7/4 E CV & Resp 90% +

Go Ahead, Trach my day

Go Ahead, Trach my day

NC Nursing Intervention 4:

Assess the patient for changes in respiratory rate and depth. The respiratory pattern affects the amount of oxygen delivered. A different delivery system may be needed.

These systems are easy to use and fairly comfortable, but the amount of oxygen delivered varies and depends on the patient's breathing pattern.

The oxygen is diluted with room air (21% oxygen), which lowers the amount actually inspired

Which amount is the normal value of a client's inspiratory reserve volume?

The normal value of inspiratory reserve volume is 3.0 L. The normal value of tidal volume is 0.5 L. The normal value of expiratory reserve volume is 1.0 L. The normal value of residual volume is 1.5 L.

Simple Facemask

40%-60% FiO2 at 5-8 L/min; flow rate must be set at least at 5 L/min to flush mask of carbon dioxide

Simple Facemask Intervention 2

Assess skin and provide skin care to the area covered by the mask. Pressure and moisture under the mask may cause loss of TISSUE INTEGRITY.

Which action will the nurse take when a client's chest x-ray shows atelectasis? Encourage incentive spirometer use

Atelectasis signifies alveolar collapse and indicates a need for the client to take deep breaths that will expand the alveoli. Oxygen administration does not improve atelectasis. Suctioning is not indicated for atelectasis and is unnecessarily invasive and uncomfortable. Postural drainage is used to help clients clear airways of secretions, but would not help decrease atelectasis.

Complication: Tracheomalacia constant pressure exerted by the cuff causes tracheal dilation and erosion of cartilage, leading to loss of tissue integrity Manifestations: -an increased amt of air is req'd in the cuff to maintain the seal. -A larger trach tube is required to prevent an air lead at stoma -Food particles are seen in trach secretions. -The pt does not receive the set tidal volume on the vent.

Management: No special management is needed unless bleeding occurs. Prevention: Use an uncuffed tube as soon as possible. Monitor cuff pressure and air volumes closely and detect changes.

NC Nursing Interventions 1

Ensure that prongs are in the nares properly rationale: a poorly fitting NC leads to hypoxemia and skin breakdown with loss of tissue integrity

Which assessment findings are consistent with a client diagnosis of right-sided heart failure? Select all that apply. One, some, or all responses may be correct. Collapsed neck veins Distended abdomen Dependent edema Decreased appetite Cool extremities

2,3,4, Right-sided heart failure is associated with increased systemic venous pressures and venous congestion, as manifested by an enlarged liver with possible ascites (distended abdomen), dependent edema, and anorexia (decreased appetite). Distended (not collapsed) neck veins occur in right-sided heart failure. Cool extremities are common in left-sided heart failure because of decreased cardiac output.

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding? Adventitious sounds Fine crackling sounds Vesicular breath sounds Diminished breath sounds

3 Vesicular breath sounds are normal respiratory sounds heard on auscultation as inspired air enters and leaves the alveoli. "Adventitious" is the general term for all abnormal breath sounds. Crackles heard at the end of an inspiration are associated with fluid in the alveoli. Diminished breath sounds are evidence of a reduction in the amount of air entering the alveoli; this usually is caused by obstruction or consolidation.

Which information would be used to determine the cause of premature atrial contractions (PACs) observed on a client's EKG? Select all that apply. One, some, or all responses may be correct. Stress level Tobacco use Caffeine intake Electrolyte levels Home medications

all of the above There are many potential causes of PACs. Substances such as caffeine, tobacco, and alcohol; stress and fatigue; and imbalances in electrolytes can all cause PACs. Certain chronic conditions that may be treated with medication are associated with the development of PACs, such as chronic obstructive pulmonary disease, hyperthyroidism, and coronary heart disease.

When a client is experiencing acute coronary syndrome, which factor would the nurse identify as the cause of the pain experienced by a client? Arterial aneurysm Heart muscle ischemia Blocking of the coronary veins Irritation of nerve endings in the cardiac plexus

2 Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial aneurysms are not a common cause of myocardial ischemia or infarction. Arteries, not veins, are involved in the pathology of an acute coronary syndrome. Tissue injury and pain occur in the myocardium, not the cardiac plexus.

