2 questions- pulse ox and pneumonia related

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Took a test on Oxygenation/Respiratory illnesses today and came across 2 tricky questions...no one seems to know the correct answer in my class and so I decided to try this route! Hope you can help!

1. Patient has been diagnosed with pneumonia and was placed in isolation with droplet precautions. Patient then spikes a fever of 101.8. What would be the nursing intervention? (Choose one)

A. Take pt off of corticosteroids

B. Maintain droplet precautions

C. Keep pt NPO

D. None of the above

(I am really talking about A and B...much debate about the correct measure between these two..I selected corticosteroids because they suppress immune response)

2. What may cause a false pulse oximetry reading? (Check ALL that apply)

A. Hypotension

B. Abnormally high Hemoglobin/Hematocrit levels

C. Respiration rate of 34b/min

D. Nail that is removed of nail polish

(I know it is not D...but is it all 3? A, B, C or B and C....or A and B.....or A and C? All of our textual support has different rationales but nothing that is clearly stating this answer)

3. Patient has small amount of sputum that he can not bring up in a cough. What would the nursing measurement be?

A. Give pt Antitussive

B. Give pt Decongestant

C. Give pt incentive spirometer

D. Give pt 1 liter of warm water

(I chose decongestant but I think that may be incorrect..but then again it may help the congestion by thinning the mucus..antitussives would suppress the cough but the cough that is there does not seem as if it is a cough related to bronchitus or anything big..and it doesn't mention an expectorant either in conjunction with that measure..incentive spirometer would only increase lung expansion and do nothing to mucus..and that is far too little of fluids to be taking in..people should intake between 2-3 liters on a normal basis)

Thank you for reading everyone!

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Specializes in Cath Lab/ ICU.
Took a test on Oxygenation/Respiratory illnesses today and came across 2 tricky questions...no one seems to know the correct answer in my class and so I decided to try this route! Hope you can help!

1. Patient has been diagnosed with pneumonia and was placed in isolation with droplet precautions. Patient then spikes a fever of 101.8. What would be the nursing intervention? (Choose one)

A. Take pt off of corticosteroids

B. Maintain droplet precautions

C. Keep pt NPO

D. None of the above

(I am really talking about A and B...much debate about the correct measure between these two..I selected corticosteroids because they suppress immune response)

2. What may cause a false pulse oximetry reading? (Check ALL that apply)

A. Hypotension

B. Abnormally high Hemoglobin/Hematocrit levels

C. Respiration rate of 34b/min

D. Nail that is removed of nail polish

(I know it is not D...but is it all 3? A, B, C or B and C....or A and B.....or A and C? All of our textual support has different rationales but nothing that is clearly stating this answer)

Thank you for reading everyone!

1- you do not take pts off steroids, you wean them off, and they are very necessary in resp illnesses. Also, taking a pt off a medication isnt really a nursing intervention. The question specifically states, "what nursing intervention" would you do...

The pt already has PNA, I would give them Tylenol to be honest if it were a PRN, draw BCx2 and sputum cx like our protocol states, if they looked really bad request a cxr I guess. But of those answers I would maintain droplet precautions.

2. A

When pts are hypotensive, they have peripheral vasoconstriction. A pulse ox cant pick up a signal if the vessels are clamped down. How would tachypnea affect a pulse ox reading?

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1. For the first one it's not A or C - the nurse can't take a patient off a medication nor can they change their diet from NPO to clear liquids and the question never said the patient is NPO or on corticosteroids to begin with.

The clue to the question is in the spike of fever which delineates an infection.

Although I would still keep droplet precaution and that might technically be right - I would think a priority intervention would be to inform MD of the spike of temperature.

2. The second question is confusing to me because of the idea of a "false pulse oximetry."

It's obviously not D.

It's not C because a common assessment for a person with a high respiration rate is getting an 02 sat. If a person is in respiration distress, the pulse ox will show it.

It may be hypotension because if a person is hypotensive, their tissue may not be adequately perfused w/ blood. But if that's the case is that a false pulse ox number? I'm not sure.

And I'm not sure with B.

Personally, I think that second question is a crappy one.

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Specializes in Cath Lab/ ICU.

"Most studies concluded hemoglobin concentration does not impact pulse oximetry accuracy until hematocrit value is less than 10 percent."

http://respiratory-care-sleep-medicine.advanceweb.com/Article/Pulse-Oximetry-Industry-Report.aspx?CP=2

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For the third question, it's C.

We can't give medication without an order for it and there was nothing in the question stating that the patient was on medication so A and B are out. 1 liter of water is not enough water.

An incentive spirometer will help breathing and it will help the patient bring up mucous. Plus it's an independent nursing intervention.

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Specializes in Cath Lab/ ICU.
.

An incentive spirometer will help breathing and it will help the patient bring up mucous. Plus it's an independent nursing intervention.

Agree. Every time I see a pt use the IS they always cough!! Thats the best time for a sample...

Q3 wasn't posted when I replied, but I agree with using the IS.

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2. What may cause a false pulse oximetry reading? (Check ALL that apply)

A. Hypotension

B. Abnormally high Hemoglobin/Hematocrit levels

C. Respiration rate of 34b/min

D. Nail that is removed of nail polish

The answer is B.

Pulse oxmetry measures the percentage of blood RBCs saturated with O2.

A person with an abnormally high Hgb/Hct will falsely register a low SpO2...they are getting plenty of oxygen, they just have too many RBCs for respiration to saturate.

Conversely someone who is anemic will show a falsely elevated SpO2- their RBCs may be 100% saturated but there aren't enough of them (RBCs) to deliver adequate oxygen.

Answers A & C have no effect on the level the machine reads.

Choice D might or might not depending on which study your instructor chooses to believe.

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