Author Question: After receiving change-of-shift report on a medical unit, which patient should the nurse assess ... (Read 70 times)

jilianpiloj · **on:** Jun 25, 2018

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?

a. A patient with cystic fibrosis who has thick, green-colored sputum
b. A patient with pneumonia who has crackles bilaterally in the lung bases
c. A patient with emphysema who has an oxygen saturation of 90 to 92
d. A patient with septicemia who has intercostal and suprasternal retractions

Question 2

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion.

Which assessment finding by the nurse is most important to report to the health care provider?
a. The patient has bibasilar lung crackles.
b. The patient is sitting in the tripod position.
c. The patient's respirations have decreased from 30 to 10 breaths/minute.
d. The patient's pulse oximetry indicates an O2 saturation of 91.

frejo · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients should also be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

Answer to Question 2

ANS: D
A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91 is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.