NGN case studies, step by step

Question 1

The client is admitted to the medical unit at 1400. Supplemental oxygen was discontinued for transport and was not resumed. Click to highlight the findings that require immediate follow-up.

Accepted Answer

Restless and pulling at the blanket; Using neck accessory muscles; SpO2 82% on room air; PaO2 47 mm Hg. Chronic obstructive pulmonary disease, or COPD, is long-term narrowing of the airways and damage to the air sacs that traps air in the lungs. A flare, called an exacerbation, is a sudden worsening, usually set off by an infection, with more breathlessness, more sputum and a change in sputum color.

The highlighted findings are the acute ones. An SpO2 of 82% and a PaO2 of 47 mm Hg are well below what this client needs, and they are lower now because the oxygen was taken off for transport. Restlessness is one of the earliest signs that the brain is short of oxygen, and it shows up long before cyanosis or a falling pressure. Neck accessory muscle use means the diaphragm cannot do the work alone, and a client working this hard can tire out.

Question 2

The nurse analyzes the client's history and the 1400 findings. For each finding below, click to specify if the finding is consistent with the disease process of chronic bronchitis or emphysema.

Accepted Answer

Productive cough on most days for 10 years: Chronic bronchitis; Cyanosis of the lips and nail beds: Chronic bronchitis; Distended neck veins with pitting edema in both ankles: Chronic bronchitis; Barrel-shaped chest: Emphysema; Hemoglobin 17.6 g/dL: Chronic bronchitis. COPD has two main patterns, and most clients have some of both. Chronic bronchitis is inflammation of the airways with too much mucus, defined as a productive cough for at least 3 months in each of 2 years in a row. Emphysema is destruction of the walls of the air sacs, so the lungs lose their elastic recoil and air gets trapped.

In chronic bronchitis the mucus blocks airflow to parts of the lung that still have blood flow, so blood passes through without loading oxygen. The client is often hypoxemic and cyanotic, which gives the bluish lips and nail beds. Long-term hypoxemia makes the lung arteries constrict, the right ventricle has to push against that pressure, and it eventually fails. That is cor pulmonale, which shows as distended neck veins and edema in the ankles. Low oxygen also drives the bone marrow to make extra red cells, which is the hemoglobin of 17.6 g/dL. These clients have been called blue bloaters.

In emphysema, trapped air widens the chest from front to back, giving a barrel shape. These clients are usually thin, breathe fast with pursed lips, and keep a near-normal SpO2 until late, which earned them the name pink puffers. This client has a barrel chest as well, which shows the overlap most clients with COPD have.

Question 3

The client has several active problems on arrival at 1400. Complete the following sentence by choosing from the lists of options. The priority problem for the client at 1400 is [Blank 1] as evidenced by [Blank 2].

Accepted Answer

Blank 1: severe hypoxemia; Blank 2: an oxygen saturation of 82% with new restlessness. Hypoxemia is a low level of oxygen in the arterial blood. Severe hypoxemia threatens the brain and heart within minutes, and in this client the oxygen dropped further when the cannula came off for transport. An SpO2 of 82% with new restlessness means the brain is already affected.

This is the problem that has to be corrected first. Oxygen goes back on now and is titrated to a target of 88% to 92%. The idea that oxygen should be withheld from a client with COPD is a dangerous misreading. A client who is truly hypoxemic always gets oxygen, and the nurse controls the dose rather than withholding it.

Question 4

The admission prescriptions are pending. At 1400, the client speaks in 2- to 3-word phrases, and the SpO2 is 82% on room air. Which of the following interventions should the nurse include in the client's plan of care?

Accepted Answer

B: Apply oxygen and titrate to maintain SpO2 at 88% to 92%; C: Position the client upright, leaning forward on the overbed table; D: Instruct the client to inhale through the nose and exhale slowly through pursed lips. Care in a COPD exacerbation aims to get oxygen in and trapped air out. Oxygen goes on now at a low, controlled dose and is adjusted to an SpO2 of 88% to 92%. A Venturi mask is often used because it delivers an exact percentage of oxygen no matter how fast the client breathes.

Sitting upright and leaning forward lets the diaphragm drop and lets the accessory muscles of the shoulders work better. Pursed-lip breathing keeps a little pressure in the airways as the client breathes out, which holds the small airways open longer so more trapped air can escape. Breathing out should take about twice as long as breathing in.

Question 5

The client returned from radiology receiving oxygen by nasal cannula at 6 L/min. At 1630, the client is drowsy and reports a headache. RR is 14, and SpO2 is 98%. Which of the following actions should the nurse take first?

Accepted Answer

D: Reapply the Venturi mask at 28% and titrate to SpO2 88% to 92%. Oxygen-induced hypercapnia is a rise in carbon dioxide caused by giving too much oxygen to a client who retains carbon dioxide. The main reason is not loss of a breathing drive. Extra oxygen relaxes the blood vessels in poorly ventilated parts of the lung, so more blood flows past alveoli that are not moving air, and oxygen also makes hemoglobin release more carbon dioxide into the plasma. The carbon dioxide rises and sedates the brain.

