The nurse notes the following findings when assessing a patient ...

[jenna1]

The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? (Select all that apply.)
 
  a. The patient is unable to count out loud past 15 after a deep breath.
  b. The patient's nails are noticeably clubbed.
  c. The patient's sputum has turned from yellow to greenish-brown.
  d. The patient has stridor with wheezes heard in all lung fields.
  e. The patient's forced vital capacity has increased from 2.8 to 3.4 L.
  f.
  The patient has become confused and mildly disoriented.

Question 2

The nurse is working with a nursing assistant to care for a patient with a new tracheostomy. Which tasks may the nurse delegate to the assistant? (Select all that apply.)
 
  a. Obtaining masks, gloves, and suction supplies from the utility room
  b. Helping to reassure the patient before, during, and after suctioning
  c. Changing the Velcro or twill ties used to secure the tracheostomy
  d. Transporting sputum specimens to the lab for culture and sensitivity testing
  e. Assessing need for suctioning of the oropharynx or tracheostomy
  f.
  Teaching the patient how to remove and clean the inner cannula

[connor417]

Answer to Question 1

ANS: A, C, D, F
A patient who is unable to count out loud past 15 after a deep breath is indicative of poor airflow through the airways, which must be addressed promptly. Greenish-brown sputum may indicate pneumonia requiring antibiotic treatment. Stridor and wheezes is indicative of an acute asthma attack. Confusion and disorientation in a patient with COPD may indicate retention of carbon dioxide.

Answer to Question 2

ANS: A, B, D
Care of a new tracheostomy may not be delegated to a nursing assistant. Obtaining supplies needed for care, helping to reassure the patient, and bringing specimens to the lab are tasks that may be assigned to the assistant.