Med-Surg Exam 4

What is an ominous sign of distress in asthmatics?

- "Silent chest" - Bradycardia - Bradypnea

What are the rules for postural drainage with percussion and vibration?

- Bronchodilators *before* drainage. - Maintain each position for 5 minutes 2-4x a day - Drain each segment towards the large airways - Do at least 1 hour before meals or 3 hours after meals.

Why do we give combination drugs (ie. bronchodilator, steroid)?

- Bronchodilators- Open air ways - Steroids- decrease inflammation

What is the priority drug for an asthmatic attack?

- Bronchodilators- SABA's for rescue inhaler - Albuterol or Maxair

How do we diagnosis chronic bronchitis?

- Chronic productive cough for 3 months out of the year for two consecutive years. - Lots of thick mucus.

What are risk factors for lung cancer?

- Cigarette smoking is most important - Environmental factors

What interventions do we do for impaired breathing pattern?

- Drug therapy- Bronchodilators, SABAs, LABAs, - Oxygen therapy - Pursed-lip breathing - Diaphragmatic breathing - Surgical therapy

What are the complications of URIs or viral infections?

- Dyspnea and crackles after the flu could indicate pneumonia. - Inadequate treatment of strep -> Rheumatic heart disease or glomerulonephritis.

What type of pt is at risk for nosocomial pneumonia?

- Endotracheal intubation - Immunosuppressive therapy

What are the infection control procedures for TB?

- Good hand-washing - Airborne isolation - HEPA masks

What would we expect to do if a CF patient coughs up green mucus?

- Green mucus is caused by pseudomas - Aerosolized tobramycin (TOBI) for Pseudomonas

What do we do for patients with Cystic Fibrosis?

- Help promote clearance of secretions - Control infection in the lungs - Provide adequate nutrition

What is happening with a patient with a muffled voice? Is it bad?

- High fever, muffled "hot potato" voice = Peritonsillar abscess is a big risk of airway obstruction. - Potentially life-threatening

What can we do to improve calorie intake for patients with COPD?

- Ice cream!! - Eat 5-6 small meals a day.

Why do CF patients get high blood glucose levels? What do you do about it?

- Inadequate insulin production. - They must have insulin, not oral meds.

The nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? a) Inspection b) Chest X-ray c) Arterial blood gas (ABG) levels d) Auscultation

d) Auscultation

Signs of respiratory distress

- Increased resp rate (in the 30s), - Use of accessory muscles - Confusion/restlessness/irritability - (hypoxia), low oxygen sat, low PaO2 - Wheezes (airway narrowing) - Crackles (fluid in the lungs - more objective than shortness of breath) - Productive cough with thick mucus

What is the difference between flu vaccination and pneumonia vaccination?

- Influenza is a common cause of pneumonia. - It's important to get the flu vaccination every year, because the strains change yearly. - Pneumonia vaccination is usually only needed once, but booster vaccinations are recommended for some people.

What do you know about Rifampin and what will you teach the pt?

- It can cause hepatotoxicity - You will teach the patient that I causes orange discoloration of urine, sweat, tears and sputum.

What is the purpose of asthma medications? How do we know they are working?

- Maintain control. - Can perform ADLs

What are home care instructions for a pt with pneumonia?

- Make sure they take full course of medications - Teach importance of follow-up care - Adequate rest - Deep breathing exercises - Nutrition- 3 L of water a day. At least 1500 Calories a day

What are the rules for using DPIs (dry powder inhalers)?

- No spacer - No shaking - Hold breath for 10 seconds - Keep away from humidity

What is a risk factor for emphysema especially in a young patient who has never smoked?

- Occupational chemicals and dust - Air pollution - Infection (TB, HIV)

Why is pursed lip breathing helpful?

- Prolongs expiration (1:3) - Decreases air trapping - Slows RR

What symptoms do you see with cor pulmonale?

- Pulmonary HTN - Hypertrophy of the right side of the heart - Symptoms of right sided heart failure.

For all respiratory problems, what should you do before you call the doctor?

- Put the HOB up, start oxygen, and assess before you call the dr.

What are signs of significant respiratory distress in asthmatics?

- RR > 30, HR > 120 - Dyspnea at rest - Tripod position - Drowsy, confused, agitated.

What are the rules for using MDIs (metered-dose inhalers)?

- Shake before use - Can add a spacer - Clean twice a week - Hold breath for 10 seconds.

