NURS 125 Exam II
Priority nursing interventions pneumonia
- raise head of bed (at least semi-Fowler's) - admin O₂ - turn/reposition pts who are immobilized - assess lung sounds - deep breathing/coughing - provide adequate rest - admin meds - monitor for complications
Asthma Etiology
- uncertain, often hypersensitivity to allergens - upper respiratory infection, anxiety, exercise can initiate, endocrine changes
s/s asthma
- wheezing - chest tightness - SOB - coughing fits (thick, clear, or yellow sputum) - tachycardia, sweating - hyperresonance - diminished breath sounds
Emphysema Risk Factors
-smoking -genetics -exposure to air pollutants/occupational exposure -childhood resp. tract infections
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
1. Metabolic acidosis A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis.
With an oxygen debt, muscle shows: 1. Low levels of ATP 2. High levels of calcium 3. High levels of glycogen 4. Low levels of lactic acid
1. Low levels of ATP With an oxygen debt, a muscle would show primarily low levels of oxygen and low levels of ATP caused by the low levels of aerobic respiration and high levels of lactic acid.
bronchodilator
a medication that relaxes and expands the bronchial passages into the lungs
status asthmaticus
a severe, life-threatening asthma attack that is refractory to usual treatment and places the patient at risk for developing respiratory failure.
community acquired pneumonia
a type of pneumonia that results from contagious infection outside of a hospital or clinic (or within 48 hours of entering a hospital/facility)
Treatment of pneumonia
- antibiotics if infectious/antimicrobial tx - possibly ventilation - increase fluids (2-3L/day) & high-calorie diet - humidified O₂ - bed rest as indicated - analgesics to relieve pleuritic chest pain
dx of pneumonia
- chest x-ray - increase WBC - decrease PaO₂ - sputum culture/sensitivity - VQ scan (identifies early Pneumocystis carinii pneumonia)
dx asthma
- physical exam - chest x-ray - sputum (casts of airways or eosinophils) - skin testing for specific allergens
treatment of asthma
*- Avoidance of triggers* - Short-acting ß2-agonists (SABA) - Inhaled corticosteroids (ICS) - Long-acting ß2-agonists (LABA) - Leukotriene antagonists (modifiers) (LTRA)
Asthma nursing interventions
- Teach to avoid triggers - Teach to administer medication by meter-dose-inhaler - Teach to administer medication by continuous nebulizer - Teach peak expiratory flow rate monitoring - Raise head of bed - Admin O₂ - Encourage diaphragmatic breathing - Provide chest percussion and postural drainage (once symptoms improve) - Promote rest, calm pt, relieve anxiety
Pneumonia Risk Factors
- advanced age - lung diease - smoking - immunosuppression - bed ridden - post- op - poor nutrition - tracheostomy or mechanical ventilation - colds/respiratory infection - chronic illness (such as lung cancer) - impaired gag reflex - aLOC
treatment of emphysema
(1) stop smoking (2) pulmonary rehab program (3) oxygen, 1-2L/min through nasal prongs ** be careful!! (4) bronchodilators (5) anticholinergics
The nurse notes that a client's arterial blood gas results reveal a pH of 7.50 and a PaCO₂ of 30 mmHg. The nurse monitors the clients for which clinical manifestations associated with these arterial blood gas results? (select all that apply). 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness
1, 2, 4, & 6 Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness/tingling of the extremities.
The client is in a state of uncompensated acidosis. The nurse would expect the arterial blood pH to be approximately 1. 7.20 2. 7.35 3. 7.45 4. 7.48
1. 7.20 The pH of the blood is maintained within the narrow range of 7.35 to 7.45. When there is an increase in H+ ions, acidosis results and is reflected in a lower pH.
