B.T., a $22$-year-old man who lives in a small mountain town in Colorado, is highly allergic to dust and pollen. B.T's wife drove him to the clinic when his wheezing was unresponsive to fluticasone/salmeterol (Advair) and ipratropium bromide (Atrovent) inhalers, he was unable to lie down, and he began to use accessory muscles to breathe. B.T. is started on $4 \mathrm{~L}$ oxygen by nasal cannula and an IV of D5W at $15 \mathrm{~mL} / \mathrm{hr}$. He appears anxious and says that he is short of breath.

$$\begin{aligned} &\text { Arterial Blood Gases }\\ &\begin{array}{ll} \mathrm{pH} & 7.31 \\ \mathrm{Paco}_2 & 48 \mathrm{~mm} \mathrm{Hg} \\ \mathrm{HCO}_3 & 26 \mathrm{mmol} / \mathrm{I} \\ \mathrm{PaO}_2 & 55 \mathrm{~mm} \mathrm{Hg} \\ \mathrm{SaO}_2 & 88 \% \end{array} \end{aligned}$$

You will need to monitor B.T. closely for the next few hours. Identify four signs and symptoms of impending respiratory failure that you will be assessing for.

C.E., a 73-year-old married man and retired railroad engineer, visited his internist, complaining, "Whenever I try to do anything, I get so out of breath I can't go on. I think I'm just getting older, but my wife told me I had to come see you about it:' His resting Spo2 registered 83%. He was sent to the local hospital for a chest x-ray examination and arterial blood gases (ABGs) after resting 20 minutes on room air. C.E. returned to the office. After evaluating t he results, t he physician told C.E. he had severe emphysema and must start on continuous oxygen (0) therapy at a 2 L flow rate. The physician completed a prescript ion for the oxygen therapy, including on the prescription C.E.'s pulse oximetry and ABG results.
What is the rationale for starting C.E. on oxygen at a 2 L flow rate?

D.S. states, “I have a nephew who rolled his Jeep and busted himself up real bad. He got hooked on those drugs, and I don't want any part of them.”

Why is D.S. experiencing difficulty using his right arm? Given the type of surgery he underwent, is this expected?

M.N., age $40$, was admitted with acute cholecystitis. After undergoing an open cholecystectomy, she is being admitted to your surgical floor. She has a nasogastric tube to continuous low wall suction, one peripheral IV, and a large abdominal dressing. Her orders are as follows:

Describe the assessment you would need to perform to differentiate what might be occurring with M.N.

You complete your assessment of G.S. You note shortness of breath (SOB), fine crackles throughout all lung fields posteriorly and in both lower lobes anteriorly, and coarse crackles over the large airways.

The nurse from the previous shift charted the following statement: “Fine and coarse crackles that clear with vigorous coughing.” Based on your knowledge of pathophysiology, determine the accuracy of this statement.

A.B., a $40$-year-old man, is admitted to your medical floor with a diagnosis of pleural effusion. He complains of shortness of breath; pain in his chest; weakness; and a dry, irritating cough. His vital signs (VS) are $142/82, 118,$ respirations are $38$ and labored and shallow, $102.1^{\circ} \mathrm{F}\left(38.9^{\circ} \mathrm{C}\right)$. His chest $x$-ray shows a large pleural effusion and pulmonary infiltrates in the right lower lobe consistent with pneumonitis.\

Review the pathophysiology and consequences of pleural effusion and pulmonary infiltrates.