MED SURG RESP TEST
The nurse witnesses a pedestrian being hit by an automobile. The nurse assesses the victim and notes responsiveness and a flail chest involving at least three ribs. Which action should the nurse take to assist the client's respiratory status until help arrives?
Apply firm but gentle pressure with the hands to the flail segment.
The nurse has conducted teaching, with a client who experienced pulmonary embolism, about methods to prevent recurrence after discharge. Which client statement demonstrates understanding of the teaching?
"I am planning to continue to wear supportive stockings."
The nurse is preparing a client diagnosed with pneumonia for discharge. Which statement by the client should alert the nurse to the fact that the client needs further teaching before being discharged?
"You can toss out that incentive spirometer as soon as I leave for home."
A client with sickle cell anemia has been admitted with reports of a sudden onset of severe acute pain in the extremities, abdomen, back, and chest. This is the client's third admission for the same reason this year. The nurse would perform actions in which priority order to help manage this client's pain?
1) Administer oxygen 2) Hydrate the patient with 0.9% normal saline. 3) Administer opiate analgesic. 4) Keep the room temperature at or above 72 F. 5) Encourage the client to keep extremities extended.
The nurse is caring for a group of clients on the clinical nursing unit. Which client does the nurse interpret to be most at risk for the development of pulmonary embolism?
A 73-year-old woman who has just had a pinning of a hip fracture
Which client would the nurse determine is at greatest risk for development of acute respiratory distress syndrome (ARDS)?
A client with pancreatitis and gram-negative sepsis
A client has a suspected diagnosis of iron deficiency anemia. On assessment, which finding would the nurse expect to note as a result of this condition?
A low hemoglobin level
The nurse is caring for a patient who presented to the emergency department with a pulmonary embolism. Which of the following puts this patient at risk for a pulmonary embolism?
Immobility
Interventions to prevent atelectasis development and pneumonia
Ambulate Incentive Spirometer use Turn/cough/deep breathe Adequate fluid intake Coughing/Chest physiotherapy
Pleural effusion care
Administer prescribed antibiotics/pain meds Oxygen as needed Ambulation as needed Assist with thoracentesis
A postoperative client suddenly develops chest pain and is experiencing dyspnea and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately plans to implement which intervention?
Administering nasal oxygen
Oxygen Saturation requirements in a pt with COPD
Allowed to be lower, usually greater than 90%
COPD
Alveoli lose elasticity resulting in retention of carbon dioxide
Which observation by the nurse indicates a need to suction a client with an endotracheal (ET) tube attached to a mechanical ventilator to help manage a pneumothorax?
Audible crackles Client notably restless Visible mucus bubbling in the ET tube High alarm pressures identified by the ventilator
A client goes into respiratory distress on the nursing unit and requires emergency intubation. After intubation, which action would the nurse take first to evaluate proper endotracheal tube (ETT)placement?
Auscultate for bilateral breath sounds.
2 causes of vitamin deficiency anemia
Autoimmune (pernicious anemia) Malabsorption Gastric bypass surgery Nutritional deficits Strict vegan diet
What causes sickle cell disease?
Autosomal recessive disorder (receives genes from both parents)
Which instruction would the nurse include in the teaching plan for a client taking iron supplements to correct iron deficiency anemia?
Avoid taking the iron supplements with MILKor ANTACIDS.
The nurse is caring for a patient who has fallen several times because of poor balance. The patient does not eat meat. These findings lead the nurse to most likely suspect what kind of anemia?
B12 deficiency
Pathophysiological characteristics of COPD
Barrel Chest Hyperinflation of the lungs Pulmonary hypertension Permanent enlargement of alveoli Poor elasticity of alveoli Mucus hypersecretion Chronic inflammation
3 Pathophysiological characteristics of asthma
Bronchoconstriction Inflammation Increased mucus production
Difference in Short acting bronchodilators, long acting bronchodilators and inhaled corticosteroids
SHORT ACTING: immediate relief for acute attack LONG ACTING: help prevent acute attacks & control asthma INHALED CORTICOSTEROIDS: help prevent acute attacks and control asthma
The nurse is assisting in planning care for a client with respiratory failure. What would be the nurse's highest priority to plan care for the client?
Conserving energy
What causes increased risk of complications of SICKLE CLELL DISEASE
Cells are shaped in C shape do not run well through vessels get caught in small spaces leads to clots and and organ damage/failure
The nurse is caring for a client diagnosed with sickle cell anemia hospitalized for the treatment of vaso-occlusive crisis. The nurse would determine that what problem should receive priority in the client's plan of care
Compromised tissue perfusion
The nurse has taught a client with asthma who is prescribed a short-acting beta-2 agonist bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which beverage from the dietary menu?