The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
1. Metabolic acidosis Metabolic acidosis is defined as a total concentration of buffer base that is lower than normal, with a relative increase in the H+ ion concentration. This results from loss of buffer bases or retentions of too many acids without sifficient bases, and occurs in conditions such as kidney disease, DKA, high fat diet, insufficient metabolism of carbohydrates, malnutrition, ingestion of toxins (such as aspirin), or sever diarrhea. In an ileostomy, intestinal secretions (high in bicarbonate) are lost through enteric drainage tubes.
A client who has AIDS develops bacterial pneumonia. On admission tot he emergency department, the clients PaO₂ is 80 mmHg. When the arterial blood gases are drawn again, the level is determined to be 65 mmHg. The nurse should: 1. Notify the physician 2. Increase the oxygen flow rate 3. Decrease the tension of oxygen in the plasma 4. Have arterial blood gases performed again to check for accuracy
1. Notify the physician This decrease in PaO₂ indicates respiratory failure; it warrants immediate medical evaluation.
Match the following: 1. _____ Sweet (acetone) odor to breath 2. _____ decreased rate and depth of respirations 3. _____ tetany 4. _____ light-headedness 5. _____ warm, flushed skin 6. _____ increased respiratory rate and depth 7. _____ headache a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis
1. Respiratory acidosis 2. Respiratory acidosis (cause) & Metabolic alkalosis (compensation) 3. Respiratory alkalosis & Metabolic alkalosis 4. Respiratory alkalosis 5. Metabolic acidosis 6. Metabolic acidosis (compensation) & Respiratory alkalosis (cause) 7. Respiratory acidosis
Match the following: 1. _____ sedative overdose 2. _____ hyperventilation 3. _____ diabetes mellitus 4. _____ gastric suctioning 5. _____ renal failure 6. _____ pain 7. _____ vomiting 8. _____ emphysema 9. _____ flail chest 10. _____ diarrhea a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis
1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Metabolic acidosis 6. Respiratory alkalosis 7. Metabolic alkalosis 8. Respiratory acidosis 9. Respiratory acidosis 10. Metabolic acidosis
Emphysema Etiology
1. Smoking 2. Genetic deficiency of alpha-1-antitrypsin (AAT)
The nurse must be alert for s/s of respiratory acidosis in the client with emphysema, because this individual has a long term problem with oxygenation maintenance and: 1. The carbon dioxide is not excreted 2. Hyperventilation occurs, even if the cause is not physiologic 3. There is a loss of carbon dioxide from the body's buffer pool 4. Localized tissue necrosis occurs as a result of poor oxygen supply to the area
1. The carbon dioxide is not excreted Retention of carbon dioxide, after exhausting the available bicarbonate ions functioning as buffers, will results in a lower pH (respiratory acidosis).
A client is scheduled for a pulmonary function test. The nurse explains that during the test the respiratory therapist will ask the client to breathe normally to measure the: 1. Tidal volume 2. Vital capacity 3. Expiratory reserve 4. Inspiratory reserve
1. Tidal volume The tidal volume is the amount of air inhaled and exhaled while treating normally.
A client with a long history of asthma is scheduled for surgery. Preoperative teaching should include the fact that the client: 1. Will be prone to respiratory tract infections 2. Can control and limit asthmatic attacks if desired 3. Should try to limit coughing, because this causes distention of the chest 4. Can control anxiety and decrease the severity of postoperative asthma attacks
1. Will be prone to respiratory tract infections Hypersecretions of the mucous glands provides an excellent warm, moist medium for microorganisms.
While receiving an adrenergic beta₂ agonist for asthma, the client complains of palpitations, chest pain, and a throbbing headache. In view of these symptoms, the most appropriate nursing action would be to: 1. Withhold the drug until additional orders are obtained from the physician 2. Tell the client not to worry, these are expected side effects from the medication 3. Ask the client to relax; then give instructions to breathe slowly and deeply for several minutes 4. Reassure the client that these effects are temporary and will subside as the body becomes accustomed to the drug
1. Withhold the drug until additional orders are obtained from the physician These drugs cause increased heart contraction (positive inotropic effect) and increased heart rate (positive chronotropic effect). If toxic levels are reached, side effects occur and the drug should be withheld until the physician is notified.
