Fundamentals exam 4

A patient tires after trying to obtain a sputum specimen; only 3 mL was obtained. Which action should the nurse take? 1. Place the specimen in a dark plastic container. 2. Obtain 20 mL of sputum. 3. Keep sputum specimen on counter for 1 hr. 4. Attach a sputum trap and suction the trachea.

4. Attach a sputum trap and suction the trachea.

nasal cannula

A device that delivers low concentrations of oxygen through two prongs that rest in the patient's nostrils. 1-6 L/min

nonrebreather mask

A face mask and reservoir bag device that delivers high concentrations of oxygen. The patient's exhaled air escapes through a valve and is not rebreathed. 60 to 100% 6 to 15 L/min

Signs of hypoxia

Blue or gray skin, decreased LOC, confusion, restlessness. ABGs

simple face mask

an oxygen-delivery apparatus used for patients who require a moderate flow rate for a short period of time via a plastic mask that fits snugly over the mouth and nose min of 5 to 10

Hemoptysis is defined as:

coughing up blood

The nurse is assigned to assist in caring for a client diagnosed with a pneumothorax who has a chest tube connected to a closed-chest drainage system. The client asks the nurse why a chest tube was inserted. Which response by the nurse explains the purpose of a chest tube? 1."To help lessen any discomfort." 2."To allow for reexpansion of the lung." 3."It will help prevent any lung infections." 4."To prevent further damage to the lung."

" 2."To allow for reexpansion of the lung A chest tube may be inserted after a pneumothorax and connected to water-seal drainage to remove the air and allow reexpansion of the lung. It does not lessen discomfort, prevent further damage to the lung, or help prevent lung infections

inspection of the chest

-Anterior and Posterior Views -Posture and position -Skin -Spine is in a straight line, ribs slope downward -Thorax is symmetrical -retraction -accessory muscles

Incentive Spirometry steps?

1) Sit upright 2) Exhale 3) Insert mouthpiece 4) Inhale for 3 seconds, and then HOLD for 10 seconds

chest tube is accidentally dislodged from the chest. what to do

1) immediately applying sterile gauze over the chest tube insertion site 2)Notify the registered nurse (RN). 3)call the primary health care provider (PHCP) 4) maintain the client in an upright position 5) stay with them

The nurse must obtain a sputum culture. Which action is best for the nurse to take? 1. Obtain the culture early in the morning. 2. Obtain the culture after breakfast. 3. Obtain the culture after giving medications. 4. Obtain the culture right before bedtime.

1. Obtain the culture early in the morning.-When obtaining a sputum specimen, keep in mind that the best time to do this is first thing in the morning. Patients may have mucus that has pooled during the night, making it easier to obtain a specimen.

The nurse is assigned to assist in caring for a client with a chest tube drainage system. Which interventions should the nurse implement? Select all that apply 1.Pin excess tubing to the bedclothes. 2.Check for subcutaneous emphysema. 3.Empty the chest tube drainage at the end of the shift. 4.Check to see that the chest tube drainage is fluctuating. 5.Maintain chest tube drainage container below the client's chest.

2.Check for subcutaneous emphysema. 4.Check to see that the chest tube drainage is fluctuating. 5.Maintain chest tube drainage container below the client's chest.

A client at risk for pulmonary embolism (PE) suddenly develops respiratory distress, chest pain, and anxiety. The nurse should plan to take which actions? Select all that apply. 1.Check vital signs. 2.Administer warfarin. 3.Notify the registered nurse. 4.Begin low-flow oxygen therapy. 5.Raise the bed to a low-Fowler's position.

1.Check vital signs. 3.Notify the registered nurse. 4.Begin low-flow oxygen therapy. Initial care for a client who might be experiencing a PE is to remain calm, stay with the client, raise the head of the bed to a high-Fowler's position, begin low-flow O2 therapy, check vital signs, notify the registered nurse and primary health care provider of the client's symptoms, start a peripheral intravenous line if one is not already established, and assist to administer heparin when it is prescribed. A low-Fowler's position would not be used initially and heparin is administered in the initial stage of a suspected pulmonary embolism.

The nurse assessing a client diagnosed with laryngeal cancer would note which signs and symptoms? Select all that apply. 1.Hemoptysis 2.Kussmaul respirations 3.Enlarged thyroid gland 4.A sensation of a "lump" in the throat 5.Hoarseness lasting more than 3 weeks

1.Hemoptysis 4.A sensation of a "lump" in the throat 5.Hoarseness lasting more than 3 weeks

Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client?