What symptoms do you see with pneumonia?

- Sudden onset of fever, chills - Cough with purulent sputum - May have pleuritic chest pain - Increase fremitus, chrackles, wheezing, dull to percussion.

What are the rules for giving oxygen to a COPD patient?

- They may never achieve a normal oxygen saturation. - We *do* put oxygen on COPD patients if their sats are in the 80's, just only *go up a liter at a time by nasal cannula* - Don't put a facemask on at 10 L

What are the s/s of lung cancer?

- Usually asymptomatic until late in the disease - Persistent couch with sputum (Hemoptysis) -usually first sign - Anorexia, fatigue, weight loss, n/v, hoarseness

What do you know about peak flows? What do you do when in the green zone, yellow zone, red zone?

- Usually the best of 3 blows. It takes about a week or more to figure out baseline. - Green - 80-100%. No changes - Yellow - 50-80%. Be more vigilant, usu. Add SABA more frequently - Red - 50% or less, take SABA, call dr or go to ER

What is an appropriate exercise goal and instructions for a patient with COPD?

- Walk 15-20 minutes a day.

What would you teach a patient about their laryngeal stoma?

- Wash around the stoma daily. - Remove and clean the tube daily - Use a plastic collar when showering. No swimming. - Wear a medical alert bracelet, that says the cant be resuscitated via the mouth or nose. - They cant smell smoke, so need smoke and CO detectors

What do you know about fenestrated trach tubes?

- When inner cannula is removed, cuff deflated, and decannulation plug inserted, air flows around the tube, through the fenestration in outer cannula and up over the vocal cords so *patient can speak.*

What is the postoperative care after head and neck surgeries?

-*#1 priority is to maintain a patent airway.* - Semi-Fowler's position decreases edema and stress on suture lines. - Will need a temporary feeding tube to allow the incision to heal. - May have a surgical drain - Exercise neck and shoulders to prevent limitation in motion.

What do you do for nosebleeds? What is the risk of this care?

-*FIRST*: apply direct pressure. Watch for low O2 -Risk for aspiration because of packing.

What is the pre-procedure and post-procedure care for bronchoscopy?

-*Pre-procedure*: NPO for 6-12 hours before. -*Post-procedure*: NPO until gag reflex returns. Watch for: laryngeal edema, hemorrhage, hemothorax. May have blood-tinged mucus. No special positioning after.

What will you teach a patient about side effects of radiation for head/neck cancer?

-*Xerostomia* (Dry mouth): Increase fluid intake, chew sugarless gum or candy, use non-alcoholic mouth rinses) -*Fatigue*: Take frequent rest periods. Regular, light exercise. -*Stomatitis*: Soft, bland foods. Frequent rinses with water. No mouthwash or spicy foods. Benadryl, Lidocaine swish/spit.

What meds affect the respiratory system?

-ACE inhibitors cause coughs. -Bronchodilators

What are normal gerontologic changes for respiratory?

-AP diameter increases -Chest is barrel-shaped. -Less tolerance for exertion, leading to dyspnea -Stiffening of the chest wall. -Decrease in elastic recoil and compliance

What is an enlarged AP diameter? What causes it?

-AP should normally be less than 1:2 -Increased with barrel chest, which can be normal aging or a sign of hyperinflation. -Caused by trapping of air in the lungs.

What is post-op care for rhinoplasty?

-Keep head elevated to decrease nasal swelling -Internal nasal packing and/or nasal septal splints may be removed by the surgeon the day after surgery

What do you know about PFTs? (Pulmonary Fxn Test)

-Measures lung volumes and airflow. *(lung function)* -No bronchodilators 6 hours before

What is care for allergic rhinitis?

-No oral steroids, just intranasal -Most important tx is to identify & avoid triggers -Antihistamines

What are the symptoms of laryngeal cancer?

-Painless growth/ulcer that doesn't heal -Persistent unilateral sore throat or ear pain -Hoarseness -Pain -Dysphagia -Airway obstruction are late symptoms

What is care for URI?

-Rest, increase fluids (to liquefy secretions) -Decongestant nasal spray for no more than 3 days (prevents rebound vasodilation and congestion) -Antipyretis and analgesics

Sputum description and the disease/disorder it goes with.

-Smokers: Clear to gray with specks of brown. -COPD: Clear, whitish or slightly yellow especially in the morning. -Pink, frothy: Pulmonary Edema (PE) -Hemoptysis: Pneumonia, TB, lung cancer, severe bronchiectasis.