At 6 L/min by nasal cannula the client is getting far more oxygen than the 28% the order allows. The drowsiness, headache, flushed skin and slower breathing are the signs of carbon dioxide building up. The first action is to bring the oxygen back to the ordered dose, by putting the Venturi mask back on at 28% and titrating to the target. The nurse then stays with the client, rechecks the level of consciousness and the breathing, and reports the change so an ABG can be drawn.

Question 6

The client has received oxygen by Venturi mask at 28% for 2 hours, along with the first doses of prednisone and doxycycline. The nurse reviews the 1830 findings. For each finding, click to specify whether the finding indicates that the client's condition has improved or requires follow-up.

Accepted Answer

Speaking in full sentences: Improved; SpO2 90% on 28% Venturi mask: Improved; Capillary glucose 264 mg/dL before dinner: Requires follow-up; PaCO2 55 mm Hg with pH 7.36: Improved; RR 20 with pursed-lip breathing: Improved. The plan is working. Talking in full sentences means the client has enough breath to spare, and an SpO2 of 90% is in the 88% to 92% target on a controlled dose of oxygen. The PaCO2 of 55 mm Hg with a pH of 7.36 is back at the client's compensated baseline, and the drowsiness has cleared. A respiratory rate of 20 with pursed-lip breathing used without reminders shows the work of breathing has eased.

The glucose of 264 mg/dL is the finding to follow up. Prednisone is a corticosteroid that reduces airway inflammation, and it also raises blood glucose by making the liver release more glucose and making the cells resist insulin. A client with no history of diabetes can still need correction insulin during a steroid course. The nurse reports it so the provider can order coverage.

Question 7

The nurse receives the handoff at 0700 on Day 3 and assesses the client. Click to highlight the findings that require immediate follow-up.

Accepted Answer

Oriented to person only; Urinary drainage bag found lying on the floor beside the bed; Grimaces when the suprapubic area is palpated; T 99.7° F (37.6° C); WBC 13,800/mm3. A catheter-associated urinary tract infection (CAUTI) is a urinary infection that develops in a client who has an indwelling urinary catheter. A catheter in place for 5 weeks is almost certainly colonized, so the nurse looks for signs that colonization has become an infection, and in an older adult those signs are often subtle.

This client was oriented to person and place at baseline and is now oriented to person only, which is new confusion. The temperature of 99.7° F (37.6° C) looks normal, but it is 1.3° C above this client's usual 36.3° C, which counts as a fever in an older adult. Suprapubic tenderness points to the bladder, and a WBC of 13,800/mm3 shows the body is fighting an infection. The drainage bag on the floor is a break in catheter care that the nurse corrects immediately.

Question 8

The nurse has reviewed the information from the Nurses' Notes, Vital Signs, and Laboratory Results at 0700 on Day 3. For each finding below, click to specify if the finding is consistent with the disease process of catheter-associated urinary tract infection or dehydration. Each finding may support more than one disease process.

Accepted Answer

WBC count of 13,800/mm3: Catheter-associated urinary tract infection; Heart rate of 102/min: Catheter-associated urinary tract infection, Dehydration; Urine cloudy with sediment: Catheter-associated urinary tract infection; Tenderness over the suprapubic area: Catheter-associated urinary tract infection; New disorientation to place: Catheter-associated urinary tract infection, Dehydration. The client was admitted for dehydration, so it is tempting to explain every new finding by the fluid deficit. Some findings fit both problems, and some fit only an infection.

Cloudy urine with sediment comes from white cells and bacteria in the urine, and suprapubic tenderness comes from an inflamed bladder wall. A raised WBC count is the body's response to infection. These point to a CAUTI. New disorientation fits both, because an older adult can develop delirium from an infection or from a fluid deficit. A heart rate over 100/min also fits both, from fever and inflammation or from a low circulating volume.

Question 9

At 1100 on Day 3, the nurse reassesses the client after the shaking chills. Complete the following sentence by choosing from the lists of options. The client is most likely experiencing [Blank 1] as evidenced by [Blank 2].

Accepted Answer

Blank 1: sepsis from a urinary source; Blank 2: a blood pressure of 88/50 mm Hg with a lactate of 3.8 mmol/L. Sepsis is life-threatening organ dysfunction caused by the body's response to an infection. This client has a clear urinary source and now has rigors, a temperature of 102° F (38.9° C), a heart rate of 118/min, and a respiratory rate of 26/min. The blood pressure of 88/50 mm Hg gives a mean arterial pressure of about 63 mm Hg, and the lactate of 3.8 mmol/L shows the tissues are short of oxygen. Falling urine output and drowsiness show organs are already affected.

The low blood pressure together with the raised lactate is the evidence that separates sepsis from a simple urinary infection. It calls for immediate cultures, antibiotics, and fluid.

Question 10

The nurse calls the rapid response team at 1100 on Day 3. Which of the following prescriptions should the nurse anticipate?

