med surg Exam 2
cardiopulmonary arrest by suppressing need to breath
Administering to much oxygen to patients with COPD will result in
Presence of gag reflex
After a bronchoscopy what should the nurse asses before allowing the client to eat or drink?
sudden onset of chest pain
An initial characteristic symptom of a simple pneumothorax is?
wheezing dyspnea and cough
Asthma three symptoms wheezing dyspnea and cough
NO
Can you accurately determine the amount of oxygen a patient is receiving via nasal canulla?
patient in slight revers trandelberg
How do you drain the middle lobes of the lungs?
high folwers or pillows under the arms and bending forward slightly
How do you drain the upper lobes of the lungs
80-100 mmHg
Normal PaO2
Pulmonary edema
The clinical finding of pink, frothy sputum may be an indication of which condition?
coughing sputum production and dyspnea
Three primary symptoms of COPD-
PaCO2
What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?
Lung scan, fluroscopy, pulmonary angiogram, Computed tomography (CT)
With which diagnostic studies would the nurse screen the client for an allergy to iodine?
visceral; parietal; fluid
__________ pleura lines the lung; ___________ pleura lines the mediastinum; space in between pleural cavity filled with ________ to keep lungs from rubbing
allergens
____________ can often cause symptoms of rhinitis.
Tachypnea
_______________ is the most common sign for a possible pulmonary embolism
Hypoxemia
a decrease in the arterial oxygen tension in the blood
Empyema
accumulation of think yellow fluid in pleural space
Decreased or absent breath sounds; decreased fremitus; and a dull, flat sound on percussion
assessment findings of pt with plueral effusion
inspiration
contraction of the diaphragm (movement of chamber floor downward) and contraction of external intercostal muscles increases space in thoracic chamber, lowering intrathoracic pressure (negative pressure); air enters the airways and inflates the lungs
Age related changes in the respiratory system
decrease in the size of the airway, decreased chest muscle mass, increased thickening of the alveolar membranes, and decreased elasticity of the alveolar sacs
postural drainage
done 2-4 times a day before meals, family may need to be taught how to do it. if you're in charge of helping them, know they usually stay in one of these positions for 10 minutes, and then they change. know if there's a position they shouldn't be in.
earliest one is low grade fever, then cough (often blood tinged), then night sweats, fatigue, weight loss.
first symptoms of TB
alveoli
gas exchange takes place; usually 3oo million in the lungs
course crackles
heard on early inspiration loud pooping sounds
Wheezes
high pitched whistle sound heard on inspiration and expiration
at least every 2 to 4 hours
how often should a patient with ineffective airway clearance vitals be assessed
Q8
how often should you take a patient's vitals that has an inflated tracheotomy cuff
lowest
if the trach has a cuff inflated, you need to keep it at the _________ possible pressure to provide adequate suction
Manatoux test. What are you measuring?
induration; not redness; 5 mm or greater is considered positive in immunocompromised pts ; 10 mm for a pt w/ healthy immune system
1/3 and 2/3
inspiration, ___/___ of the respiratory cycle; and expiration, +___/___ of the respiratory cycle
Surfactant
keeps the alveoli from collapsing
Friction rub
rubbing heard on inspiration
Mediastinum
separates two lungs
incentive spirometor
sitting upright. supposed to use diaphragmatic breathing. as they breathe in, they put the mouthpiece in their mouth and breathe in slowly through their mouth. try to hold the air for at least 3 seconds to keep the ball between the lines, then exhale through mouthpiece. they should do this up to 10 times. too quickly = hyperventilate. repeat every hour while awake, encouraged to stop to cough
rheumatic fever (heart problem)
strep infection can lead to _____________ _________ if not treated
symptoms of oxygen toxicity
substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates on x-ray
mild productive cough to acute illness; pleural friction rub
symptoms of lung absess
bronchodilators and corticosteriods
treating asthma
Iv antibiotic for first few days then oral. fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, and antihistamines
treatment of bacterial pneumonia
antihistamines (for allergic reaction like sneezing) and corticosteroids.
treatment of colds isn't as useful in OAs because of the SE they make should us what to treat them
a client experiencing hypothermia
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?
An infection of pneumococcal pneumonia
A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum?
Frontal
A patient with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges (under eyes). The nurse knows that the patient is referring to which sinus?