How do you know the cuff is appropriately inflated on a trach?

-The pt cant speak when it is inflated -Verify pressure with a manometer (20mmHg or <25cm H2O).

What non-respiratory data is important to obtain when assessing the respiratory history?

-What medications they are taking -Travel (TB) -Vaccinations -Night sweats? (TB) -Anxiety?

How do you test for fremitus?

-You can test with your hands or stethoscope. Saying certain words help feel the vibration. (like in health assessment we learned "nine-nine-nine". -Increased over lung filled with fluid or denser lung tissue.

What is the focus of your assessment when a patient is in respiratory distress?

Assess Lungs FIRST

What medications should be avoided in asthmatics?

Beta-Blockers

What test do we do for suspected PE?

CT scan. Uses iodine based dye

What diagnostic test confirms the presence of active TB?

CXR

What are the rules for percussion and vibration?

Done *after* postural drainage to loosen the secretions

How do you know a pt with pneumonia is improving?

Improvement of symptoms

What is pursed lip breathing?

It is done by relaxing the face muscle w/o puffing the cheeks. Inhale through the nose slowly.

How long do pts with TB have to take medications?

It is recommended that pts take the TB drugs every day for 6 months. (http://www.tbfacts.org/tb-treatment.html)

What is the biggest priority assessment after neck surgery?

Maintain a patient airway.

How do we prevent pertussis?

Make sure adults get booster immunizations so they don't infect unvaccinated kids.

How do you calculate pack-year history?

Multiply # of packs smoked per day by the # of years smoked

Do you have to treat all pts with positive TB skin tests?

No, a positive test only means that a person has been exposed. Once you test positive, you will always test positive, so you will need a CXR annually to look for active TB

What is the goal for impaired gas exchange?

Oxygen saturation or PaO2

How is a patient positioned for thoracentesis?

Position upright, no sedation.

How do you read a TB test?

Pt will have induration >10mm (not redness) where the test was done.

What do you do when someone coughs out their trach?

Put it back in!!

What must you do before deflating a trach cuff?

Suction, to prevent aspiration.

How do you know a pt with TB is no longer infectious?

Three negative sputum smears

What are the risk factors for development of laryngeal cancer?

Tobacco and Alcohol use

Should COPD patients stop smoking? Why or why not?

Yes... It slows the progression of the disease.

A client with chronic obstructive pulmonary disease is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory rate, the nurse notes an abnormal inspiratory-expiratory (I:E) ratio of 1:4. What is a normal I:E ratio? a) 1:2 b) 2:1 c) 1:1 d) 2:2

a) 1:2

For a client with an endotracheal (ET) tube, which nursing action is most essential? a) Auscultating the lungs for bilateral breath sounds b) Turning the client from side to side every 2 hours c) Monitoring serial blood gas values every 4 hours d) Providing frequent oral hygiene

a) Auscultating the lungs for bilateral breath sounds

A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding? a) Bronchophony b) Tactile fremitus c) Crepitation d) Egophony

a) Bronchophony

The home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met? a) Decreased oxygen requirements b) Increased sputum production c) Decreased activity tolerance d) Normothermia

a) Decreased oxygen requirements

A client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature? a) Inflamed lung tissue b) Sudden onset c) Responsiveness to penicillin d) Elevated white blood cell (WBC) count

a) Inflamed lung tissue

A 33-year-old woman with primary pulmonary hypertension is being evaluated for a heart-lung transplant. The nurse asks her what treatments she is currently receiving for her disease. She is likely to mention which treatments? a) Oxygen b) Aminoglycosides c) Diuretics d) Vasodilators e) Antihistamines f) Sulfonamides

a) Oxygen c) Diuretics d) Vasodilators

The nurse administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? a) Respiratory rate of 22 breaths/minute b) Dilated and reactive pupils c) Urine output of 40 ml/hour d) Heart rate of 100 beats/minute

a) Respiratory rate of 22 breaths/minute

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should: a) instruct the client to drink 2 L of fluid daily. b) maintain the client on bed rest. c) administer anxiolytics, as prescribed, to control anxiety. d) administer pain medication as prescribed.

a) instruct the client to drink 2 L of fluid daily.