Which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site?

Mild soap and water are used to cleanse the stoma site. Sterile saline, a humidifier, or pans of water can be used to humidify the air entering the stoma. There is no need to use steroid cream at the site unless instructed by the health care provider. Non-oil-based, rather than oil-based, lubricants can be used as needed for lubrication of the site.

Simple Facemask Intervention 4

Provide emotional support to the patient who feels claustrophobic. Emotional support decreases anxiety, which contributes to a claustrophobic feeling.

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats per minute. The rhythm is regular. Which would the nurse conclude that the client is experiencing? Atrial fibrillation Sinus tachycardia Ventricular fibrillation First-degree atrioventricular block

b The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.

Which action would the nurse take when suctioning a client's endotracheal tube? Hyperoxygenate with 100% oxygen before and after suctioning. Suction two or three times in quick succession to remove secretions. Use the technique of short, pushing movements when applying suction. Apply suction for no more than 10 seconds while inserting the catheter.

1 Suctioning can lead to hypoxemia and the nurse would minimize this by hyperoxygenating the client before and after each suctioning attempt. Because suctioning irritates the airway and leads to transient hypoxemia, suctioning should be performed only as needed to maintain a patent airway. One suctioning pass is frequently adequate to clear secretions; excessive suctioning irritates the mucosa, which increases secretion production. Short, pushing movements can cause tracheal damage. To prevent trauma to the trachea, suction should be applied only while removing the catheter, not while inserting.

When a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factors that may have contributed to the ankle swelling? Select all that apply. One, some, or all responses may be correct. Intake of salty foods Dietary fat intake Medication compliance Family stresses Recent travel

1,3,5,

When caring for a client with a diagnosis of right ventricular heart failure, the nurse expects which assessment findings? Select all that apply. One, some, or all responses may be correct. Dependent edema Swollen hands and fingers Collapsed neck veins Right upper quadrant discomfort Oliguria

124 With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.

Which action would the nurse take to prevent postoperative respiratory complications after abdominal surgery? Implement postural drainage. Encourage pursed-lip breathing. Assist with incentive spirometry. Teach sustained exhalation.

3 Incentive spirometry expands collapsed alveoli and enhances surfactant activity, thereby preventing atelectasis. Postural drainage helps clear accumulated secretions from the pulmonary tree and would typically be used for clients with pneumonia who have secretions at distal areas of the lungs. Pursed-lip breathing is used for clients with chronic obstructive pulmonary disease (COPD) to help with more complete expiration; it would not directly promote alveolar expansion. Sustained exhalation would occur with pursed-lip breathing and would not directly assist with alveolar expansion.

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen? To prevent dyspnea To prevent cyanosis To increase oxygen concentration to heart cells To increase oxygen tension in the circulating blood

3 Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.

Partial Rebreather Mask

60%-75% at 6-11 L/min, a liter flow rate high enough to maintain reservoir bag two-thirds full during inspiration and expiration

Simple Facemask Intervention 5

Suggest to the primary health care provider to switch the patient from a mask to the nasal cannula during eating. Use of the cannula promotes GAS EXCHANGE during eating.

A client is extubated in the postanesthesia care unit after surgery. For which common response would the nurse be alert when monitoring the client for acute respiratory distress? Bradycardia Restlessness Conitricted pupils Clubbing of the fingers

2 Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia.

The nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response would the nurse expect? Hypokalemia Metabolic acidosis Respiratory alkalosis Decreased carbon dioxide level

2 Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.