Accepted Answer

B: Two sets of blood cultures before the first antibiotic dose; D: A broad-spectrum IV antibiotic started within 1 hour; E: An isotonic crystalloid bolus of 30 mL/kg given in portions. The first hour of sepsis care starts several actions together. Cultures are drawn first so the antibiotic does not sterilize them, but drawing them must not delay the antibiotic. A broad-spectrum antibiotic is given within 1 hour, because every hour of delay raises the risk of death. A client with hypotension or a lactate of 4 mmol/L or more receives 30 mL/kg of isotonic crystalloid, which is 1,860 mL for this 62-kg client, given in portions with reassessment of the lungs and breathing after each.

Question 11

At 1115 on Day 3, the blood cultures have been drawn and the first fluid bolus is infusing. The nurse prepares to replace the urinary catheter and collect the urine culture before the first antibiotic dose. Place the following actions in the order the nurse should perform them.

Accepted Answer

1: Deflate the balloon completely with a syringe and remove the existing catheter; 2: Wash the perineal area and the penis with soap and water and dry them; 3: Open the sterile catheter kit and put on the sterile gloves; 4: Cleanse the meatus with the antiseptic in the kit and insert the new catheter; 5: Aspirate urine for culture from the sampling port of the new catheter. A catheter that has been in place for weeks is coated inside and out with biofilm, a layer of bacteria in a protective film. Urine collected through it reflects the catheter, not the bladder, and the biofilm protects bacteria from the antibiotic, so the catheter is replaced before the culture and before the first dose. Catheter replacement takes only minutes and is done within the first hour, so the antibiotic is still started on time.

The balloon is deflated fully before removal, because pulling against an inflated balloon tears the urethra. Perineal care with soap and water then removes debris and bacteria from the skin. The nurse opens the kit and puts on sterile gloves only after the dirty part of the work is done, then cleanses the meatus with the kit antiseptic and inserts the new catheter. The culture is aspirated from the new catheter's sampling port with a sterile syringe, and the antibiotic starts right after.

Question 12

On Day 5 at 0800, the nurse reassesses the client and compares the findings with those at 1100 on Day 3. For each assessment finding, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined.

Accepted Answer

Nonblanchable redness over the right heel: Declined; Blood pressure of 128/72 mm Hg: Improved; Oriented to person and place: Improved; Urine output of 45 to 60 mL/hr: Improved; Lungs clear on auscultation: Has not changed; Temperature of 98.6° F (37.0° C): Improved. The client is back to his baseline orientation, the fever is gone, the blood pressure has risen from 88/50 mm Hg to 128/72 mm Hg, and the urine output of 45 to 60 mL/hr is well above the minimum of 0.5 mL/kg/hr, which is 31 mL/hr for 62 kg. The lactate has fallen from 3.8 to 1.2 mmol/L. All of these show the sepsis has responded to the antibiotic, the fluid, and the new catheter.

The lungs were clear on Day 3 and are still clear, which is reassuring after a large fluid bolus in an 84-year-old client.

The heel finding is new. A 2 cm area of nonblanchable redness over intact skin is a stage 1 pressure injury, and it developed while the client was drowsy, hypotensive, and lying still with the heels on the mattress. The nurse floats the heels off the bed with a pillow under the calves or a heel protector, repositions the client at least every 2 hours, and reports the finding.

NGN case studies, step by step.

Case study 1

The client is admitted to the medical unit at 1400. Supplemental oxygen was discontinued for transport and was not resumed. Click to highlight the findings that require immediate follow-up.

The nurse analyzes the client's history and the 1400 findings. For each finding below, click to specify if the finding is consistent with the disease process of chronic bronchitis or emphysema.

The client has several active problems on arrival at 1400. Complete the following sentence by choosing from the lists of options.

The admission prescriptions are pending. At 1400, the client speaks in 2- to 3-word phrases, and the SpO2 is 82% on room air. Which of the following interventions should the nurse include in the client's plan of care?

The client returned from radiology receiving oxygen by nasal cannula at 6 L/min. At 1630, the client is drowsy and reports a headache. RR is 14, and SpO2 is 98%. Which of the following actions should the nurse take first?

The client has received oxygen by Venturi mask at 28% for 2 hours, along with the first doses of prednisone and doxycycline. The nurse reviews the 1830 findings. For each finding, click to specify whether the finding indicates that the client's condition has improved or requires follow-up.

Case study 2

The nurse receives the handoff at 0700 on Day 3 and assesses the client. Click to highlight the findings that require immediate follow-up.

At 1100 on Day 3, the nurse reassesses the client after the shaking chills. Complete the following sentence by choosing from the lists of options.

The nurse calls the rapid response team at 1100 on Day 3. Which of the following prescriptions should the nurse anticipate?

At 1115 on Day 3, the blood cultures have been drawn and the first fluid bolus is infusing. The nurse prepares to replace the urinary catheter and collect the urine culture before the first antibiotic dose. Place the following actions in the order the nurse should perform them.

On Day 5 at 0800, the nurse reassesses the client and compares the findings with those at 1100 on Day 3. For each assessment finding, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined.

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