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Final
Final note cards
| Question | Answer |
|---|---|
| 1. The nurse is assessing a 7-year-old boy with pharyngitis. The nurse would least likely expect to assess which of the following? A)Working hard to breathe B)Difficulty swallowing C)Rash on the abdomen D)Sore throat and headach | Working hard to breathe |
| Pharyngitis is most common sign for | Rhuematic fever |
| The nurse hears wheezing when auscultating a 4-year-old. Which of the following conditions would the nurse most likely rule out based on the assessment findings? A)Bronchiolitis B)Asthma C)Influenza D)Cystic fibrosis | Influenza |
| The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurse anticipates which of the following as most helpful in determining the extent of the child's hypoxia? | Pulse Oximetry |
| A rapid strep test has confirmed that a 5-year-old girl has a group A Streptococcusinfection. When teaching the parents about measures to implement, which of the following would be the least immediate concern | Childs Toothbrush |
| A nurse is administering 100% oxygen to a child with a pneumothorax based on the understanding that this treatment is used primarily for which reason? | Hasten air reabsorption |
| Bacterial pneumonia is suspected in a 4-year-old boy with fever, headache, and chest pain. Which assessment finding would most likely indicate the need for this child to be hospitalized? | |
| The nurse is educating the parents of a 7-year-old boy with asthma about the medications that have been prescribed. Which of the following drugs would the nurse identify as an adjunct to a b2-adrenergic agonist for treatment of bronchospasm | A)Ipratropium |
| A nurse is preparing a teaching plan for the family of a child with allergic rhinitis. When describing the immune reaction that occurs, the nurse would identify the role of which immunoglobulin? | IGE |
| A group of nursing students are reviewing the medications used to treat asthma. The students demonstrate understanding of the information when they identify which agent as appropriate for an acute episode of bronchospasm | Albuterol |
| The nurse is preparing to perform a physical examination of a child with asthma. Which of the following techniques would the nurse be least likely to perform | palpation |
| shape of larynx- child | funnel |
| A nursing instructor is preparing a class on chronic lung disease. Which of the following would the instructor include when describing this disorder | it is most commonly seen in premature infants |
| Page 5 21. A nurse is teaching the parents of a child diagnosed with cystic fibrosis about medication therapy. Which of the following would the nurse instruct the parents to administer orally? | pancreatic enzymes |
| When performing the physical examination of a child with c, which of the following would the nurse expect to assess? | decreased tacticle fremeitius |
| 2 year old with hypoxia related to respiratory infections the nurse understands what hypoxia | decreased alveoli |
| The nurse is preparing to provide tracheostomy care to an infant. After gathering the necessary equipment, which of the following would the nurse do next? | Position the infant supine with a towel roll under the neck |
| A child is brought to the emergency department by his parents because he suddenly developed a barking cough. Further assessment leads the nurse to suspect that the child is experiencing croup. Which of the following would the nurse have most likely assess | inspiratory stridor |
| normal finding for a tracheostomy | pale pink stoma,clear clean teach tube |
| Using A tubular inhaler steps (Asmanex | 1.loads the dose 2. twist the grip 3. exhale deeply 4. Hold it horizontally 5. place mouth around mouth piece 6. inhale 7. rinse and spit |
| Inspiratory | stridor |
| RSV obtain to make sure its right | nasopharangyeal |
| cystic fibrosis can't swallow pills what do you do | Sprinkle |
| Chest physiotherapy | segments in order Anterior Posterior lateral superior |
| Child exacerbation of asthma. What would the nurse find in lab values | hyperinflation of the lungs |
| Viral respiratory illness Viral none reported since 2004, CDC Transmitted by respiratory drplets | SARS |
| Accumulation of thick, purulent fluid in pleural spaces | Empyema |
| Clinical manifestations of Empyema | Fever, Night sweats, pleural pain, cough, dyspnea, anorexia, weight loss if immunocompromised symptoms may be vague |
| Assessment and Diagnostic Findings for Empyema | Decreased or absent breath sounds Dullness on chest percussion Decreased remits Chest CT Thoracentesis |
| Medical management for Empyema | Drain pleural cavity to expand the lungs Antibiotics (usually IV) Surgical removal of exudate Chest tube Monitored by CXR |
| Nursing Management for Empyema | Support Lung expanding breathing exercises caring for drainage equipment patient education |
| Erythema without induration Reaction of 0-4mm is considered not significant | Shows a reaction but not pulmonary Tuberculosis |
| What is a positive TB TEST | An induration of 10mm or > is usually considered significant in people who have normal or mildly impaired immunity Injected into the intradermal layer of the inner aspect of the forearm, 4 inches below the elbow 0.5 inch tb syringe 26-27g, inserted r |