When a client's rhythm strip shows that the P and QRS waves are consistent, with a P wave preceding every QRS complex and a PR interval of 0.26 seconds, how would the nurse interpret the rhythm? Complete heart block Normal sinus rhythm First degree atrioventricular (AV) block Second degree AV block

3 In first degree AV block, P and QRS waves are consistent in shape. A P wave precedes every QRS complex, and the PR interval is greater than 0.20 seconds. Normal sinus rhythm reflects normal conduction of the sinus impulse through the atria and ventricles; PR interval is 0.12 to 0.20 seconds, and every QRS is preceded by a P wave. In second degree AV block, 1 or more P waves are not conducted to the ventricles and therefore not followed by a QRS. In third degree AV block or complete heart bock, the QRS has no relationship with P waves.

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? Decreases chest pain Conserves energy Increases oxygen saturation Promotes elimination of CO2

4 Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO2. It also helps clients slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation.

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? Administer sedatives as frequently as possible. 2 Turn the client every 4 hours. 3 Increase ventilator settings every 2 hours. Suction as needed.

4 The nurse should observe the client's need for tracheal/oral/nasal suctioning every 2 hours and provide adequate suctioning as needed. The nurse should not routinely administer sedatives as frequently as possible; they should be administered as needed, based on the needs of the client. The nurse should turn the client every 2 hours, not 4 hours. The nurse should not adjust vent settings every 2 hours; however, the nurse should check ventilation settings at least once a shift.

NC Nursing Interventions 3:

Assess the patency of the nostrils. Rationale: Congestion or a deviated septum prevents effective delivery of oxygen

A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention? Administer opioids frequently. Assess for signs of pneumonia. Give medication to suppress coughing. Limit fluid intake to prevent pulmonary edema.

Clients with pleuritic disease are prone to developing pneumonia because of impaired lung expansion, air exchange, and drainage. Opioids are contraindicated because opioids depress respirations. Coughing should not be suppressed; it enhances lung expansion, air exchange, and lung drainage. Oral fluids should be encouraged; pulmonary edema does not develop unless the client has severe cardiovascular disease.

Atrial fibrillation and pulmonary embolism ...

Inadequate atrial contraction that occurs during fibrillation leads to pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism, whereas dislodgement of thrombus in the left atria may lead to embolic stroke.

Low flow

Low-flow systems include the nasal cannula, simple facemask, partial rebreather mask, and nonrebreather mask

Partial Rebreather Mask Intervention 1

Make sure that the reservoir does not twist or kink, which results in a deflated bag. Deflation results in decreased oxygen delivered and increases the rebreathing of exhaled air

Simple Facemask Intervention 3

Monitor the patient closely for risk for aspiration. The mask limits the patient's ability to clear the mouth, especially if vomiting occurs.

Which assessment finding is consistent with bronchospasm? Wheezing Rhonchi Pleural friction rub Low-pitched crackles

Wheezing, a high-pitched, musical, continuous sound that does not clear with coughing, is caused by airway narrowing, which occurs with bronchospasm, for example. Rhonchi are associated with obstruction by a foreign body or thick mucus. Pleural friction rub can be heard in cases of pleurisy. Pneumonia may be present in a client who exhibits low-pitched crackles.

Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. One, some, or all responses may be correct. Providing oxygen Assessing vital signs Obtaining a 12-lead EKG Drawing blood for cardiac enzymes Auscultating heart sounds Administering nitroglycerin

all of the above The nurse would provide oxygen to a client with chest pain, as the heart may be getting insufficient oxygen as a result of occluded coronary vessels. The nurse would also assess the client's vital signs, obtain a 12-lead EKG, and auscultate heart sounds to determine rhythm changes related to cardiac ischemia. The nurse would need to draw blood for evaluation of cardiac enzymes. Changes in the levels of these enzymes (including troponin, creatine kinase, and myoglobin) can indicate damage to heart tissue. Nitroglycerin is administered to promote coronary vasodilation.

Simple Facemask Intervention 1

Be sure that mask fits securely over nose and mouth. A poorly fitting mask reduces the FiO2 delivered.

Partial Rebreather Mask Intervention 2

Adjust the flow rate to keep the reservoir bag inflated. The flow rate is adjusted to meet the pattern of the patient.

