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NUR 237 unit 4 pt 1
| Question | Answer |
|---|---|
| Bronchovesicular | normal lung sounds and equal |
| Adventitious | abnormal lung sounds |
| Bronchial | normal lung sounds |
| vesicular | normal lung sounds |
| pleura friction rub | sandpaper sound in the chest that is heard with a stethoscope and can be felt during breathing, caused by inflamed and roughened pleural surfaces rubbing against each other |
| pleurisy | inflammation of the pleurae, which impairs their lubricating function and causes pain when breathing. It is caused by pneumonia and other diseases of the chest or abdomen. |
| pleural infusion | an abnormal buildup of fluid in the space between the lungs and the chest cavity |
| if pt presents wheezing from allergies | remove triggers ex: if you have a pollen allergy avoid going outside |
| structures of respiratory system | nose, mouth, pharynx, larynx, trachea, bronchi, bronchioles, and alveoli |
| sinus 4 cavities behind nose | frontal, maxillary, ethmoid, and sphenoid |
| sinus function | warm humidfy air, take air off skull, trap particles, vocal qualities |
| septum | divider, divides left from right |
| pharynx | the throat |
| larynx | voice box |
| when i have a cold im contagious for the first 3 days but i may feel bad for 7-14 days | |
| Rhinititis | common cold |
| pt has to stay home for 3 days when symptoms start | |
| trachea | wind pipe |
| kieselbach | a network of blood vessels on the nasal septum where most nosebleeds (epistaxis) occur |
| Epitaxies | nose bleed |
| how to stop nose bleed | have person sit down, sit forward, pitch nose 8-12 minutes, repeat x1 if still bleeding send them to er or urgent care |
| tampon | drainage device for nose |
| if pt is presenting swallowing after nose bleed | they're swallowing the blood |
| bronchi branch out to bronchioles | |
| What are three main causative factors of respiratory disorders? | trauma/disease, perfusion issues (cardiac disease, emboli), harmful environmental substances, restrictive/obstructive diseases. |
| What are the structures of the upper respiratory system responsible for? | Airway protection (epiglottis) and speech production (larynx). |
| TEST anything over 6L is a waste | body can't metabolize it |
| What are key nursing responsibilities for respiratory diagnostic tests? | Proper prep, patient teaching, specimen collection, monitoring for complications. |
| What instructions help prevent long-term respiratory problems? | Smoking cessation, avoiding allergens, good hygiene, rest and nutrition. |
| What are the structures of the upper respiratory system responsible for? | Airway protection (epiglottis) and speech production (larynx). |
| What are the major functions of the lower respiratory system? | Oxygen delivery to alveoli, lung protection, respiratory regulation, thoracic/muscle effect on breathing, gas exchange. |
| What are vesicular breath sounds? | Low to medium pitch, soft “whoosh,” inspiration 2–3× longer than expiration. |
| What are the 5 A’s of smoking cessation? | Ask about tobacco use Advise about the health benefits of quitting Assess readiness to quit Assist in creating a cessation plan Arrange follow-up |
| What prevention measures reduce risk of respiratory disorders? | Frequent hand hygiene, avoiding crowds, not smoking, avoiding allergens, adequate rest & nutrition. |
| What conditions can cause respiratory disorders? | Trauma, diseases, cardiac disorders, emboli, harmful environmental substances, restrictive/obstructive diseases. |
| How to do a throat culture | sterile q tip is placed inside persons, throat if it touches teeth or tongue start over put in tube with liquid |
| peakflowmeter | |
| What prevention measures reduce risk of respiratory disorders? | Frequent hand hygiene, avoiding crowds, not smoking, avoiding allergens, adequate rest & nutrition. |
| What diagnostic tests assess respiratory disorders? | Visual exam of nose/throat, throat culture, TB test, lung function tests, peak flow, lung biopsy |
| Scant, sticky, rust-colored sputum suggests what | Pneumococcal pneumonia. |
| Blood-tinged or bloody sputum may indicate what? | TB, ulcerated pulmonary vessel, or bronchogenic carcinoma. |