The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1. pH 7.25, PaCO₂ 50 mmHg 2. pH 7.35, PaCO₂ 40 mmHg 3. pH 7.50, PaCO₂ 52 mmHg 4. pH 7.52, PaCO₂ 28 mmHg
1. pH 7.25, PaCO₂ 50 mmHg Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. This can lead to respiratory acidosis.
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50, PaCO₂ 30 mmHg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L 2. Potassium level of 3.0 mEq/L 3. Magnesium level of 2.0 mg/dL 4. Phosphorous level of 4.0 mg/dL
2. Potassium level of 3.0 mEq/L All of the other options identify normal laboratory values. Respiratory alkalosis causes a shift from K+ outside of the cells to enter the cells, in order to brings H+ out of the cells. This shift causes hypokalemia.
A client receiving morphine is being monitored by the nurse for s/s of overdose. (select all that apply) 1. Polyuria 2. Lethargy 3. Bradycardia 4. Dilated pupils 5. Slow respirations
2, 3, 5 Morphine is a CNS depressant.
The nurse must assess the client with gastric lavage or prolonged vomiting for: 1. Acidosis 2. Alkalosis 3. Loss of oxygen from the blood 4. Loss of osmotic pressure of the blood
2. Alkalosis Excessive loss of gastric fluid results in excess loss of HCl and cal lead to alkalosis. The HCl is not available to neutralize the sodium bicarbonate secreted into the duodenum by the pancreas. The intestinal tract absorbs the excess bicarbonate and alkalosis results.
Larger than normal amounts of acetoacetic acid have been entering the blood as one of the indirect results of a client's insulin deficiency. Like lactic acid and other nonvolatile acids, acetoacetic acid is buffered int he blood chiefly by: 1. Potassium 2. Bicarbonate 3. Carbon dioxide 4. Sodium chloride
2. Bicarbonate Sodium bicarbonate is a base and one of the major buffers in the body.
The nurse observes an anxious client hyperventilating and intervenes to prevent: 1. Cardiac arrest 2. Carbonic acid deficit 3. Reduction in serum pH 4. Excess oxygen saturation
2. Carbonic acid deficit Hyperventilation causes excessive loss of carbon dioxide, leading to carbon acid deficit and respiratory alkalosis.
A client is admitted with suspected atelectasis. When assessing this individual, the nurse would expect: 1. Slow, deep respirations 2. Diminished breath sounds 3. A dry, unproductive cough 4. A normal oral temperature
2. Diminished breath sounds Because atelectasis involves collapsing of alveoli distal to the bronchioles, breath sounds would be diminished in the lower lobes.
A client states that the physician said the tidal volume is slightly diminished and asks the nurse what this means. The nurse explains that tidal volume is the amount of air: 1. Exhaled forcibly after normal expiration 2. Exhaled after there is normal inspiration 3. Trapped in the alveoli that cannot be exhaled 4. Forcibly inspired over and above a normal inspiration
2. Exhaled after there is normal inspiration Tidal volume is defined as the amount of air exhaled after a normal inspiration.
When suctioning a client with a tracheostomy, the nurse must remember to: 1. Use a new sterile catheter with each insertion 2. Initiate suction as the catheter is being withdrawn 3. Insert the catheter until the cough reflex is stimulated 4. Remove the inner cannula before inserting the suction catheter
2. Initiate suction as the catheter is being withdrawn During suctioning of a client, negative pressure (suction) should not be applied until the catheter is ready to be drawn out because, in addition to removal of secretions, oxygen is being depleted.
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
2. Metabolic alkalosis Metabolic alkalosis is defined as a deficit or loss of H+ ions/acids or an excess of base that results from the accumulation of base or loss of acid without a comparable loss of base in the body fluids.