After auscultating the chest, how will the nurse document findings of bilateral, high-pitched, continuous whistling sounds heard during each expiration? Crackles Wheezes Rhonchus Pleural friction rub

2 Wheezing, an adventitious breath sound, is a high-pitched continuous whistling that does not clear with coughing. Crackles are popping, discontinuous sounds caused by air moving into previously deflated airways. Rhonchus is a lower-pitched, coarse, continuous snoring sound that arises from the large airways. Pleural friction rub is a loud, rough, grating sound produced by inflammation of the pleural lining.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. Which term would be used when documenting this assessment finding? Fine crackles Adventitious sounds Vesicular breath sounds Diminished breath sounds

3 Vesicular breath sounds are expected respiratory sounds heard on auscultation as inspired air enters and leaves alveoli. Fine crackles are faint crackling sounds heard at the end of inspiration; they are associated with pulmonary edema. "Adventitious sounds" is a general term for all abnormal breath sounds. Diminished breath sounds are evidence of a decreased amount of air entering the alveoli; this usually is caused by obstruction or consolidation

When a client arrives in the emergency department and reports dyspnea, which finding by the nurse indicates that an inhaled bronchodilator may be needed for treatment? Oral temperature 101°F (38.3°C) Use of accessory muscles for breathing Inspiratory and expiratory wheezes Dullness to percussion at lung bases

3 Wheezing is caused by airway spasm and narrowing, and inhaled bronchodilators will relax bronchospasm and open the airways rapidly. Fever may indicate pneumonia and the nurse would anticipate obtaining cultures and administration of intravenous fluids and antibiotics. Use of accessory muscle is seen with many respiratory problems and inhaled bronchodilators may not be helpful, depending on the client diagnosis. Dullness to percussion may be associated with diagnoses such as pleural effusion and would not be treated with an inhaled bronchodilator.

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? Level of consciousness and pupil size Characteristics of pain and blood pressure Quality of respirations and presence of pulses Observation of abdominal contusions and other wounds

3 Assessing breathing and circulation are the priorities in trauma management; basic life functions must be maintained or reestablished (ABCs: airway-breathing-circulation). Level of consciousness and pupil size are assessments associated with head injury; in this situation these follow determination of respiratory and circulatory status, which are the priorities. Although blood pressure is an important assessment associated with adequacy of circulation, it is obtained after assessments associated with patency of airway and breathing; a client's pain is addressed after ABC needs are assessed and interventions implemented to support life. Assessment for abdominal injury and other wounds follows determination of respiratory and circulatory status, which are the priorities.

The nurse is assessing an electrocardiogram (ECG) rhythm strip. Which component of the tracing will the nurse observe to determine ventricular depolarization? P wave T wave PR interval QRS complex

4 The QRS complex represents ventricular depolarization. The P wave represents atrial depolarization. Normally a P wave indicates that the sinoatrial node initiated the impulse that depolarized the atrium. The T wave represents ventricular repolarization. The interval from the beginning of the P wave to the next deflection from the baseline is called the PR interval and represents depolarization of the sinoatrial node, both atria, and the atrioventricular node.Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.

NC Nursing Interventions 2

Apply water soluble jelly to nares PRN this subtance prevents mucosal irritation related to the drying effect of oxygen: promotes comfort.

For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. One, some, or all responses may be correct. Weight loss Unusual fatigue Dependent edema Nocturnal dyspnea Increased urinary output

Unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure. Weight gain, not loss, occurs because of fluid retention. Urinary output decreases, not increases, with heart failure because the sympathetic nervous system and the renin-angiotensin-aldosterone system stimulate the retention of sodium and water in the kidneys. Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude.

When arterial blood gases done on a client who is being resuscitated after cardiac arrest show a low pH, which factor is the likely cause of the laboratory result? Ketoacidosis Irregular heartbeat Lactic acid production Sodium bicarbonate administration

3 Cardiac arrest causes decreased tissue perfusion, which results in anaerobic metabolism and lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Sodium bicarbonate causes alkalosis, not acidosis.

