Exam 2 - EAQ
How would we prevent an infection for a patient with tracheostomy?
chlorhexidine mouthwash decreases the bacteria in their mouth
What is atelectasis and what would we expect to hear?
collapsed lung; incomplete expansion of alveoli Diminished breath sounds
What is atelectasis?
collapsed of aveoli / lung
breathing exercises help which body part?
diaphragm
A COPD patients lung sounds
diminished breath sounds
Which action would a nurse take to decrease retained secretions in 13-year-old with an exacerbation of chronic bronchitis?
Increase fluid intake to at least 2000 mL/day.
Which observation indicates a desired response in a client with a chest tube due to a crushing chest injury?
Increased breath sounds
Which strategy will the nurse use to improve oxygenation in the client with ARDS
Prone positioning
Which would the nurse do to best facilitate communication postoperatively for a client who had a partial laryngectomy and tracheostomy?
Provide a means for the client to write
Which statement by the client leads the nurse to suspect the pleural effusion has returned after a thoracentesis?
"I get sharp, stabbing pain when I take a deep breath"
Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place?
"Restraints are a last resort to prevent accidental extubation"
COPD patient can have how much oxygen?
1-2 liters Low concentration!
Which response by the nurse is appropriate for a client emphysema who is questioning why he or she has a barrel chest?
The air sacs in your lungs are no longer elastic, and this causes an increase in the lung size
What would we hear when a patient has pneumothorax?
absent breathe sounds
The nurse explains that the client is not to consume any food or drink after a bronchoscopy to decrease the risk for which complication?
aspiration
Which action would the nurse do when caring for a client with COPD and pleuritis?
assess for signs of pneumonia
Which would most concern the nurse if seen in a client during a current acute exacerbation of asthma?
Absence of wheezing this means that the airways have become so narrow that the client is unable to move any air.
A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. Which summary represents this documentation of findings, crackles and rhonchi in the left lower lungs"?
An inaccurate interpretation
Which complication would the nurse monitor for in a client with chronic asthma?
Atelectasis
A patient needs to be restrained that had a tracheostomy?
Because they are attempting to pull out the tube
Which response is it a priority to monitor for after a throacentesis?
Blood!
A patient has pneumonia and taking antibiotics
Breathing exercises
Which long-term problem would the nurse monitor for in a client diagnosed with emphysema?
Carbon Dioxide retention
Which complications are most associated with chronic obstructive pulmonary disease (COPD)?
Cardiac problems
If there is excessive tiding for a chest tube what would we do?
Check for air leaks
What are signs and symptoms of Atelectasis?
Chest pain, dyspnea, Diminished breath sounds, crackles and even altered levels of consciousness caused hypoxia
What are the TB skin test classes?
Class 0: Did not give them a test Class 1: Skin Test Class 2: Chest Xray Class 3: Active TB
What would be our priority with tracheostomy?
Clear airway, with suctioning
What is our priority for someone with a tracheostomy?
Clear the airway
Which medication type will the nurse explain that includes fluticasone/salmeterol and mometasone furoate. Formoterol fumarate dihydrate while teaching about asthma medications?
Combination medication
what would our priority for a patient that just had a tracheostomy?
Communication! Provide the patient with pencil and paper
COPD patient has gained 5 lb of fluid, what is it called
Cor Pulmonale
Which type of lung sounds would the nurse expect to hear when caring for a client with heart failure exacerbation?
Crackles
If a patient has heart failure, what would we hear during auscultation and which side?
Crackling because the heart cannot get rid of the fluid. Left side!
What would we teach a patient after a chest tube is removed?
Deep breathing and incentive spirometer every hour
Which sign would the nurse expect to find in a client admitted with atelectasis?
Diminished breath sounds on auscultation
Which intervention is the priority when the client returns to the nursing unit following a right pneumonectomy.
Encourage deep breathing Helps keep the airway patent and prevents atelectasis of the remaing lung
After a bronchoscopy, which intervention is the most important
Ensure NPO until gag reflex returns
Which medication would be used to liquefy mucus for a client with a harsh, dry, cough due to bronchitis
Expectorant agent
Which medication would be used to liquefy mucus for a clien with a harsh dry cough due to bronchitis?
Expectorant agent Liquifies the mucus and helps them cough
What symptom would we report to the doctor when we have a patient has a cold or flu?
Fever
A patient that has inflamed pleura would have which type of sound?
Frictional rub
How do you position a patient with a pneumothorax?
High Fowler's position
Which race is most likely to develop pneumonia without vaccination?
Hispanic people
if a patient is having bronchitis, what is one thing we need to ensure they are doing?
Hydrate, with at least 2,000 mL of water daily.
You have a cold, but your doctor will not give you an antibiotic, because
It's a virus and cannot be cured that way
Which intervention would the nurse use to prevent aspiration in a client who underwent a partial laryngectomy?
Keep suction machine close during meals
Which is the priority in the immediate postoperative period for a laryngectomy?
Keep the trachea free of secretions
How should a patient with a tracheostomy be positioned?