Cranberry juice
The area of injury moves inward when the patient breathes in and moves outward when the patient breaths out.
Flail Chest
Treatments for ANEMIA
DIET changes (green, leafy vegetables) IRON supplementation BLOOD transfusions
Intervention to help thin mucus secretions
DRINK FLUIDS
The nurse is caring for a patient with hypercapnic respiratory failure. The nurse knows that manifestations of hypercapnic respiratory failure can include which of the following two findings?
Decreased level of consciousness Decreased respiratory rate
The nurse is assigned to care for a client with a diagnosis of sickle cell anemia. The nurse reviews the plan of care and notes documentation of 4 client problems. Which problem would the nurse select as the priority?
Dehydration
The nurse is assessing the respiratory status of a client with pleural effusion after a thoracentesis has been performed. The nurse would become concerned with which assessment finding?
Diminished breath sounds on the affected side
A client diagnosed with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crisis would the nurse provide to the client?
Drink plenty of fluids. Wash hands before meals and after the grocery store Report a sore throat to the provider immediately
A nurse is caring for a patient who has sustained blunt chest trauma in a motor vehicle accident and is diagnosed with a hemothorax. Which of the following findings would the nurse expect to observe during the initial assessment of this patient?
Dullness to percussion and decreased breath sounds on the affected side
Which sign/symptom is an indication that the client experiencing postoperative blood loss is
Fatigue
Manifestations of VITAMIN DEFICIENCY ANEMIA
Fatigue, dizziness mood changes, memory loss mobility changes, visual deficits
The nurse understands that one component of COPD includes a disorder that causes permanent enlargement of the alveoli, loss of alveolar elasticity, and CO2 trapping is classified as what disorder?
Emphysema
A nurse is caring for a 77 year old patient with Chronic Obstructive Pulmonary Disease (COPD). Which of the following nursing interventions is most appropriate to include in the patient's care plan?
Encourage high-calorie, high-protein diet and small frequent meals.
What is one feature of Virchows Triad that increase the likelihood of developing a clot
Epithelial tissue injury Venous Stasis Increased coagubility
The nurse is orienting a group of nurses to the ICU and is teaching them about the oxyhemoglobin dissociation curve. The nurse explains to the group, that according to this curve, the oxygen saturation will equal the pO2. True or False
False
The nurse knows that individuals with sickle cell disease are not at risk for developing cardiac and neurological problems since this is a hematological problem. True or False?
False
Pleural Effusion
Fluid builds up, increasing the intrapleural pressure
Discuss care of PT on ventilator to prevent VAP
HOB elevated 30 degres Oral care every 2 hours Suction as needed Minimize breaking circuit
Interventions for sickle cell crisis
HYDRATION to reverse agglutination of cells PAIN medication OXYGEN administration Avoid flexion of joints
Two types of resp failure and differences
HYPOXIA: dyspnea, confusion, irritability, retractions, tachycardia HYPERCAPNIA: headache, change in behavior, bradypnea, asterixis, coma
The nurse is caring for a patient who was admitted to the hospital 72 hours ago for a total knee replacement, and the patient has developed left lower lobe pneumonia. The nurse understands that this pneumonia will be classified as which of the following?
Hospital acquired pneumonia (> 42hrs)
The nurse is caring for a patient with vitamin deficiency anemia and knows that this is common in what patient population?
Hx. of gastric bypass
The nurse is caring for a patient suffering a sickle cell crisis and knows that the treatment during the crisis will include which of the following?
Hydration
The surgical nurse is describing what atelectasis is to a student nurse. The nurse correctly describes this disorder as
Inability of the lungs to inflate properly
A client prescribed albuterol sulfate by inhalation cannot cough up secretions. The nurse would teach the client which action to best help clear the bronchial secretions?
Increase the amount of fluids consumed every day.
A client has been diagnosed with left tension pneumothorax. Which finding observed by the nurse indicates that the pneumothorax is rapidly worsening? Select all that apply
Increased cyanosis Tracheal deviation to the right Observable asymmetry of the thorax Diminished breath sounds on the left
The nurse is teaching a student nurse about the pathophysiology of asthma attacks and will include which of the following?
Increased mucous production Swelling of airways Bronchoconstriction
A nurse is caring for a patient diagnosed with Acute Respiratory Distress Syndrome (ARDS). The patient is experiencing severe dyspnea, hypoxemia, and bilateral infiltrates on the chest X-ray. Which of the following interventions should the nurse prioritize?
Initiate mechanical ventilation with low tidal volumes
A client with significant flail chest has arterial blood gases (ABGs) that reveal a Pao2 of 68 and aPaco2 of 51. Two hours ago the Pao2 was 82 and the Paco2 was 44. Based on these changes, which item would the nurse assure easy access to in order to help ensure client safety?