Which action will the nurse take when measuring a client's pulmonary artery wedge pressure (PAWP)? Deflate the balloon as soon as the PAWP is measured. Have the client bear down when measuring the PAWP. Place the client in high-Fowler position to measure the PAWP. Advance the catheter if a typical PAWP tracing is not obtained.

1 Although the balloon must be inflated to measure the PAWP, it is deflated as soon as the PAWP is obtained to allow blood to continue to flow through the pulmonary artery. Bearing down will increase intrathoracic pressure and lead to an inaccurate PAWP reading. The client would be positions in a supine position at 0 to 45 degrees for PAWP measurement. Repositioning of the catheter may be done by the health care provider, but is not within the scope of nursing practice.

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? Initiate oxygen via a nasal cannula Administer the prescribed morphine Prepare the client for endotracheal intubation Place a nitroglycerin tablet under the client's tongue

1 Supplemental oxygen supports the body while the cause of the problem is identified; supplemental oxygen can be instituted without a prescription in an emergency. Morphine is used in the treatment of chest pain, but it is not the priority intervention. Endotracheal intubation is not the priority intervention. If the client's condition deteriorates and the client becomes unconscious or experiences respiratory failure or obstruction, endotracheal intubation is warranted. Nitroglycerin is available in most client acute care areas and does lessen chest pain if the pain is cardiac in origin, but it is not the priority intervention and requires a prescription.

When a client with angina is scheduled to have a cardiac catheterization, which explanation would the nurse give about the purpose of the procedure? To obtain the pressures in the heart chambers To determine the existence of congenital heart disease To visualize the disease process in the coronary arteries To measure the oxygen content of various heart chambers

3 Angina usually is caused by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization. Although pressures can be obtained, they are not the priority for this client; this assessment is appropriate for those with valvular disease. Determining the existence of congenital heart disease is appropriate for infants and young adults with cardiac birth defects. Measuring the oxygen content of various heart chambers is appropriate for infants and young children with suspected septal defects

A client is hospitalized with emphysema. The nurse recognizes the importance of assessing for clinical indicators of hypoxia based on which condition associated with the disease? Pleural effusion Infectious obstructions Loss of aerating surface Respiratory muscle paralysis

3 Destruction of the alveolar walls leads to diminished surface area for gaseous exchange and to increased carbon dioxide levels in the blood. Pleural effusion occurs when there is seepage of fluid into the intrapleural space; this does not occur with emphysema. Infectious obstructions occur in conditions in which microorganisms invade lung tissue; emphysema is not an infectious disease. Muscle paralysis may occur in diseases affecting the neurological system. Emphysema does not affect the neurological system; therefore it is not a neurological disease.

A client's respiratory status deteriorates, and endotracheal intubation and positive-pressure ventilation are instituted. The nurse would take which immediate action? Prepare the client for emergency surgery. Facilitate the client's verbal communication. Assess the client's response to the interventions. Maintain sterility of the ventilation system that is being used

3 If a client is not responding to interventions, the plan must be changed to support respiration. Preparing the client for emergency surgery is presumptive; there are insufficient data to conclude that surgery is necessary. Endotracheal intubation does not permit verbal communication. Maintaining sterility of the ventilation system that is being used is important, but it is not the priority.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing?

The pH indicates acidosis; the PCO2 level is the parameter for respiratory function. The expected PCO2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.

When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, which action will the nurse include? Ambulating the client 2 hours after the procedure Checking the vital signs every 15 minutes for 8 hours Maintaining the supine position for a minimum of 4 hours Keeping the client nothing by mouth for 4 hours after the procedure

The supine position prevents hip flexion, decreasing risk for clot disruption and bleeding at the catheter insertion site; if the head of the bed is elevated, it should not exceed 20 degrees. Hip flexion when rising to ambulate traumatizes the catheter insertion site and should be avoided for at least 4 hours to promote healing. Checking the vital signs every 15 minutes for 8 hours will interfere with rest; the vital signs are measured every 15 minutes until stable, usually for 1 hour. The gastrointestinal system is not involved, and general anesthesia is not used.