A
Acute pharyngitis of a bacterial nature is most commonly caused by group __ beta-hemolytic streptococci
Emphysema
High or increased compliance occurs in which disease process?
lose
Often ______ weight with any respiratory disorder because to SOB to eat
Want to obtain sputum test results before patient on antibiotic after test put patient on broad spectrum antibiotic until results obtained
Sputum test
thoracic; abdominal; partial
The diaphragm separates the __________ and ______________ cavities. On inspiration, the diaphragm contracts and moves downward, creating a ___________ vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity.
Enema
What do you need before a Gallion test?
Semi Fowlers at lowest
When respiratory problems are a result of trauma or infection how should the patient be positioned?
chest tubes
wet suction = traditional. three chambers. suction would be added to provide negative pressure to encourage drainage of fluid and air. the amount of suction is determined by the water level, so as you put more fluid into H2O chamber, you'll get more suction. should expect intermittent bubbling of the water chamber; if its continuous, that means there's an air leak. if chest tube is disconnected and air enters the pleural space, pt can develop a pneumothorax. dry suction = has chambers and a water filled chamber as well. but there should never be any bubbling (this indicates an air leak). may go home w a chest tube so you have to teach them how to care for it (breathing and shoulder exercises--esp. if they've had part of their lung removed). no shoulder exercises = leads to frozen shoulder.
nail polish, cold hands, cardiac distress, shock, and sepsis
what are some things that can impair pulse ox function?
bronchoscopy
when pneumonia is sever ________________ can be used to clear secretions
Bronchi and bronchioles
where air exchange takes place
drug abusers and alcoholics, post op pts., immobility, smoking, elderly
who's at a higher risk for developing pneumonia, as well as post-op patients
mucous membranes
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:
Impaired gas exchange
A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority?
Crackles
A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?
assess the client's trachestomy and auscultate lungs every 15 mins
A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse should
Rhonchi
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?
using the minimal-leak technique with cuff pressure less than 25 cm H2O.
A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:
Inspecting the roof of the nasopharynx
A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by:
palpates the thyroid cartilage
A young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse:
usually intubated and should be placed in prone position to increase oxygenation
ARDS
21
Air we breath is ___% oxygen
lateral diameter should be greater than the anteriorpostier diameter
During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?
barrell chest, Sit in tripod position shoulders go up when breathing and use accessory muscles abdomen to breath, resp acidosis
Emphysema causes
chest percussion, postural drainage, vibrations, coughing, breathing techniques (diaphragmatic, pursed-lip)
Examples of Chest PT
Diaphragm contracts and elongates the chest cavity
For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration.
patient prone with hips elevated with pillows or reverse trandelenberge
How do you drain the base lobes of the lungs?
Sub Q epinephrine
How should you treat a laryngeal obstruction if cause by an allergen
Keep HOB elevated >30 degrees and Avoid stimulation of gag reflex with suctioning or other procedures
Interventions to prevent aspiration
hyper inflation (no breath sounds)
Is dead space in lungs causing
Oxygen toxicity; 50
May occur when too high a concentration of oxygen (greater than ____%) is administered for an extended period
suctioning, CPT, position changes, promote increased mobility
Measures to clear occluded airway
higher to lower
Oxygen diffuses from areas of______ partial pressure to areas of ________ partial pressure
ow grade fever, congestion, sneezing, watery eyes. often times, virus causes cold sores.
SYmptoms of rhinovirus (common cold)
Warm and humidify inspired air
The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
Anterior surface of the right side of the chest, between the fourth and fifth rib.
The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:
Dull
The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?
the client remains on bed rest and typically lies on the unaffected side for at least 1 hour to promote expansion of the lung on the affected side
The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?
Wheezes
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated?
Angiotensin converting enzyme (ACE) inhibitors (losartan)
The nurse is interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking?
Take deep breaths and cough forcefully
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
destruction of alveoli leading to impaired o2 diffusion
The patho of emphysema involves
Increase fluid intake (10 8oz glasses of water daily if no contraindication)
The patient is experiencing thick secretions and an unproductive cough what would be a non-pharmacological intervention for the nurse to implement to break up secretions?
10 per hour
The patient should be encouraged to use an incentive spirometer approximately a ____ breaths per _____ between treatments while awake
Hypotension
The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?
Venturi mask
The primary oxygen administration method for a patient with COPD is a __________ ________
wheezing.
