NUR 2050 - Final Exam Content (Oxygenation)

Why is TB skin test not an appropriate TB assessment measure for patients who received the BCG vaccine?

Vaccination with BCG may cause a false positive reaction to a TB skin test due to the vaccine itself.

1.) What is the purpose of a sputum culture? 2.) When should it be obtained

1.) Identify agent causing infection 2.) Best obtained in morning

1.) What is Interferon-Gamma Release Assays (IGRA) test? 2.) What does a positive and negative test mean?

1.) Measure how the immune system reacts to the bacteria that cause TB. 2.) Positive IGRA: (Have TB, past or present) Means that the person has been infected with TB bacteria. Additional tests are needed to determine if the person has latent TB infection or TB disease (current). Negative IGRA: (Never had TB) Means that the person's blood did not react to the test and that latent TB infection or TB disease is not likely.

A client with newly diagnosed chronic obstructive disease is to be discharged home with oxygen per nasal prongs. Which teaching points should the nurse include in this client's discharge plan? Select all that apply. 1.Apply petroleum jelly on lips and nose to prevent dryness and irritation. 2.Avoid areas where people are smoking cigarettes or cigars. 3.Increase oxygen flow at night during hours of sleep. 4.Place gauze between the ears and oxygen tubing to prevent skin irritation. 5.Request a large, pressurized oxygen tank for use during car travel. 6.Avoid use of a microwave oven when using oxygen

2. Avoid areas where people are smoking cigarettes or cigars. 4.Place gauze between the ears and oxygen tubing to prevent skin irritation.

After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the health care provider? A. Green sputum B. Dry cough C. Hemoptysis D. Laryngeal stridor

Answer: D. Laryngeal stridor ABC's priority! Narrowing of airway (swelling, inflammation, allergic reactions)

Match the oxygen delivery devices with its correct description? A. Nasal cannula B. Simple mask C. Partial rebreather mask D. Nonrebreather mask E. Venturi mask F. Ambi mask 1. 5-8L/min, use only for a few hours because of low humidity, short term emergencies, operative procedures and when nasal cannula is not appropriate. Advantages=vents allow CO2 to escape. Disadvantages=difficulty keeping in place, skin break down possible, eating and talking is difficult and have a higher chance of aspiration. 2. 10-15L/min, high concentration of delivered oxygen, prevents rebreathing. Disadvantage=malfunction of bag could cause CO2 build up and suffocation. 3. 100% oxygen. Advantages=pump oxygen during emergencies, only apparatus that you use if pt. is not breathing. Disadvantages=higher chance of vomiting, air can be forced 4. 1-6L/min, use longer term, low flow, and when pt. is in stable. Advantages=easily tolerated, lo

A. Nasal cannula w/ 4. 1-6L/min, use longer term, low flow, and when pt. is in stable. Advantages=easily tolerated, longtime use appropriate, does not impede with eating/talking. Disadvantages=easily dislodged, can cause dryness, doesn't work well with mouth breathers and can cause skin breakdown. B. Simple mask w/ 1. 5-8L/min, use only for a few hours because of low humidity, short term emergencies, operative procedures and when nasal cannula is not appropriate. Advantages=vents allow CO2 to escape. Disadvantages=difficulty keeping in place, skin break down possible, eating and talking is difficult and have a higher chance of aspiration. C. Partial rebreather mask w/ 6. 8-11L/min, use when pt. needs to breathe some CO2/room air. Advantages=permits concentration of O2, can inhale room air if supply is briefly disrupted. Disadvantages=eating and talking difficult, tight seal requiring, skin breakdown possible. D. Nonrebreather mask w/ 2. 10-15L/min, high concentration of delivered oxygen, prevents rebreathing. Disadvantage=malfunction of bag could cause CO2 build up and suffocation. E. Venturi mask w/ 5. Precise O2 delivery. Advantages=tells exactly what you're giving, most precise concentration of O2, good for COPD pts. Disadvantage=difficulty talking and eating. F. Ambi mask w/ 3. 100% oxygen. Advantages=pump oxygen during emergencies, only apparatus that you use if pt. is not breathing. Disadvantages=higher chance of vomiting, air can be forced

Which of the following topics need to be taught to a patient regarding oxygen safety in regard to combustion? A. No smoking, especially around an oxygen tank B. Important to clean the oxygen tank every 74 hours C. Avoid oily hair products, greases, flammable solutions D. No frayed cords or extension cords E. Check use of electrical equipment F. Ensure to place the oxygen tank in a area with moisture G. Grounded electrical equipment and outlets

A. No smoking, especially around an oxygen tank C. Avoid oily hair products, greases, flammable solutions D. No frayed cords or extension cords E. Check use of electrical equipment G. Grounded electrical equipment and outlets

Match the induration level is considered abnormal for the following patients. A. Patient whose occupation is nursing B. Patient who has no known risk factors C. Patient whose husband recently diagnosed with active TB D. Patient with diabetes miletus E. Patient who is taking steroids F. Patient with HIV G. Patient with renal faliure 1. 5 mm 2. > 10 mm 3. 15 mm