To facilitate maximum air exchange, a client should be placed in the: 1. Supine position 2. Orthopneic position 3. High-Fowler's position 4. Semi-Fowler's position
2. Orthopneic position The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange, because the abdominal organs do not provide pressure against the diaphragm and gravity facilitates the descent of the diaphragm.
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45 PaCO₂ 30 mmHg, and HCO₃⁻ 20 mEq/L. The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated
2. Respiratory alkalosis, compensated The pH is at the high end of the normal value and the PaCO₂ is low. Because the pH has returned to a normal value, compensation has occurred.
What would be the priority goal established for a client with asthma for is being discharged from the hospital? 1. The clients is able to obtain pulse oximeter readings 2. The client demonstrates use of metered-dose inhaler 3. The client knows the primary care provider's office hours 4. The client can identify the foods that may cause wheezing
2. The client demonstrates use of metered-dose inhaler Clients with asthma use metered-dose inhalers to administer medications prophylactically and/or during times of an asthma attack; this is an important skill to have before discharge.
When the alveoli lose their normal elasticity as a result of emphysema, the nurse teaches the client exercises that lead to effective use of the diaphragm because: 1. Inspiration has been markedly prolonged and difficult 2. The residual capacity of the lungs has been increased 3. The client has an increase in the vital capacity of the lungs 4. Abdominal breathing is an effective compensatory mechanism that is spontaneously initiated
2. The residual capacity of the lungs has been increased Loss of elasticity causes difficult exhalation, with subsequent air trapping. Clients who have emphysema are taught to use accessory abdominal muscles and to breathe out through pursed lips to help keep the air passages open until exhalation is complete.
The nurse understands that in the absence of pathology, a client's respiratory center is stimulated by: 1. Oxygen 2. Lactic acid 3. Calcium ions 4. Carbon dioxide
4. Carbon dioxide The respiratory center in the medulla responds primarily to the increased carbon dioxide concentration in the blood.
An acceleration in oxygen dissociation from hemoglobin, and thus oxygen delivery to the tissues is caused by: 1. A decreasing oxygen pressure in the blood 2. An increasing carbon dioxide pressure in the blood 3. A decreasing oxygen pressure and/or an increasing carbon dioxide pressure in the blood 4. An increasing oxygen pressure and/or a decreasing carbon dioxide pressure in the blood
3. A decreasing oxygen pressure and/or an increasing carbon dioxide pressure in the blood The lower the PaO₂ and the higher the PaCO₂, the more rapidly oxygen dissociates from the oxygen-hemoglobin molecule.
To help a client obtain maximum benefits after postural drainage, the nurse should: 1. Administer prn oxygen 2. Place the client in a sitting position 3. Encourage the client to cough deeply 4. Encourage the client to rest for 30 minutes
3. Encourage the client to cough deeply Coughing is needed to raise secretions for expectoration.
When a spontaneous pneumothorax is suspected in a client with a history of emphysema, the nurse should call the physician and: 1. Administer 60% O₂ via Venturi mask 2. Place the client on the unaffected side 3. Give O₂ 2L/min via nasal cannula 4. Prepare for IV administration of electrolytes
3. Give O₂ 2L/min via nasal cannula Oxygen is supplied to prevent anoxia but not too high in concentrations. In an individual with emphysema a low PaO₂, not hight PaCO₂ is the respiratory stimulus.
A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. The client should be instructed to: 1. Perform the procedure once in the morning and once at night 2. Move the trunk from an upright to a bending position while exhaling 3. Inhale completely and then blow out as hard and as fast as possible through the mouth piece 4. Place the mouthpiece between the lis and in front of the teeth before starting the procedure
3. Inhale completely and then blow out as hard and as fast as possible through the mouth piece A peak flow meter measures the peak expiratory flow rate (PEFR), the maximum flow of air that can be forcefully exhaled in 1 second; this monitors the pulmonary status of a client with asthma.
corticosteroids
A group of hormones, including cortisol, released by the adrenal glands at times of stress
Legionnaire's disease
A severe, often fatal bacterial disease characterized by pneumonia, dry cough and sometimes gastrointestinal symptoms. ** mortality ~ 15%
The nurse is aware that when emphysema is present, there is a decreased oxygen supply because of: 1. Pleural effusion 2. Infectious obstructions 3. Loss of aerating surface 4. Respiratory muscle paralysis
3. Loss of aerating surface Destruction of alveolar walls leads to diminished surface area for gaseous exchange and an increased CO₂ level in the blood.