The primary symptom of emphysema is
Patient is gradually removed from the ventilator Then from either the endotracheal or tracheostomy tube And finally from oxygen
Three steps if weaning
Pinch soft portion of nose for 5 to 10 minutes Phenylephrine spray, vasoconstriction
Treatment of epitaxis
antibiotic for 5-7 days; amoxicillin or augmentin are the drug of choice (augmentin is more effective on the ears)
Treatment of upper resp infections
Indicates funnel chest (pectus excavatum)
Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration.
Collaborative Problems
Ventilator problems Alterations in cardiac function Barotrauma Pulmonary infection and sepsis Delirium
Ventilation is the movement of air in and out of the respiratory tract.
What is the difference between respiration and ventilation?
incentive spirometer
What is the mainstay treatment for chronic atelectasis?
1:2
What is the normal ratio of the AP diameter to lateral diameter
smoking
What is the number 1 detriment to lung health?
move the mucus back to the larynx
What is the purpose of the cilia in the pharynx?
cyanosis
What observation by the nurse is indicative of a late symptom of hypoxia?
avoid caffeine and tobacco (can eat)
What should patients avoid before a chest x-ray?
lymph nodes, trachea, tonsils, adenoids for swelling (inspect oral mucousa of mouth and trachea)
What should the nurse palpate if upper resp infection suspected?
at least 3 months of two consecutive years
When you diagnose chronic bronchitis it has to be
Venturi mask
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
Emphysema
Which of the following disease processes cause increased compliance?
non-re-breathing mask
Which oxygen administration device has the advantage of providing a high oxygen concentration
Type 2
Which type of alveoli cell produces surfactant?
IV antibiotic therapy for 3 weeks or longer, followed by oral antibiotics for 4 to 12 weeks
lung absess treatment
Emphysema- decreased tactile fremitus, sob, decreased breath sounds, barrel chest, hyperresonance when percussing lungs
manifestations of emphysema
knife like pain on inspiration (inflammation of pleural tissue causing friction rub)
pleurisy is characterized by
confusion and heart failure
pneumonia symptoms unique to older adults
after larynegeal surgery
postop priority is to maintain a patent airway, help them relax, and maintain nutrition and hydration
increase fluid intake, stay rested, sometimes using expectorants.
treatment of rhinovirus
Gargles for sore throat Use alternative communication Encourage liquids; at least 2 to 3 L/day Soft bland diet Rest Elevate head Ice collar to reduce inflammation and bleeding Hot packs to reduce congestion in sinuses Analgesics for pain
treatment uri
shunting of blood and results in hypoxia
What does an imbalanced V/Q ratio cause?
Hyperesonence
What sound can be heard when percussing the over-inflated lung tissue associated with a client with emphysema?
Emphysema
Lung compliance (the ability of the lungs to stretch) is a physical factor that affects ventilation. A nurse is aware that a patient who has lost elasticity in the lung tissue has a condition known as:
IHN and rifampin commonly used but it is a multidrug therapy (usually for drugs given two days a week fir 8 weeks then second therapy lasts 7 months
TB treatment
95% (92% for patients with COPD)
What is a safe but low oxygen saturation level for a patient?
clubbing of fingernails
What is a symptom of chronic hypoxia?
vibrating vest to loosen secretions (cystic fibrosis)
What is an HFCWO vest?
Test should be done several hours after a meal. Patient will be ordered bronchodilator for after initial test and then will redo test to look for improvement A nose clip prevents air from escaping through the client's nose when blowing into the spirometer. Patient should wear comfortable unrestricted clothes.
What is some patient education for a patient how is having a pulmonary function test using a spirometer?
humidifier
What should you suggest patients on a mini nebulizer treatment at home should get
Emphysema
While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding?
bacterial phenmonia
lung abssesses are a result of
Level of consciousness (LOC)
A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?
hoarsness
Earliest sign of laryngeal cancer
limit speech
First line intervention for pharyngitis and laryngitis
pneumonia and accumulation
Lung consolidation such as in ____________ or fluid ___________________ produces the dull sound.
CPAP machiene
what do people with sleep apnea often wear at night?
Manatoux test
what is the Tb skin test called
increase fluid intake
what is the best way to promote drainage of the sinuses?
infection prevention
what is the primary function of the tonsils