| Diagnostic Tests with TB | Complete History Physical Exam TB Skin Test CXR ( Chest X-ray) AFB ( acid fast bacilli) Sputum culture |
| When is the best time to get a sputum sample and how do you collect it | First thing in the morning before fluids or fluid ask the patient to cough deep |
| INH, Rifamin ,Pyrazinamide, ethambutol or combination side effects are often the reason people fail to adhere to the prescribed med regimen | TB medication therapy |
| How should you take TB medication and What foods and Drugs should u avoid | Take on an empty stomach or 1 hour before meals (causes GI upset). Food interferes with absorption INH- avoid foods with tyramine, histamine - tuna, yeast extracts. If they do eat these foods will cause Flushing hypotension,lightheadedness, palpitation |
| This medication can increase the metabolism of certain other meds making them less effective such as : Beta-blockers , oral anticoagulants such as warfarin, oral hypoglycemic agents, oral contraceptives,theophylline,and verapamil orange urine and orange | Rifampin |
| Patient teaching with tuberculosis | Cover their mouth and nose when they cough or sneeze dispose of facial tissues in plastic bags wear a mask when in public until sputum samples are documental as free of AFB |
| Acute inflammation of the mucous membranes of trachea and baronial tree often follows infection of URI | Tracheobronchitis |
| first 48 hours acquired in hospitals | hospital- acquired pneumonia |
| A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? | Notify the rapid response team |
| A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client’s oxygen saturation has not significantly improved. What response by the nurse is best? | The blood clot interfere with the perfusion of oxygen |
| A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? | interrupt intubation and give oxygen. Each intubation should not exceed 30 seconds , 15 seconds is preferable |
| An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the client’s lung sounds. d. Suction the endotracheal tube | Listen to Breath sounds |
| .A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrai | Assess the reason for agitation |
| A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtain | B ensuring the bag mask is on the table |
| A client is on mechanical ventilation and the client’s spouse wonders why ranitidine (Zantac) is needed since the client “only has lung problems.” What response by the nurse is best? a. “It will increase the motility of the gastrointestinal tract.” b. | It will prevent ulcers from mechanical ventilation |
| A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionat | A. Altepaste |
| .A client is brought to the emergency department after sustaining injuries in a severe car crash. The client’s chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nur | Prepare for intubation |
| A student nurse asks for an explanation of “refractory hypoxemia.” What answer by the nurse instructor is best? a. “It is chronic hypoxemia that accompanies restrictive airway disease.” b. “It is hypoxemia from lung damage due to mechanical ventilatio | D |
| The Gold standard for diagnosis a PE is | Pulmonary angiography |
| A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury | B,D,E |
| When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. | CDE |
| A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. G | A,B,C,E |
| The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer m | A,B,C,D |
| A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client’s bedside. b. Ensure the client can communicate if awake. c. Keep the televisi | A,B,D,E |
| The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inabili | A,B,D |
| Tidal Volume KG times 6ml equals= tidal volume mechanical setting | |
| The active phase of ventilation Involves movement of muscles and the thorax to bring air into the lugs | Inspiration |
| The passive phase of ventilation -movement of air out of the lungs | Expiration |
| Refers to the take of oxygen and release of carbon dioxide | Gas exchange |
| Gas exchange is made possible by | respiration and perfusion |
| Gas exchange occurs via | diffusion ( movement of oxygen and carbon dioxide between air and blood |
| Inadequate amount of oxygen available to the cells | Hypoxia |
| Difficulty breathing | Dyspnea |
| Decreased rate or depth of air movement into the lungs | Hypoventilation |
| Factors affecting Cardiopulmonary Functioning and Oxygenation | Level of health Developmental considerations Lifestyle considerations environmental considerations psychological health considerations |
| Diagnostic tests to assess cardiopulmonary function | Cardiac coronary cauterization Cardiac exercise stress testing Echocardiogram Endoscopic studies Holter monitor Lung Scan Skin Tests Radiography |
| Collaborative cardiopulmonary problems | Alterations in cardiac functions Barotrauma Pulmonary infection Sepsis |
| Bony landmarks are more prominent due to loss of subcutaneous fat Kyphosis contributes to the appearance of leaning forward Barrel chest deformity may result in increased anterior-posterior diameter Tissues and airways become more rigid, and diaphragm | Respiratory Functioning in the older adult |