The position of a conscious client during suctioning is: a. Fowler's b. Supine position c. Side-lying d. Prone

a. Fowler's Position a conscious person who has a functional gag reflex in the semi fowler's position with the head turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client is unconscious place the patient a lateral position facing you.

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? a) Immediately before a meal b) At least 2 hours after a meal c) When bronchospasms occur d) When secretions have mobilized

b) At least 2 hours after a meal

When a client's ventilation is impaired, the body retains which substance? a) Sodium bicarbonate b) Carbon dioxide c) Nitrous oxide d) Oxygen

b) Carbon dioxide

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find? a) Decreased respiratory rate b) Dyspnea on exertion c) Barrel chest d) Shortened expiratory phase e) Clubbed fingers and toes f) Fever

b) Dyspnea on exertion c) Barrel chest e) Clubbed fingers and toes

An elderly client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza? a) Septicemia b) Pneumonia c) Meningitis d) Pulmonary edema

b) Pneumonia

The nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority? a) Avoid contact with fur-bearing animals. b) Change filters on heating and air conditioning units frequently. c) Take prescribed medications as scheduled. d) Avoid goose down pillows.

c) Take prescribed medications as scheduled.

The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: a) helping him communicate. b) keeping his airway patent. c) encouraging him to perform activities of daily living. d) preventing him from developing an infection

b) keeping his airway patent.

Presence of overdistended and non-functional alveoli is a condition called: a. Bronchitis b. Emphysema c. Empyema d. Atelectasis

b. Emphysema

Which task can be safely delegated to a licensed practical nurse (LPN)? a) Teaching a newly diagnosed diabetic about insulin administration. b) Admitting a client who underwent a thoracotomy to the nursing unit from the postanesthesia care unit. c) Changing the dressing of a client who underwent surgery two days ago. d) Administering an I.V. bolus of morphine sulfate to a client experiencing incisional pain

c) Changing the dressing of a client who underwent surgery two days ago.

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? a) Administering oxygen, coughing, breathing deeply, and maintaining bed rest b) Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer c) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer d) Administering pain medications, frequent repositioning, and limiting fluid intake

c) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

A client who sustained a pulmonary contusion in a motor vehicle accident develops a pulmonary embolism. Which nursing diagnosis takes priority with this client? a) Excess fluid volume related to excess sodium intake b) Acute pain related to tissue trauma c) Ineffective breathing pattern related to tissue trauma d) Activity intolerance related to insufficient energy to carry out activities of daily living

c) Ineffective breathing pattern related to tissue trauma

The nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? a) Make inhalation longer than exhalation. b) Exhale through an open mouth. c) Use diaphragmatic breathing. d) Use chest breathing.

c) Use diaphragmatic breathing.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's teenage daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 3 to 5 days b) 1 to 3 weeks c) 2 to 4 months d) 6 to 12 months

d) 6 to 12 months

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? a) Nonproductive cough and abdominal pain b) Hypertension and lack of fever c) Bradypnea and bradycardia d) Chest pain and dyspnea

d) Chest pain and dyspnea

The physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which of the following? a) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years b) Isolation until 24 hours after antitubercular therapy begins c) Nothing, until signs of active disease arise d) Daily doses of isoniazid, 300 mg for 6 months to 1 year

d) Daily doses of isoniazid, 300 mg for 6 months to 1 year

The nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Nonproductive cough and normal temperature b) Sore throat and abdominal pain c) Hemoptysis and dysuria d) Dyspnea and wheezing

d) Dyspnea and wheezing

On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? a) Fever b) Tachypnea c) Tachycardia d) Hypotension

d) Hypotension

A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first? a) The client with anorexia, weight loss, and night sweats b) The client with crackles and fever who is complaining of pleuritic pain c) The client who had difficulty sleeping, daytime fatigue, and morning headache d) The client with petechiae over the chest who's complaining of anxiety and shortness of breath

d) The client with petechiae over the chest who's complaining of anxiety and shortness of breath

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/min. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer: a) alprazolam (Xanax). b) propranolol (Inderal). c) morphine. d) albuterol (Proventil).

d) albuterol (Proventil).

A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum

d. A cough with the expectoration of mucoid sputum One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.

The most important action the nurse should do before and after suctioning a client is: a. Placing the client in a supine position b. Making sure that suctioning takes only 10-15 seconds c. Evaluating for clear breath sounds d. Hyperventilating the client with 100% oxygen

d. Hyperventilating the client with 100% oxygen