine, the symptoms are
reported to have worsened. He reports a 4/10 chest pain when he coughs and takes deep
breaths.

Vital signs: temperature 103.7 o F (39.8o C), Pulse 81/minute, Respirations 23/minute, Blood
pressure 139/78 mm Hg, oxygen saturation 89% on room air.

He was recently hospitalized for several days with an acute coronary syndrome that resulted in
angioplasty and the placement of a stent in the coronary artery. The client has a medical
history of hyperlipidemia, osteoarthritis in the knees, and hypertension.

The emergency department (ED) nurse is caring for a client with dyspnea and a
cough.

Assessment

▪ Lethargic and completely oriented

▪ Glasgow Coma Scale 15
▪ Expiratory wheezes bilaterally, labored respirations, frequent cough
▪ No peripheral edema, Radial pulses 2+, Capillary refill < 3 seconds
▪ Normoactive bowel sounds in all quadrants, no distention
▪ Denies dysuria or urinary frequency
▪ Skin is hot and flaky
 Orders

▪ Establish peripheral vascular access device

▪ CBC, CMP, Blood cultures
▪ Sputum culture
▪ 0.9% saline 500 mL bolus over one hour
▪ Nasal cannula oxygen at 4 liters/minute
▪ Albuterol 2.5 mg via nebulizer
▪ Acetaminophen 500 mg PO q 6 hours PRN fever
▪ Activity as tolerated
▪ Azithromycin 500 mg IVPB, Daily

Which (3) three assessment findings require follow-up?

a. Blood pressure
b. Capillary refill
c. Glasgow Coma Scale
d. Oxygen saturation
e. Medical history
f. Respiratory rate
g. Lung sounds
Which (3) three assessment findings require follow-up?

a. Blood pressure
b. Capillary refill
c. Glasgow Coma Scale
d. Oxygen saturation
e. Medical history
f. Respiratory rate
g. Lung sounds

The concerns from the assessment include the client’s oxygen saturation,
respiratory rate, and lung sounds. The client's low oxygen saturation requires
immediate follow-up along with the tachypnea and expiratory wheezes. These
clues indicate that the client is experiencing respiratory distress.

Complete the following sentences by choosing from the list of options.

The nurse should recognize that Select:

the expiratory wheezes indicate upper airway narrowing.
______________ (select one from airway inflammation.
corresponding options) thick, tenacious secretions.

The nurse understands that if Select:

oxygen and a _____________are bronchodilator
not given, the hypoxia may
worsen (Select one from epinephrine
corresponding options) diuretic
Complete the following sentences by choosing from the list of options.

The nurse should Select:

recognize that the upper airway narrowing.
expiratory wheezes airway inflammation.
indicate __________ thick, tenacious secretions.

Select:
The nurse understands that if bronchodilator
oxygen and a ______ are not
given, the hypoxia may worsen. epinephrine
diuretic

Rationale
Wheezes make classic high-pitched, squeaky, musical, continuous sound
associated with air rushing through the narrowing of the lower airways.
Wheezes are not commonly cleared with coughing and require treatment
such as a bronchodilator for treatment. Thick, tenacious secretions would
produce a rhonchi type of sound. Inflamed pleura rubbing together
characterizes a pleural friction rub.
Which problem is the client most likely experiencing?

a. Asthma
b. Pneumonia
c. Pleural effusion
d. Septic shock

Which problem is the client most likely experiencing?

a. Asthma
b. Pneumonia
c. Pleural effusion
d. Septic shock

This client most likely has pneumonia. His biggest risk factor was recent hospitalization which puts
him at risk for health care–associated pneumonia which is more pathogenic. Other symptoms
supporting this likely problem include productive cough, fever, adventitious lung sounds, and
dyspnea.

The client does not have tachycardia which is one of the hallmarks of shock. A pleural effusion is
excluded because it generally does not feature a fever. Asthma is excluded because the client does
not have a medical history of this disorder.
The nurse develops a plan of care for this client and anticipates which orders and
prescriptions from the physician? Select all that apply.

a. Supplemental oxygen
b. Chest radiograph (x-ray)
c. 0.9% saline infusion
d. Hourly blood glucose
e. Laboratory work (CBC, CMP)
f. Blood cultures
g. Acetaminophen
h. Strict bed rest
i. Albuterol via nebulizer
j. Bedside thoracentesis

The nurse develops a plan of care for this client and anticipates which orders and
prescriptions from the physician? Select all that apply.

a. Supplemental oxygen
b. Chest radiograph (x-ray)
c. 0.9% saline infusion
d. Hourly blood glucose
e. Laboratory work (CBC, CMP)
f. Blood cultures
g. Acetaminophen
h. Strict bed rest
i. Albuterol via nebulizer
j. Bedside thoracentesis
Complete the following sentences by choosing from the list of options.
Select
The priority for the nurse is to apply supplemental oxygen.
___________________________ obtain blood cultures.
administer azithromycin.

Select
To optimize this client’s outcome,
physical therapy.
the nurse plans to collaborate with
respiratory therapy.
__________________________
case management.

It would be appropriate for the

Select
nurse to delegate the administration of albuterol via
_______________________________ nebulizer
_________ to the licensed starting of peripheral vascular
access
practical/vocational nurse
initiation of the nursing care plan
(LPN/VN)

Complete the following sentences by choosing from the list of options.

Select:
The priority for the nurse is apply supplemental oxygen.
to____________ obtain blood cultures.
administer azithromycin.

To optimize this client’s outcome, Select:

the nurse plans to collaborate physical therapy.
with___________ respiratory therapy.
case management.

It would be appropriate for the

Select:
nurse to delegate administration of albuterol via nebulizer
the_____________ to the licensed starting of peripheral vascular access
practical/vocational nurse initiation of the nursing care plan
(LPN/VN)
Rationale:
The nurse's priority is administering the supplemental oxygen as this client is hypoxic.
The nurse can optimize the client’s outcomes by collaborating with respiratory
therapy. When supervising an LPN/VN, it would be appropriate for the LPN/VN to
administer the nebulizer treatment as this is within their scope. Initiating the care plan
and starting vascular access must be completed by the registered nurse.

The nurse re-assesses and updates the nurse’s note after administering the nasal cannula oxygen
and albuterol via nebulizer. Which finding indicates that the client requires further intervention?

a. Reports of nervousness
b. Respiratory rate
c. Pulse rate
d. Oxygen saturation
The nurse re-assesses and updates the nurse’s note after administering the nasal cannula oxygen
and albuterol via nebulizer.
Which finding indicates that the client requires further intervention?

a. Reports of nervousness
b. Respiratory rate
c. Pulse rate
d. Oxygen saturation

Reports of nervousness are a common side effect associated with albuterol. Albuterol causes
stimulation in the sympathetic nervous system and may raise the pulse, making the client feel
nervous/jittery. These are expected effects. The client’s respiratory rate has decreased, but his
oxygen saturation is still a concern because, despite the supplemental oxygen, his saturation is
concerning at 92%