| Large amounts of sputum suggests what? | Pneumonia or bronchitis. |
| Scant sputum suggests what? | Asthma |
| Very thick, viscous sputum indicates what? | Inadequate hydration. |
| What factors increase respiratory infection risk? | Age >65, smoking, extended-care residence, chronic respiratory disorders, CV disorders, renal disease, diabetes/metabolic issues, weak immune system. |
| Follow up visits for smokers | ask every visit if they're still smoking |
| tracheostomy | a surgical procedure that creates a stoma (opening) in the neck to access the trachea (windpipe) |
| NPO | "nothing per os" nothing by mouth |
| put cover on trach when showering | don't let soap and water get inside |
| difference between ectomy and ostomy | an ostomy creates a new surgical opening (a stoma) for waste to exit the body, while an ectomy surgically removes an organ or part of an organ |
| CPAP | obstructive sleep apnea (OSA) |
| PTs with OSA experience tiredness and exhaustion because | throughout the night they're not getting enough oxygen |
| NURSES DO NOT adjust CPAP machine oxygen | only respiratory therapist or physician adjust O2 |
| continues positive air pressure device | BIPAP |
| have pt on 2 to 3 pillows not laying flat for breathing issues | |
| When does barrel chest occur? | when someone has COPD (a rounded, bulging chest with an increased front-to-back diameter) |
| COPD | a progressive lung disease that causes airflow limitation and breathing problems due to damage to the airways and lungs |
| chronic bronchitis | long term bronchitis |
| Pulmonary fibrosis | a lung disease where lung tissue becomes scarred and thickened, making it difficult to breathe |
| emphysema | a lung condition that causes shortness of breath by damaging the tiny air sacs (alveoli) in the lungs, which leads to air trapping and a loss of elasticity |
| laryngitis | the inflammation of the larynx (voice box) that causes hoarseness or a complete loss of voice |
| what to do when you have laryngitis at home | Rest voice, gargle with salt water |
| small, medicated or non-medicated candies that are dissolved in the mouth to soothe a sore throat, relieve cough symptoms, or freshen breath | lozenges |
| emollients | which are substances like creams, ointments, lotions, or gels that soothe, soften, and moisturize the skin to prevent or treat dryness, roughness, or irritation |
| sinusitis | sinus infection (use warm moist packs) |
| cyanosis | blue color |
| 4 arteries behind nose that converge at artieries | |
| tonsilitis | fever, sore throat, yellow plaques |
| viral infection | don't take antibiotics, nursing interventions (gargle, rest) |
| Nursing intervention for laryngitis | gargle and rest after 2 weeks get antibiotics or steroids from doctor |
| nasal fracture | use warm cool packs "helps with pain, swelling and bleeding" |
| Rhinoplasty | nose job |
| classic signs for low pt O2 sat | restlessness, confusion, anxiety |
| treatments for cancer | radiation, chemotherapy, surgery |
| pt has voice box removed what is the name of the procedure? | laryngectomy |
| if person can't talk to pt | write it down |
| pt has allergies how do you avoid allergic rhinitis | avoid environmental triggers |
| how do you do a nasal inhaler | squeeze and inhale at the same time in one nostril close the other |
| pt has trach and went home what do you want to tell about trach care | use a humidifier (to soften mucus) |
| ALWAYS NOTE COLOR AND CONSISTENCY OF SPUTUM | |
| nuchal rigidity | sign of bacterial meningitis |
| frequent nose bleeds can be caused by | drug use, hypertension, leukemia |
| respiratory rest vs respiratory and failure | the inability of the lungs to adequately perform gas exchange (oxygenate the blood and remove carbon dioxide), while respiratory arrest is the complete and sudden cessation of breathing |
| allergic salute | hand moving wiping nose, nose running |
| why is the pt so restless even after full nights of rest | lack of oxygen to the brain during the night |
| the nurse is caring for client that had tolsilectomy | give popsicles |
| On initial assessment, a patient who just had a tonsillectomy and an adenoidectomy is restless and swallows frequently. What is the most likely explanation? | Bleeding |