The arterial blood gases of a client with COPD deteriorate, and respiratory failure is impending. The nurse should first assess the client for: 1. Cyanosis 2. Bradycardia 3. Mental confusion 4. Distended neck veins
3. Mental confusion Decreased oxygen to the vital centers in the brain results in restlessness and confusion.
To monitor for the complication of subcutaneous emphysema after the insertion of chest tubes, the nurse should: 1. Assess for the presence of a barrel-shaped chest 2. Auscultate the breath sounds for crackles and rhonchi 3. Palpate around the chest tube insertion sites for crepitus 4. Compare the length of inspiration with the length of expiration
3. Palpate around the chest tube insertion sites for crepitus Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sounds heard when tissues containing gas are palpated.
A client with emphysema experiences a sudden episode of shortness of breath. The physician diagnoses a spontaneous pneumothorax. The nurse is aware that the probably cause is: 1. Pleural friction rub 2. Tracheoesophageal fistula 3. Rupture of sub pleural bleb 4. Puncture wound of the chest wall
3. Rupture of a sub pleural bleb The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters.
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/min. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following? 1) A decreased pH and an increased CO2 2) An increased pH and a decreased CO2 3) A decreased pH and a decreased HCO3- 4) An increased pH with an increased HCO3-
4) An increased pH with an increased HCO3- Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid. S/S would include hypoventilation (to compensate) and tachycardia.
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, PaCO2 is 90, and HCO3- is 22. the nurse interprets the results as indicating which condition? 1) Metabolic Acidosis with compensation 2) Respiratory Acidosis with compensation 3) Metabolic Acidosis without compensation 4) Respiratory Acidosis without compensation
4) Respiratory Acidosis without compensation Because the bicarbonate level is within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. The pH is not within normal limits.
The nurse administers oxygen at 2L/min via nasal annular to a client with emphysema. The nurse should observe the client closely for: 1. Cyanosis and lethargy 2. Anxiety and tachycardia 3. Hypermia and increased respirations 4. Drowsiness and decreased respirations
4. Drowsiness and decreased respirations Clients with COPD respond only to the chemical stimulus of low oxygen levels. Administration of high concentrations of oxygen will eliminate the stimulus to breathe, leading to decreased respirations and lethargy.
Discharge planning for a male college student with recently diagnosed asthma should initially focus on: 1. Teaching the client how to make his room allergy-free. 2. Referring the client to a support group for individuals with asthma. 3. Collaborating with the client and college to ensure a speedy return to school. 4. Ensuring that the client understands his disease and the best way to care for it.
4. Ensuring that the client understands is disease and the best way to care for it. Understanding the disease the and details of care are essential for the client to become self-sufficient in the home.
A client's arterial blood gas report indicates the pH is 7.52, PaCO₂ is 32 mmHg, and HCO₃ is 24 mEq/L. What is a possible cause of these results? 1. Airway obstruction. 2. Inadequate nutrition 3. Prolonged gastric suction 4. Excessive mechanical ventilation
4. Excessive mechanical ventilation The high pH and low carbon dioxide are consistent with respiratory alkalosis, which can be caused by aggressive mechanical ventilation.
Air rushes into the alveoli as a result of the: 1. Relaxation of the diaphragm 2. Rising pressure in the alveoli 3. Rising pressure in the pleura 4. Lowered pressure in the chest cavity
4. Lowered pressure in the chest cavity Thoracic pressure is reduced because thoracic volume is increased as the diaphragm descends.