Lateral/Fowlers because it helps the drainage of secretions HOB elevated
What substance will the home health nurse instruct a client to use after a laryngectomy to cleanse the stoma site?
Mild soap and water
Which substance will the home health nurse instruct a client to use after laryngectomy to cleanse the stoma site?
Mild soap and water
What findings would the nurse expect when caring for a client with cor pulmonale?
Neck vein distension Lower extremity edema Right upper quandrant abdominal tenderness Elevated BNP levels
Which type of pressure will be reestablished when the chest tube and closed chest drainage system are effective?
Negative pressure in pleural space
Tuberulosis Symptoms include
Night sweats and Blood tinged sputum
Which clinical manifestations would be expected of a client with tuberculosis (TB)?
Night sweats and blood-tinged sputum
if a patient came in and they got pnemonia after?
Nosocomial pneumonia
Which health care providers prescription would the nurse question while caring for a client suffering from COPD
O2 per nasal cannula at 7 L/min
What position would we place a patient with emphysema
Orthepenic
If a patients chest tube is dislodged what would we do?
Place petroleum, cleanest available
What electrolyte would a patient when they take a diuretic
Potassium
Which mechanism represents why the client with COPD uses pursed-lip breathing?
Prolonged exhalation to decrease air trapping
Who would we notify when there is an "outbreak" of TB?
Public Health Department
What can sleep apnea cause?
Pulmonary edema
Which finding would the nurse expect when assessing a client with pleural effusion?
Reduced or absent breath sounds at the base of the lung
Who would the nurse consult with to meet the clients needs based on information below that was obtained from a client with COPD? -Dyspneic on exertion -Diminished Appetite -Uses oxygen all the time
Registered dietician
which complication is the nurse trying to prevent by encouraging a client to turn side to side and complete deep-breathing exercises after abdominal surgery?
Respiratory Acidosis
A patient with asthma is having ?
Respiratory Alkalosis
rheumatic fever (rheumatic heart disease)
Rheumatic fever - an acute inflammatory disease of the heart potentially involving all layers (endocardium, myocardium, and pericardium) Rheumatic heart disease - a chronic condition resulting from RF that is characterized by scarring and deformity of heart valves.
What sounds are heard when auscultating a COPD patient?
Rumbling and coarse Rhonchi
Which action would the nurse teach the client to do when teaching about nebulizer use?
Seal the lips tight around the mouthpiece and breathe in and out, taking slow, deep breaths.
A patient had thoracic surgery one week ago and are having pain while coughing, what would we educate the patient to do?
Split pillow!
Administering a shot (TB, Pneumonia), if they have a low immune system and have a possibility for infection
Stay with the patient, monitor to see if they have a reaction to the medication
which action would the nurse complete when caring for a client with tracheostomy?
Sterile gloves
What would the nurse include in a plan of care for a client who just had a total laryngectomy?
Suctioning
A patient with asthma sometimes get prescribed a serious of meds what must the nurse educate the patient to do ?
Take the combination of Beta Blockers and steroids
Which action performed by the client indicates a need for correction in a client with asthma who was just taught about self-management of long-acting medication?
Taking the medication when an asthma attack is triggered
If two adjacent ribs are broken into two or more parts, what would we see?
That the chest will not move equally, it will be a paradoxal movement
Which action will the nurse take first when the low flow alarm is persistently sounding on a client who is sedated and mechanically ventilated?
Ventilate manually and call for assistance
How would the nurse document a client who was intubated 3 days ago and has developed pneumonia
Ventilator-associated pneumonia
Where would we place a pulse ox
Warmest finger No nail polish and no acrylic If unable then ear
Why would we only give 1-2 liters of oxygen in a patient with COPD?
We still want the respiratory center to work
The patient has advanced emphysema and complains of dyspnea and fatigue. What would the most appropriate nursing intervention be for the patient problem of activity intolerance related to an imbalance between the oxygen supply and demand?
optimum rest
A bed bound patient can develop what?
pneumonia
What would someone be at risk for if they are immobilized?
pneumonia
Which action will the nurse take when noticing a client with chest trauma begins to experience dyspnea, tachycardia, restlessness, anxiety, decreased movement of chest wall and absent breath sounds on the affected side?
prepare for insertion of a chest tube
What breathing technique would you teach a COPD patient ?
pursed lip breathing
pneumonectomy is what?
removal of a lung
Which explanation is appropriate when a client with a spontaneous pneumothorax asks, why did they put this tube into my chest?
remove air from pleural space remove negative pressure
If a patient asks why they need to have a chest tube?
remove air from the pleural space
Which condition is the nurse attempting to prevent when encouraging a surgical client to turn from side to side and complete deep-breathing exercises?
respiratory acidosis and pneumonia (they have shallow breathing) Incentive spirometer Ambulate
What would we emphasize with a patient taking antibiotics?
take them until completion because our body becomes
What is an intervention to prevent the spread of TB?
use of an N-95 mask or HEPA