Intubation tray
The nurse is caring for a perimenopausal patient who is experiencing heavy vaginal bleeding and the patient is experiencing shortness of breath, dizziness, and fatigue. The nurse notes she has pallor. The nurse knows the clinical picture is most associated with which of the following anemias?
Iron deficiency
Pallor
Loss of color from skin
Emergent action of nurse caring for a pt with suspected hemothorax
Needle decompression Chest tube placement
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding?
Noticeably diminished breath sounds
The nurse is teaching a group of nurses new to the bariatric surgery unit about the risk factors for obstructive sleep apnea. The list of risks will include which of the following two risk factors?
Obesity Advanced Age
A client with the diagnosis of pneumonia experiences dyspnea when engaging activities. Which action would the nurse implement to help address client safety?
Observe vital signs and oxygen saturation periodically during activity.
Primary pt complain for sickle cell crisis
PAIN
What is PEEP and it's role in ARDS
POSITIVE END EXPIRATORY PRESSURE. (amount of pressure left in lungs after expiration) -Assists with oxygenation in ARDS bc the lungs are STIFF and cant sustain alveolar collapse -increasing PEEP is often needed to keep airways open and maintain oxygenation
A client is admitted to the hospital in sickle cell crisis. For which clinical indicator would the nurse monitor the client?
Pain (severe pain in the bones and joints along with jointswelling)
Which assessment data would support a client's diagnosis of anemia? Select all that apply
Pallor, cold feet and hands, dizziness
A client is recovering from acute respiratory distress syndrome (ARDS). The nurse determines that the client's condition is improved upon reading which entry in the medical record?
Pao2 84, no infiltrates on chest x-ray
Characteristics of Flail Chest
Paradoxical chest movement
A client's arterial blood gas (ABG) analysis shows a pH of 7.34. To help establish a diagnosis of respiratory acidosis, the nurse monitors for which ABG value as the primary cause of the lowered pH?
Pco2 is greater than 50 mm Hg.
Pulmonary embolism is what type of V/Q mismatch?
Perfusion defect
A client arrives at the emergency department with an episode of status asthmaticus. Which action would the nurse take first?
Place the client in high-Fowler's position.
Which actions would the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilation?
Practice meticulous hand hygiene.
Describe the purpose of anticoagulants in the care of a Pt with DVT/PE
Prevent clot from getting bigger/development of new one DONT make current ones smaller
A client diagnosed with pneumonia reports a decreased sense of taste that has greatly affected themotivation to eat and drink. Which action would the nurse take to help increase the client's appetite?
Provide mouth care before meals.
Breathing technique recommended with pt with COPD
Pursed Lip breathing Pursed lips and focus on expiration being longer than inspiration
Manifestations of Asthma
SOB Tachypnea Coughing, wheezing Diminished breath sounds Tripoding Chest tightness/pain
Patient education for sickle cell disease
Seek routine medical care UpToDate on vaccinations Avoid extreme temps and altitudes
A client is diagnosed with a flail chest. Which characteristics related to breathing would the nurse observe for in the client?
Severe dyspnea and paradoxical chest movement
The nurse is receiving report on a patient with hypoxemic respiratory failure. The nurse anticipates which four clinical manifestations associated with this diagnosis?
Somnolence Agitation Increase in heart rate Drop in oxygen saturation
Side effect of short acting bronchodilator
Tachycardia Jitteriness Insomnia
IRON administration pt education
Take on EMPTY STOMACH Can cause NAUSEA CONSTIPATION AND DARK STOOLS Avoid antacids Take with Vitamin C
Cause of PNEUMOTHORAX
Tall/thin Smoking, COPD Trauma
The client diagnosed with asthma awakens frequently during the night with chest tightness, wheezing ,and coughing. How would the nurse interpret these assessment findings?
The client may need a longer-acting bronchodilator.
The nurse instructing a client diagnosed with iron-deficiency anemia about the administrationof oral iron preparations would tell the client to take the iron preparation withwhich best fluid to enhance absorption?
Tomato juice (vitamin c rich fluid)
Tension pneumothorax
Tracheal deviation
Presentation difference between Pneumothorax and tension pneumothorax
Tracheal deviation & Mediastinal shift
The nurse knows that breath sounds over the area of a pleural effusion can be absent.
True
A nurse is providing education to a patient with asthma about managing and preventing asthma attacks. Which of the following should the nurse include as common triggers that can exacerbate asthma symptoms?
Upper respiratory infection Pet dander Running for exercise Secondhand cigarette smoke
The nurse is caring for a ventilated patient who has ARDS. The nurse knows that one characteristic of this syndrome includes which of the following?
White out on chest Xray because of widespread atelectasis
ARDS
Widespread alveolar collapse