A. Patient whose occupation is nursing = > 10mm B. Patient who has no known risk factors = 15 mm C. Patient whose husband recently diagnosed with active TB = 5 mm D. Patient with diabetes miletus = > 10mm E. Patient who is taking steroids = 5mm F. Patient with HIV = 5 mm G. Patient with renal failure = > 10 mm

Which of the following complications should the nurse look for after a patient has had a bronchoscopy done? A. Perforation/hole in airway B. Increased blood pressure C. Bleeding D. Acid reflex E. Irritation in airway and vocal cords F. Aspiration G. Infection

A. Perforation/hole in airway C. Bleeding E. Irritation in airway and vocal cords F. Aspiration G. Infection

A client has a positive reaction to the Mantoux test. How should the nurse interpret this reaction. The client has: A. Active tuberculosis. B. Been exposed to Mycobacterium tuberculosis. C. Developed a resistance to tubercle bacilli. D. Developed passive immunity to tuberculosis.

Answer: B. Been exposed to Mycobacterium tuberculosis.

A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. Following the procedure, what nurse should the nurse be a nursing priority? A. Encourage the client to gargle with oral lidocaine to decrease throat irritation. B. Monitor the client for signs of pneumothorax. C. Administer pain medication as needed to relieve mediastinal discomfort. D. Advise the client not to talk until the gag reflex returns.

Answer: B. Monitor the client for signs of pneumothorax. ABC is always priority and respiratory risk is present

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? A. Nasal Cannula B. Venturi mask C. Tracheostomy collar D. Non-rebreather

Answer: B. Venturi mask

Which action by the student nurse when applying a partial rebreather mask to a patient with low oxygen saturation needs correction by the nursing instructor? A.Applying humidified oxygen to prevent nasal dryness B.Removing the mask every 2 to 4 hours to evaluate the skin for breakdown C.Filling the reservoir bag with oxygen after placing the mask on the patient D.Monitoring patient's SpO2 and respiratory rate to prevent hypoxia

Answer: C. Filling the reservoir bag with oxygen after placing the mask on the patient

A client had a Mantoux test result of an 8-mm induration. When should the nurse interpret the test as positive? When the client: A.Lives in a long-term care facility. B.Has no known risk factors. C.Is immunocompromised. D.Works as a health care provider in a hospital.

Answer: C. Is immunocompromised.

The nurse is planning to assist the health care provider with a thoracentesis for a client who has a pleural effusion. Which position for the client would be appropriate for this procedure? A. Lying supine with the arms extended B. Lying prone with the head supported by the arms C. Sitting upright and leaning on an overbed table D. Side lying with the knees drawn up to the abdomen

Answer: C. Sitting upright and leaning on an overbed table

A patient who is one-day post op from a hysterectomy asks why they need to use the incentive spirometer. What should the nurse respond? A. "Using the incentive spirometer strengthens your abdominal muscles, helping you recover faster from surgery." B. "You need to use the incentive spirometer because the doctor ordered it for you and it is important to follow what the doctor says." C. "Consistent use of the incentive spirometer helps your body filter out built up CO2 after your surgery." D. The incentive spirometer helps keep your lungs well inflated and healthy, reducing the risk of respiratory illnesses like pneumonia."

D. The incentive spirometer helps keep your lungs well inflated and healthy, reducing the risk of respiratory illnesses like pneumonia.

What is the difference between a non-rebreather mask and a partial rebreather mask?

Non-rebreather: One way valve, only 100% oxygen present. Partial rebreather: Air you breath out, will be mixed with 100% oxygen.

A patient comes in with suspected carbon monoxide poisoning. The nurse first puts on an oxygen mask on the patient and then puts a pulse ox on the patent. Looking at the patient's SpO2 using the pulse ox, it gives a reading of 98%. The student nurse asks the nurse why the patient still has an oxygen mask when the SpO2 reading is within normal range. How should the nurse respond?

Pulse ox can detect that something is bonded to the hemoglobin in the red blood cells, but can not distinguish if it is O2 or CO2. So it is important to give oxygen to patient exposed to carbon monoxide and not think a normal SPO2 means the patient is ok.

What is the difference between PaO2 and SpO2. What is the normal ranges for both?

SpO2 is oxygen saturation, which is a measurement of the percentage of hemoglobin that is bound to oxygen. Normal range 95%-98% PaO2 is partial pressure of oxygen, and its a measurement of the pressure of the oxygen that found in the blood. Normal range 80-100

What is a TB skin test?

Test that help determine person's body was infected with TB bacteria. A minute amount of purified protein derivative (PPD) is injected and the site is examined after 48-72 hours; a red, raised lesion 5 mm or more in diameter constitutes a positive test

What is the non-rebreather reservoir and what is an important nursing consideration regarding the reservoir?

The bad connected to the oxygen mask. It is important to inflate the bag with oxygen BEFORE placing it on the patient.

Match the definition with the correct term. A. Tracheostomy B. Bronchoscopy 1. A procedure to look directly at the airways in the lungs using a thin, lighted tube 2. An opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs

Tracheostomy: an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs Bronchoscopy: a procedure to look directly at the airways in the lungs using a thin, lighted tube