| No suction attached Can be done with any of the systems discussed When wall suction is turned off the system must be opened to the atmosphere so that air can escape from the system | Gravity drainage only |
| Nursing management for Chest Drainage systems | Instruct the patient to perform the valsava manuever Chest tube is quickly clamped and removed by the physical Simultaneously, cover the wound with air tight occlusive petroleum gauze then thoughouly cover and seal with non porous tape |
| Low pitched, soft sound during expiration heard over most of the lungs | Vesicular |
| High- Pitched and longer heard primarily over the trachea | Bronchial |
| Medium-Pitched and sound during expiration, heard over the upper anterior chest and intercostal area | Bronchovesicular |
| Values Measured from Pulmonary function tests | Tidal Volume Vital capacity Forced Vital capacity Forced Expiratory Volume Total Lung capacity- amount of max air in the lungs Residual Volume Peak expiratory flow rate |
| Abnormal ( adventitious) Lung sounds | Crackles, Wheezes |
| intermittent sounds occurring when air moves through airway that contains fluid Classified as fine, medium, coarse | Crackles |
| Continuous sounds heard on expiration and sometimes on inspiration as air passes through the airways constricted by swelling, secretions or tumors Classified as Sibilant or Snorous | Wheezes |
| Nursing Interventions Promoting Adequate Respiratory Functioning | Teaching about pollution-free environment Promoting optimal function Promoting comfort Managing chest tubes Promoting and controlling coughing Suctioning the airway Meeting oxygenation needs with medication |
| How do you promote proper breathing | Deep breathing Using incentive spirometry Pursed lip breathing Diaphragmatic breathing |
| Administration of oxygen greater than ____ ( the concentration of oxygen in the room air) to provide adequate transportation of oxygen in the blood to decrease the work of breathing and to reduce stress on the myocardium | 21 % |
| Precautions for oxygen administration | Avoid open flames Place no smoking signs in obvious places check to see that electrical equipment in the room is good working order Avoid using oil in the area (oils spontaneously in oxygen) |
| Complications of oxygen therapy | Suppressed respiratory drive and low 02 tension Oxygen toxicity |
| O2 Concentrations of greater than 50% for extended periods of time (longer than 48 hours can cause an overstimulation free radicals which can severely damage cells | Oxygen toxicity |
| Symptoms of Oxygen Toxicity | substernal discomfort, parethesias, dyspnea, restlesness,fatigue, malaise , progressive respiratory difficulty, refractory hypoxemia, alveolor atelectasis, and alveolar infiltrates on x-ray |
| Prevention of Oxygen Toxicity | Use lowest effective concentration of oxygen peep or cap prevent or reverse atelectasis and allow lower oxygen percentages to be used |
| Two types volume or flow Device encourages patient to inhale slowly and deeply maximize lung inflation and alveoli expansion used to prevent atelectasis | Incentive Spirometry |
| Patient teaching and home considerations for Respiratory functioning | Breathing and coughing techniques positioning addressing pain and discomfort promoting mobility and arm and shoulder exercises diet prevention of infection signs and symptoms to report |
| Provides patent airway, access for mechanical ventilation,facilitates removal of secretions | Endotracheal Intubation |
| Positive pressure device to maintain ventilation and oxygenation | Mechanical Ventilation |
| Vital capacity is | 10-15ml |
| Process of withdrawal of dependence upon the ventilator | Weaning |
| Use of mask or other device to maintain a seal and permit ventilation | Noninvasive Positive-Pressure Ventilation |
| Managing Chest Tubes | Assist with insertion of the chest tube monitor the patients respiratory status and vital signs Check the dressing Maintain the potency and integrity of the drainage system |
| _______ is a vacuum which is used to maintain inflation of the lungs | Pleural space |
| Bubbling will not occur if the chest tube is in what area | Mediastinum |
| Drainage( Fluid Collection) Chamber | Collects fluid from the chest fluid level must be monitored and should be documented changes and or problems should be reported to the provider |
| Water Seal Chamber | The water seal Chamber is a one way valve that allows air to exit the chest and prevents air form re-entering the chest the water seal should be 2cm of water the water seal level fluctuate with respirations due to changes in intrathoracic pressure |
| The amount of suction is controlled by the amount of water in the chamber not by the wall suction suction is usually set at 20cm h20 there should be a slow but steady bubbling in the chamber | Water suction chamber |
| Dry suction water seal system with one way valve | There is no water seal chamber the one way valve replaces the water seal there is no water in the suction chamber the regulator dial replaces the waters |
Created by:
Kmajors0403