| A 45-year-old man who is eating steak suddenly rises from his seat. His hands are grasping his throat. What actions should be performed? Identify the correct sequence. | Ask if he is choking → Wrap arms around him → Position fist above umbilicus → Deliver upward thrusts |
| When caring for a patient who had a rhinoplasty, you should perform which intervention(s) in the immediate postoperative period? (Select all that apply.) | Observe for frequent swallowing |
| The spouse of a patient with a tracheostomy asks, “What is the purpose of the cuff on the tracheostomy tube?” What is the best response? | “It allows the ventilator to deliver a full breath of air.” |
| A patient has sinusitis. Which nonpharmacologic intervention(s) would be appropriate? (Select all that apply.) | Inhale moist steam Increase fluids Encourage rest Use sinus irrigation kit |
| While deciding whether to sign the surgical consent for tracheostomy for a patient with face and neck trauma, the patient’s spouse asks, “What is the purpose of this procedure?” Which response(s) demonstrate(s) nursing knowledge regarding the procedure? | Helps suction secretions Bypasses an obstructed upper airway Temporary airway while healing |
| A 55-year-old man with a new tracheostomy is unable to cough. Breath sounds are diminished. Pulse oximetry is 88% on 100% humidified air. What is the priority nursing action? | 2. Suction respiratory secretions. |
| A patient is newly diagnosed with a squamous cell carcinoma of the larynx. What is an early sign and symptom for this diagnosis? | Hoarseness |
| A student is caring for a patient diagnosed with OSA. The patient is not convinced that the CPAP machine is worth the effort. What teaching can the student provide regarding the most important reason for the patient to receive treatment? | Untreated OSA can lead to heart attack and stroke. |
| A nurse is caring for a patient who is postoperative for tonsillectomy. Within the first 24 hours, which food item would be the most appropriate to offer the patient? | Popsicles |
| You are caring for a patient with signs and symptoms of influenza. What home care for this respiratory condition would be appropriate? | Consider analgesics and antipyretics. |
| A 58-year-old man is admitted with bacterial pneumonia. He has a high fever accompanied by chills, a cough productive of rust-colored sputum, and a general feeling of malaise. The medical diagnosis is confirmed by: | Chest radiographs. |
| Which patient is at greatest risk for developing a pulmonary embolism? The patient who: | The patient who has been immobile for 1 week and is mildly dehydrated. |
| A frail 40-year-old woman is admitted with complaints of fever, fatigue, coughing, difficulty breathing, and weight loss. Place the following nursing interventions in priority order. | Assess work of breathing and oxygen saturation Auscultate lung sounds Review and implement provider orders Weigh the patient |
| A person having a tuberculosis (TB) blood test would need further teaching about the test if they stated which of the following? | This test will determine if I have active or inactive TB.” |
| A nursing student is reviewing signs and symptoms with a group of people who are at risk for lung cancer. You would intervene if the student says which of the following? | “Weight loss and fatigue are the first symptoms to manifest.” |
| Which action is appropriate in the care of a patient who is on mechanical ventilation? | Auscultate the lungs bilaterally to ensure both lungs are being ventilated. |
| A 55-year-old man was admitted for complaints of a recurring, irritating “smoker’s” cough with small amounts of sputum and was diagnosed with chronic bronchitis. What is the most likely clinical finding? | Elevated hemoglobin and hematocrit. |
| A patient is immobilized and has been lying in bed for an extended period. What nursing intervention(s) should be done to prevent hypostatic pneumonia? (Select all that apply.) | Turn every 2 hours Encourage coughing and deep breathing Perform good hand hygiene |
| ou admit a patient who was diagnosed with active pulmonary tuberculosis. What nursing intervention(s) would help control the spread of the disease? (Select all that apply.) | Use airborne isolation Wear an N95 respirator Use good hand hygiene |
Created by:
kaimcd