120 test 3
A patient with pulmonary hypertension has a positive vasoreactivity test. What medication does the nurse anticipate administering to this patient?
Calcium channel blockers Explanation: Patients with a positive vasoreactivity test may be prescribed calcium channel blockers. Calcium channel blockers have a significant advantage over other medications taken to treat PH in that they may be taken orally and are generally less costly; however, because calcium channel blockers are indicated in only a small percentage of patients, other treatment options, including prostanoids, are often necessary
S&S of acute oxygen deficit
Restlessness Confusion Lethargy Nasal flaring Use of accessory muscles Orthopnea Cyanosis Pallor
pleural effusion
fluid within the pleural space
Which assessment finding puts a client at increased risk for epistaxis?
-COCAINE -Using nasally inhaled illicit drugs, such as COCAINE increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis.
A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to
-Check the clear fluid for glucose. -The client's signs and symptoms are consistent with a fracture of the nose. Clear fluid draining from either nostril suggests leakage of cerebrospinal fluid. This can be checked by assessing for glucose, which is in cerebrospinal fluid. This finding is important to identify, because infection can be transmitted through the opening in the cribiform plate. Other options, such as applying an ice pack to the nose and administering ibuprofen, are appropriate interventions but not most important for this client. Reassuring the client that the nose is not fractured is premature until all assessments are completed. (less)
Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
-Record the observation -Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes.
relief measure for dypnea
-pt at rest in high fowlers -lean forward with arms and upper body supported on a table -used pursed lip breathing -administering O2 -opiods -benzodiazapines ( antianxiety)
An adult client is choking and loses consciousness. Place the next steps in the procedure, from first to last, that the nurse will employ to help the client.
1.Lower the victim to the ground. 2.Straddle the victim's body and place the heel of one hand on top of the other. 3.Position the hands midway between the umbilicus and the xiphoid process. 4.Deliver thrusts and repeat. 5.Open the mouth to assess if the object can be swept out with a hooked finger. 6.If the airway remains obstructed, repeat the procedure. Explanation: If the object is not ejected or coughed out and the victim loses consciousness, lower the victim to the ground. Straddle the victim's body and place the heel of one hand on top of the other. Position the hands midway between the umbilicus and the xiphoid process. Deliver thrusts and repeat. Open the mouth to assess if the object can be swept out with a hooked finger (do not sweep the mouth in children). If the airway remains obstructed, repeat the procedure.
When preparing a chest drainage system, the nurse would fill the water seal chamber to which mark?
2 cm level
You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following?
Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.
A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?
An antiviral agent such as acyclovir Explanation: Herpes labialis is an infection that is caused by herpes simplex virus type 1 (HSV-1). It is characterized by an eruption of small, painful blisters on the skin of the lips, mouth, gums, tongue, or the skin around the mouth. The blisters are commonly referred to as cold sores or fever blisters. Medications used in the management of herpes labialis include acyclovir (Zovirax) and valacyclovir (Valtrex), which help to minimize the symptoms and the duration or length of flare-up.
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?
Angiotensin converting enzyme (ACE) inhibitors Explanation: Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors. The other medications listed are not associated with causing a cough
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?
Angiotensin converting enzyme (ACE) inhibitors Explanation: Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors. The other medications listed are not associated with causing a cough.
a client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?
Apply direct continuous pressure. Explanation: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.
what to teach pt when on tetracylcines.
Be sure to wear sunscreen while taking this medicine." Explanation: Tetracycline may cause a photosensitivity reaction in clients. The nurse should caution the client to use sunscreen when taking this drug. Dairy products can reduce the effectiveness of tetracycline, so the nurse should not advise him or her to take the medication with milk. A metallic taste accompanies administration of metronidazole (Flagyl). Administration of tetracycline does not necessitate driving restrictions.
A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?
Bronchophony Bronchophony is an increased intensity and clarity of voice sounds heard over a bronchus surrounded by consolidated lung tissue. Over normal lung tissue, the words are unintelligible; however, over areas of tissue consolidation, such as with pneumonia, the words are clear because the tissue enhances the sounds. Tactile fremitus is the vibration felt when the client speaks while the nurse holds her hand against his chest. Crepitation is a crackling sound heard in certain diseases such as pneumonia. Egophony is an abnormal change in tone heard when the client speaks normally as the nurse auscultates his chest.
The nurse is preparing a client for a diagnostic procedure. What should the nurse remember when providing information and appropriate explanations about diagnostic procedures to clients?
Energy levels of clients may be decreased. Explanation: Clients need information and appropriate explanations of any diagnostic procedures that they experience. Nurses must remember that clients may need to compromise their breathing during a diagnostic procedure. They may also experience low energy levels. Therefore, explanations should be brief yet complete and may be repetitive. The nurse must also ensure that clients have adequate rest before and after the procedures.