1.Repositioning client every 2 hours 2.Position on the side until fully recovered 3.Encouraging coughing and deep breathing 4.Monitoring pulse oximetry readings frequently 5.Encouraging the use of an incentive spirometer

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse should monitor the status of breath sounds in that area by placing the stethoscope in which location? 1.Near the lateral twelfth rib 2.Just under the left clavicle 3.In the fifth intercostal space 4.Posteriorly under the left scapula

2.Just under the left clavicle apical=apex

The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client? 1.The client inhales slowly. 2.The client is breathing through the nose. 3.The client removes the mouthpiece from the mouth to exhale. 4.The client forms a tight seal around the mouthpiece with the lips.

2.The client is breathing through the nose.

The nurse contributes to the staff education program about respirations. Which statement by the staff members indicates successful teaching? 1. "The respiratory center of the brain is in the hypothalamus." 2. "Oxygen and carbon dioxide move by filtration in the lungs." 3. "Normally, respirations are regulated by increases in carbon dioxide levels." 4. "Internal respiration occurs between the alveoli and the capillaries."

3 "Normally, respirations are regulated by increases in carbon dioxide levels." When carbon dioxide increases above normal amounts, it causes the blood to become more acidic. The chemoreceptors respond by sending the message to the medulla, which in turn causes the respiratory rate to increase to "blow off" or remove excess carbon dioxide, returning the blood pH to normal levels.

Which sputum finding would concern the nurse the most? 1. Thick yellow sputum. 2. Thin green sputum. 3. Pink frothy sputum. 4. Rust-colored sputum.

3. Pink frothy sputum.

. A patient's chest tube becomes disconnected from the drainage unit when the patient was transferred from the bed to the chair. Which action is the nurse's first priority? 1. Check for bubbles in the water seal chamber. 2. Milk the tubing of the chest tube system. 3. Place the end of the tube in water. 4. Clamp the chest tube with padded hemostats.

3. Place the end of the tube in water.

The nurse is suctioning a patient for secretions. Which action should the nurse take? 1. Suction the mouth first, then the nose. 2. Use suction by placing thumb on valve continuously. 3. Suction no longer than 10-15 seconds. 4. Use the dominant hand to control the suction.

3. Suction no longer than 10-15 seconds.(hold you breath)

he nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse should review the results of which diagnostic test to confirm this diagnosis? 1.Chest x-ray 2.Bronchoscopy 3.Sputum culture 4.Tuberculin skin test

3.Sputum culture Rationale: A definitive diagnosis of tuberculosis is confirmed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made on the basis of a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

Which term would the nurse use in report to describe a patient who gets short of breath walking down the hall? 1. Subcutaneous emphysema. 2. Air hunger. 3. Orthopnea. 4. Exertional dyspnea.

4. Exertional dyspnea. If the patient has to stop to rest or catch his or her breath when ambulating a brief distance, then the patient is short of breath, known as exertional dyspnea.

The nurse is performing oropharyngeal suctioning after nasopharyngeal suctioning. Which actions should the nurse take? Select all that apply. 1. Remove glove over the nasopharyngeal catheter to discard. 2. Put on sterile gloves. 3. Reuse tonsil tip. 4. Suction each side of the throat, cheek pouches, and around tongue. 5. Suction mouth one time.

4. Suction each side of the throat, cheek pouches, and around tongue.

chest tube

Chest tubes are inserted to reinstate negative pressure within the pleural space · To release air- Inserted in to the pleural space through an incision in the anterior superior surface of the chest in the 2nd to 4th intercostal space to release air To drain fluid and blood- inserted in the anterior, inferior area of the chest between the 8th and 9th intercostals

Venturi mask

A face mask and reservoir bag device that delivers specific concentrations of oxygen by mixing oxygen with inhaled air. COPD

tension pneumothorax

A life-threatening collection of air within the pleural space; the volume and pressure have both collasped the involved lung and caused a shift of the mediastinal structures to the opposite side.

ABGs

Arterial Blood Gases pH 7.35- 7.45 HCO3 (Bicarbonate) normal values 22-26 mEq/L PaCO2 ( CO2 or carbon dioxide content) 35-45 mm Hg PaO2 (oxygen saturation in arteria blood)- 80-100 mm Hg

chemical regulation of repression

CO2 O2 Blood Ph

chamber one of chest tube

Chamber 1 (left)- wet suction, bubbles should be present in this chamber, gentle bubbling should occur (safety: be sure you know how to use and evaluate the chest drainage system in your facilty)

Chest Tube Chambers

Chamber 1: collects fluid draining from patient Chamber 2: water seal prevents air from re-entering patient's pleural space Chamber 3: suction control of system

Chamber 2 of chest tube

Chamber 2 (middle)- water seal; required to reestablish negative pressure in the pleural space and prevent air from reentering the cavity through the chest tube, water level will rise and fall with inhalation and expiration (tidaling), if patient has a pneumothorax, you will see air leave the chest and make bubbles in this chamber (safety: if patient has RESOLVED pneumothorax, and bubbles are present check all tubings and connections to ensure there are no air leaks)

Chamber 3 of chest tube

Chamber 3 (right)- collection chamber; where blood and other fluid collect, this drain is never emptied. Amount of drainage should gradually decrease every day (safety: sudden increase in total output or a sudden increase in bright red output occurs, notify physician immediately, could be indicative of a hemorrhage)

chest excursion

Equal movement of the thoracic diaphragm during breathing

Skin color finding for pts w/ impaired O2

Cyanosis Pallor

pallor

Extreme or unnatural paleness

most common signs of asperation

Fever and tachypnea

air hunger

Gasping respiration is known as air hunger.