In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 1. Chest tube insertion 2. Aggressive diuretic therapy 3. Administration of beta blockers 4. Positive end expiratory pressure
4. Positive end expiratory pressure Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation.
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. On the basis of this documentation, which pattern did the nurse observe? 1. Respirations that cease for several seconds 2. Respirations that are regular but abnormally slow 3. Respirations that are labored and increased in depth and rate 4. Respirations that are abnormally deep, regular, and increased in rate
4. Respirations that are abnormally deep, regular, and increased in rate Kussmaul's respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. Bradypnea is respirations that are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.
asthma
A chronic pulmonary disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing.
terbutaline
Beta 2 agonist
True/False Corticosteroids are prescribed for asthma clients for their bronchodilating effect
False Corticosteroids are five to clients with asthma for their anti-inflammatory effect
carbonic acid
H2CO3
bicarbonate
HCO3-
Status asthmaticus treatment
IV fluids, potent systemic bronchodilator, steroids, epinephrine, oxygen (humidified) ** unrelieved by epinephrine requires noninvasive positive pressure ventilation
Epinephrine
Neurotransmitter secreted by the adrenal medulla in response to stress. Also known as adrenaline.
Dx of emphysema
PFT, chest xray, ABGs, ECG (tall, symmetrical P waves), and CBC (increased RBC)
S/S of emphysema
Pink Puffers barrel chest, pursed lip breathers, distant quiet breath sounds, wheezes, pulmonary blebs on radiograph
Beta-adrenergic agonists
Stimulate the beta-receptors in the sympathetic nervous system, increasing calcium flow into the myocardial cells, and causing increased contraction
True/False Sudden changes in temperature can induce an asthma attack in susceptible persons
True Sudden changes in temperature can cause a person with asthma to have an asthma attack
True/False The diet for a client with pneumonia should be high calorie with increased fluids
True increased fluids can help thin secretions and the body needs the extra calories when it's ill
the diagnostic test that can identify early Pneumocystis carinii pneumonia is a...
VQ scan
Theophylline
a bronchodilator used to treat asthma and bronchitis and emphysema
emphysema
a chronic, irreversible disease of the lungs characterized by abnormal enlargement of air spaces in the lungs accompanied by destruction of the tissue lining the walls of the air spaces.
Which laboratory results are consistent with long-term COPD? (select all that apply) a. Erythrocytosis b. Hypoxemia c. Hypercapnia d. Leukopeia
a, b, & c COPD is characterized by a decrease in oxygen and increase in carbon dioxide, so hypoxemia and hypercapnia are expected. Erythrocytosis or an increase in RBCs also occurs as a compensatory effort to maintain tissue oxygenation.
Management of an acute attack of asthma might include which of the following medications? (select all that apply) a. subcutaneous epinephrine b. inhaled albuterol c. oral corticosteroids d. IV theophylline e. inhaled cromolyn sodium
a, b, & d Epinephrine stimulates the beta-2 adrenergic receptors on respiratory smooth muscle resulting in bronchodilation. Albuterol is a SABA bronchodilator. Theophylline is a methylxanthine bronchodilator.
The plan of care for which client would involve monitoring for respiratory acidosis? a. A 24-year old with Guillain-Barre syndrome b. A 37-year old with pancreatic drainage c. A 50-year old who required a massive blood transfusion following a MVA d. A 70-year old with chronic congestive heart failure
a. A 24-year old with Guillain-Barre syndrome Guillain-Barre syndrome can affect the muscles of respiration, decreasing alveolar ventilation.