Which of the following is a priority nursing intervention that the nurse should perform for a patient who has undergone surgery for a nasal obstruction?
Ensure mouth breathing Explanation: For a patient who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating mouth breathing. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.
Grading dyspnea
Grade 0- no trouble except with strenous exeercise Grade 1- troubled by breathlessness when hurrying on a level path or walking up a slight hill Grade 2- walks slowly on a level path due to breathlessness or has to stop to breath when walking on a level path. Grade 3- stops to breath after walking 100 yards grade 4- too breathless to leave house or breathless when undressing/dressing.
A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?
Group A, beta-hemolytic streptococci Explanation: Viral infection causes most cases of acute pharyngitis. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial infection accounts for the remainder of cases. Ten percent of adults with pharyngitis have group A beta-hemolytic streptococcus (GABHS), which is commonly referred to as group A streptococcus (GAS) or streptococcal pharyngitis.
A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?
Group A, beta-hemolytic streptococcus Explanation: The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Frequently occurring bacterial pathogens include group A, beta-hemolytic streptococcus, the most common organism.
Which diagnostic is more accurate in detecting malignancies than a CT scan?
PET A PET scan is more accurate in detecting malignancies than a CT scan, and it has equivalent accuracy in detecting malignant nodules when compared with invasive procedures such as thorascopy. The gallium scan is used to stage bronchogenic cancer and document tumor regression after chemotherapy or radiation. An MRI is used to characterize pulmonary nodules, to help stage bronchogenic carcinoma, and to evaluate inflammatory activity in interstitial lung disease. Pulmonary angiography is used to investigate thromboembolic disease of the lungs
The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?
PaCO2 When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases.
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
Partial laryngectomy Explanation: In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.
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?
Rhonchi Explanation: Rhonchi are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis.
An 18-month-old child is brought to the Emergency Department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?
Right upper lung Explanation: Aspiration of foreign objects is more likely in the right mainstem bronchus and right upper lung.
The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure?
Sudden onset in client who had normal lung function Explanation: Acute respiratory failure occurs suddenly in a client who previously had normal lung function.
Which type of the alveoli cells produce surfactant?
Type II cells—produce surfactant, a phospholipid that alters the surface tension of alveoli, preventing their collapse during expiration and limiting their expansion during inspiration
A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?
Use of accessory muscles Explanation: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy
ventilation
Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.
pneumothorax
air in the pleural cavity
S&S of oxygen toxicity
chest pain, parasthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory distress, atelectasis, pulmonary infiltrates, and fibrosis
S&S of hemorrhage
cool skin, confusion, ^ HR, labored breathing, blood in the stool
anemic hypoxia
decreased effective hemoglobin concentration (decreased in oxygen carrying capacity of the blood)
Hypoxemic hypoxia
decreased oxygen level in the blood causing decreased oxygen levels to the tissues.
S&S of chronic hypoxia
fatigue, drowsiness, dypnea o exertion, and inattentiveness. clubbing of fingers.
circulatory hypoxia
inadequate capillary circulation
nutrients needed for RBC production
iron folic acid Vitamin B12F
A late complication of radiation therapy includes
laryngeal necrosis. Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy.
what medications should NOT be given when a pt has fever, nausea or pain?
laxative (can cause perforation) or cathartic
S&S of pyloric obsturcton
nausea, vomiting, distended abdomen, abdominal pain
S&S of acute onset hypoxia
neurologic and cardiovascular impairment
Pink frothy sputum may be an indication of
pulmonary edema. Explanation: Profuse, frothy pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms
Report theses S&S immediately if seen on a pt with a chest tube
rapid or shallow breathing, cyanosis, pressure in the chest, subcutaneous emphysema, symptoms of hemorrhage, and major change in VS
complications with laryngectomy
respiratory distress, hypoxia, hemorrhage, infection, wound breakdown, aspiration tracheal stenosis
S&S of penetration/perforation
severe abdominal pain, rigid and tender abdomen, vomiting, elevated temp, and ^ HR
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
swallow reflex The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.
histotoxic hypoxia
toxic substance such as cyanide interferes with the ability of tissues to use oxygen.
The nurse assesses a patient with pneumonia and notes bronchial breath sounds over consolidated lung areas. Which of the following breath sounds are diagnostic for pneumonia? Select all that apply.
• Crackles • Egophony • Whispered pectoriloquy • Percussion dullness Explanation: Physical examination findings may reveal bronchial breath sounds over consolidated lung areas: soft, high-pitched crackles, inspiratory vesicular sounds that are longer than expired normal breath sounds; increased tactile fremitus (vocal vibration detected on palpation), percussion dullness, egophony, and whispered pectoriloquy (whispered sounds are easily auscultated through the chest wall). Wheezes and friction rubs are not diagnostic for pneumonia