Green sputum is a sign of

Green sputum is not life threatening, as it may indicate a bacterial infection.

palpation of chest

Hands are placed on the chest to assess excursion and vibration.

Chest assessment

Inception palpation auscultation

Endotracheal suctioning

Insert until you feel resistance, withdraw applying intermittent suction with twirling motion for no more than 10-15 seconds,

Where in the brain is the respiratory center located?

The respiratory center is in the medulla, located in the brainstem.

Causes of impaired O2

Obstruction Alveolar damage Chronic lung disease Damage or trauma

orthopnea

Orthopnea indicates the patient has to be sitting or upright to breathe. Patients with impaired oxygenation often assume a position of sitting upright and leaning slightly forward with arms and head over a table. This is the orthopneic position.

What never controls diaphragm

Phrenic nerve

Assessment of Cough

Productive- Sputum Consistency -thick, tenacious (sticky) Amount Nonproductive

Pursed-lip breathing (PLB)

Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. 1)The client should close the mouth and breathe in through the nose. 2) purses the lips and breathes out slowly through the mouth without puffing the cheeks. 3)spend at least twice the amount of time breathing out that it took to breathe in. 4) use the abdominal muscles to assist in squeezing out all of the air. -instructed to use this technique during any physical activity, to inhale before beginning the activity, and to exhale while performing the activity. The client should never hold his or her breath.

Rust-colored sputum indicates I

Rust-colored sputum indicates the presence of blood and may be seen in some pneumonia infections and tuberculosis. This is not as life threatening as pink, bubbly sputum

Assessment of those with impaired O2

Skin color Respiratory effort Cough (effective or ineffective) chest appearance O2 status ( good or poor, room air or NC) O2 Saturation

Diagnostic tests for the respiratory system

Sputum specimens Throat cultures Arterial blood gas Pulmonary Function test peak flow

mechanical ventilation

use of an automatic mechanical device to perform all or part of the work of breathing -move air in and out of the lungs

Exhalation

The passive part of the breathing process in which the diaphragm and the intercostal muscles relax, forcing air out of the lungs.

subcutaneous emphysema

The presence of air in soft tissues, causing a characteristic crackling sensation on palpation.

Thick Yellow Sputum is a sign of

This is not life threatening. Thick yellow sputum may be indicative of a bacterial infection.

cyanosis

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

incentive spirometry

a common postoperative breathing therapy using a specially designed spirometer to encourage the patient to inhale and hold an inspiratory volume to exercise the lungs and prevent pulmonary complications

face tent

a soft, oxygen-delivery mask that fits under the patient's chin, loosely covers the mouth and nose, and is held in place by an adjustable elastic strap

pnumothorax

air in the pleural cavity

fluctuations in chest tube means

an irregular rising and falling in number or amount; a variation. in fluild within the 3rd chamber- hemorrhage

Hypoxia

deficiency in the amount of oxygen reaching the tissues

hypoxemia

deficient oxygen in the blood

exertional dyspnea (DOE)

effort at breathing when physically active

flail chest

fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment

Peripheral neuritis

inflammation of one or more peripheral nerves -manifested by numbness, tingling, and paresthesia in the extremities

SOB

shortness of breath

Partial rebreather mask

simple mask with a reservoir bag that should be at least one third to one half full on inspiration and delivers from 40% to 70% FIO2 with a flow rate of 6 to 10 L/min. The flow rate should be a minimum of 10 L/min and deliver FIO2 of 60% to 80%. Frequently inspect the reservoir bag to make sure that it is inflated. If it is deflated, the patient is breathing large amounts of exhaled carbon dioxide. High-flow oxygen systems should be humidified.

tracheostomy

surgical creation of an opening into the trachea through the neck

Inhalation

the act of taking in air as the diaphragm contracts and pulls downward

plueral effusion

the build up of plueral fluid between layers of tissue that line the lung and chest cavity

thoracentesis

the surgical puncture of the chest wall with a needle to obtain fluid from the pleural cavity

pneumonectomy

the surgical removal of all or part of a lung care: 1.turned slightly Q2 2.Administer humidified oxygen. 3.Instruct on the use of the incentive spirometer. 4.Monitor vital signs and pulse oximetry frequently.