A client with COPD complains of headache and a "racing" heart; he is also restless and somewhat confused. What problem would the nurse suspect? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
a. Respiratory acidosis Headache, tachycardia, restlessness, and confusion are s/s of respiratory acidosis for which a client with COPD is at risk.
pneumonia
acute inflammation of the lung parenchyma leading to consolidation of lung tissue as the alveoli fill with exudate that impairs gas exchange
risk factors of asthma attack
allergen, allergic rhinitis, upper airway infection, sudden changes in temperature/weather
An elderly confused client with an impaired gag reflex is at high risk for...
aspiration pneumonia
When assessing a client with emphysema, which finding would the nurse conclude needed further investigation because it is not an expected characteristic of the disease? a. Pursed-lip breathing b. Persistent productive cough c. Grunting at the end of expiration d. Prolonged expiration
b. Persistent productive cough Persistent productive cough is not a symptom of emphysema rather there is minimal cough and sputum production. All other symptoms are consistent with the diagnosis of emphysema.
Which is a characteristic assessment finding in clients with bacterial pneumonia? a. Increased PaO₂ b. Rust-colored sputum c. Expiratory wheeze d. Nonproductive cough
b. Rust-colored sputum Rust-colored sputum, pleuritic chest pain, cough, and fever are all classic signs of bacterial pneumonia.
How should the nurse interpret the finding of a "barrel chest" on examination of a patient? a. Sign of long-term hypoxia b. Sign of chronic air trapping c. Sign of excess mucus production d. Sign of congenital bronchospasm
b. Sign of chronic air trapping Barrel chest, a condition in which the AP diameter of the chest is greater than normal results from hyperinflation due to chronic air trapping.
A 61-year old client with a history of chronic renal failure is admitted with a possible appendicitis. Based on this history, which acid-base imbalance is most likely to be found when laboratory test results are assessed? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
c. Metabolic acidosis Chronic renal failure is the most common cause of metabolic acidosis.
The nurse should expect to include bed rest, a high-calorie diet, and extra fluids in the plan of care for a client with which disorder? a. Cystic fibrosis b. Emphysema c. Pneumonia d. Lung cancer
c. Pneumonia Bed rest is only necessary for clients with pneumonia; the other disorders allow for ambulation.
Pneumonia Etiology
causes include bacteria, fungi, viruses, parasites, aspiration
asthma is most common in...
children
The four cardinal s/s of bacterial pneumonia are...
cough, sputum production, pleuritic chest pain, and fever
Which client would be most at risk for developing aspiration pneumonia? a. An infant with a tracheoesophageal defect repair b. An alert 10-year old with cystic fibrosis c. A 50-year old man with fractured ribs and a fractured leg from a MVA d. A confused 75-year old with a CVA
d. A confused 75-year old with a CVA confusion and impaired gag reflex are two of the major risk factors for aspiration pneumonia
When assessing a client with fractured ribs, which ABG values would be expected? a. PaO₂ 89 mmHg, PaCO₂ 41 mmHg b. PaO₂ 101 mmHg, PaCO₂ 50 mmHG c. PaO₂ 94 mmHg, PaCO₂ 35 mmHG d. PaO₂ 76 mmHg, PaCO₂ 48 mmHG
d. PaO₂ 76 mmHg, PaCO₂ 48 mmHG Hypoxemia and hypercapnia are expected.
Which client is at risk for metabolic acidosis? a. A 17-year old with cystic fibrosis b. A 35-year old pregnant woman c. A 48-year old with hypoparathyroidism d. a 65-year old with an ileostomy
d. a 65-year old with an ileostomy Ileostomy drainage places a client at risk for metabolic acidosis.
what causes asthma?
exposure to substance results in increased histamine production causing edema of mucus membrane, spasm of smooth muscle of bronchi/bronchioles, and accumulation of secretions
s/s of pneumonia
fever/chills, green/rust-colored sputum, shortness of breath, (sharp/plueritic) chest pain, headache, crackles, tachycardia, cyanosis, tachypnea (rapid and shallow)
pneumonia primary problem
impaired gas exchange
decreased breath sounds accompanied by pleuritic pain that worsens with coughing or deep breathing is consistent with a diagnosis of...
pleural effusion
Hospital acquired pneumonia
pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization.
most common cause of pneumonia in infants and young children
viruses
Legionella bacteria are found in...
water
