Oxygenation/Gas Exchange
Which description of symptoms would the nurse expect to obtain from a client with exacerbation of sarcoidosis?
Shortness of breath, non-productive cough, and chest pain - Sarcoidosis = systemic disorder affecting lungs and lymphatic systems - granulomas form in absence of infection or environmental agents - manifestations = SOB, non-productive cough, chest pain, fever, sweating, anorexia, weight loss, fatigue, myalgia , skin papules, plaques, uveitis
What is the most common debilitating disease of childhood among those of European descent?
Cystic fibrosis
A nurse is teaching clients about the benefits of smoking cessation. What should the nurse include as the most accurate reason for the development of a chronic "smoker's cough"?
Damage to cilia in the respiratory tract make it necessary to cough to clear the airway. - cilia function in mucociliary escalator, helping move materials (bacteria, dust) from airways into mouth to be swallowed. - Damage = cough = remove substance from airway
A nurse is assessing a 2-week-old infant with pulmonary edema. Which symptom indicates the infant is experiencing respiratory distress?
Grunting during expiration - Children w/ restrictive lung disorders (pulmonary edema, RDS) = breathe faster and shallow breaths - Child tries to raise end-expiratory pressure = prolong O2/CO2 exchange across alveolar-capillary membrane
Which is an infection-related cause of delirium?
Pneumonia - infection-related causes of delirium = pneumonia, spesis, UTI, meningitis - Lithium toxicity = drug-related - Renal failure, sleep deprivation = physiologic causes
An adolescent diagnosed with thalassemia major (Cooley's anemia) is at risk for which condition?
chronic hypoxia and iron overload - Thalassemia major = increase destruction of RBC, shorten lifespan of RBCs = anemia -> increase RBC production, no mature cells = chronic hypoxia - RBC destruction + transfusions = overload
A 7-year-old child is hospitalized with cystic fibrosis. To help the child manage secretions and avoid respiratory distress, the nurse should:
perform chest physiotherapy every 4 hours. - aids in loosening secretions in entire respiratory tract.
Which is an age-related change associated with the nervous system?
postural hypotension - postural hypotension, cerebral atrophy, decreased cerebral function, and decreased nerve impulse conduction * Hinkle, Ch. 11, pp 201
The nurse is reinforcing teaching with a group of caregivers of children diagnosed with asthma. Which statement best indicates an understanding of the management and treatment for this diagnosis?
"We have taken the carpet out of our house and let my mom take our dog." - removal of allergens and prevention is important aspect of Tx
A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem?
apnea - cold stress leads to hypoglycemia, increased respiratory distress, apnea, metabolic acidosis
Tetralogy of Fallot is a congenital condition of the heart that manifests in four distinct anomalies of the infant heart. It is considered a cyanotic heart defect because of the right-to-left shunting of the blood through the ventricular septal defect. A hallmark of this condition is the "tet spells" that occur in these children. What is a tet spell?
A hypercyanotic attack brought on by periods of stress - Ch. 27, Page 712
The nurse is caring for a child who has recently been intubated. The nurse notes that the tracheal tube has an end-tidal CO2 monitoring device that is purple in color. What is the first intervention by the nurse?
Auscultate the chest to determine breath sounds. - specific colors mean tracheal tube placemen - purple = little/no CO2 detected --> first step is to auscultate
Premature infants who are treated with mechanical ventilation, mostly for respiratory distress syndrome, are at risk for developing bronchopulmonary dysplasia (BPD), a chronic lung disease. What are the signs and symptoms of BPD?
rapid and shallow breathing and chest retractions - demonstrates barrel chest, tachycardia, rapid and shallow breathing, chest retractions, cough and poor weight gain. *Chapter 30: respiratory tract infections = pp 801
A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first?
Administer O2 - demonstrating clinical manifestations of fatty embolus
Which condition may cause intrauterine asphyxia? Select all that apply.
Cord Compression Placental Abruption Intrauterine growth restriction (IUGR) - alter uteroplacental blood flow and may cause intrauterine asphyxia * Ch. 23: Nursing Care of Newborn - pp 848
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?
Corticosteroids - Corticosteroids, bronchodilators = open airways, ease breathing - Corticosteroids = decrease inflammation
The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize?
Document normal findings. - VS WNL - HR: 110-160 BPM - RR: 30-60 breaths/min - Temp: 36.5-37.5 - BP: 60-80/40-45
Which is true regarding the pulmonary circulation?
It is a low pressure system that allows improved gas exchange - Consists of right heart, pulmonary artery, capillaries, veins - Smaller of systems at functions at a lower pressure to help with gas exchange
The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response?
There is more fluid present in the lungs at birth after c-section delivery vs. vaginal delivery. - labor stimulates surfactant production --> fetal lung fluid squeezed out as fets moves out of birth canal - organically clearing airway, stimulate lung expansion
