Respiratory
Medication for pulmonary edema
1. diuretics- to immediately remove excess fluid from the lungs 2. Nitroglycerin- reduce the preload of the heart 3. Ace inhibitor- decrease afterload and improve CO *Dr. will order fluid restriction
Pulmonary edema presentation
1. dyspnea and tachypnea 2. tachycardia 3. diaphoresis 4. lung crackles 5. cough up pink foamy sputum (due to RBCs leaking)
Doffing PPE
1. Gloves 2. Goggles/face shield 3. Gown 4. Mask
What kind of infection is TB?
Bacterial infection
For pt with pulmonary edema, _ is needed.
Supplemental o2.
Atelectasis symptoms
breathing difficulty, pleurisy (chest pain with inspiration), cough, fever
who cannot receive influenza vaccine nasal spray?
immunocompromised patients- uses live virus
Nursing assesment for pulmonary edema
1 VS 2. continuous pulse oximetry 3. listen to lungs
The client has suffered from a chest injury. What are some nursing interventions approrpriate to this situation?
1. Provide humidified O2: this client is at risk for impaired oxygenation and the nurse will plan to support with supplemental oxygen as needed, 2. Monitor for shock: a client with a chest injury is at high risk for hypovolemic shock and must be monitored. 3. Monitor ABGs: due to the risk for impaired oxygenation and gas exchange, ABGs will need to be monitored in order to recognize potential decompensation.
Proper use of inhaler
1. Shake 10-15 times 2. Lagrge breath, exhale 3. Spacer in mouth, seal with lips 4. Tilt head back slightly 5. Depress inhaler, breathe in slowly and deeply 6. Hold 5-10 seconds 7. Breathe outs slowly
How O2 is given to the pt with pulmonary edema?
1. Start with NC or mask 2. If no improvement, use BiPAP 3. If pt stopped breathing, intubation
Therapeutic managemet of ARDS
1. Treat underline cause 2. Ventilatory support- prone position, increase PEEP 3. Prevent complications- VAP (follow tha VAP bundle)
COPD assessment
1. accessory muscle use 2. adventitious lung sounds 3. barrel chest 4. congestion on x ray 5. ABG increased PCO2 and decreased pH
Therapeutic management
1. bronchodilater, corticosteroid 2. monitor SpO2 and ABG 3. CPT 4. increase fluid intake to 3L (to thin out the secretion) 5. Pt education (pursed lip breathing, small frequent meal
The provider writes an order for aclient to have a chest tube removed. Which of the following are appropriate reasons to discontinue a chest tube?
1. Absence of bubbling in the chamber during expiration- when bubbling in the chamber ceases during expiration, the client's lung is re-expanded. 2. Improved respiratory status- chest tubes may be removed when the client has an improvement in resiratory status, as this indicates that the reason for placing the chest tube has improved. 3. Bilateral breath sounds- when breath sounds can be heard on both sides, the client's lung has expanded on the affected side. 4. symmetrical rise and fall of the chest- when the chest rises and falls symmetrically, this indicates that the hemothorax or pneumothorax has resolved/ *A client may have a pulse ox reading above 90%, but his does not mean that the cleint's hemothorax/pneumothorax has resolved.
A nurse is caring for a client with pulmonary edema. Which of the following factors can predispose a client to developing this condition? Select all that apply.
1. Acute respiratory distress syndrome When a lung injury occurs that causes a physiological response like acute respiratory distress syndrome (ARDS), pulmonary edema can occur. 2. Heart failure Pulmonary edema occurs as a build up of fluid in the lungs, which causes shortness of breath. The condition is more likely to develop in situations where a client has excess fluid in the body. Heart failure is an example of a condition that can lead to pulmonary edema. 3. Inhalation of toxic gases Inhaling toxic gases causes pulmonary injury which can result in severe pulmonary edema.
Therapeutic management of TB
1. Airborne isolation- negative pressure room, wear particulate respirator (N-95) 2. Place and read TB skin test 48-72 hours 3. RIPE therapyx 6-12 months: Rifampin, Isoniazide, Pyrazinamide, Ethambutol 4. support respiratory system
Nasal Cannula 1L/min -%?
24% From 24%, every 1L/min is +4%
Venturi mask FiO2
24-80%
The limit of O2 intake for COPD patient
2L/min They are in 50-50 club- PaO2 50 (60-100), PaCO2 50(35-45). This is what they are accustomed to. For a normal person, breathe drive is high CO2, but for COPD patient, it is no longer the drive. Now their drive is low O2 level. If you increase O2 level, it seems to fix the problem, but it reduces the breathe drive (RR will decrease), CO2 will rise leading to CO2 toxicity.
Treatment for atelectasis
Re-inflate alveoli 1. CPT- vibrate pt's chest to mobilize and remove secretions (wear vest, cupping) 2. IPPB- intermittent positive pressure breathing 3. IS- incentive spirometer 4. position change- mobilize secretions- turn, cough, deep breath
The nurse is caring for a client with pneumonia. Upon assessment, the nurse notes crackles in the lungs. The client appears breathless and asks if his oxygen is turned on. The nurse checks the nasal cannula and flowmeter, confirming a rate of 5LPM per nasal cannula (FiO2 40%). Vital signs reflect the following: O2 81% on 5 LPM NC, BP 145/84, Pulse 110, RR 28. ABG values are as follows: pH 7.47, PaCO2 29, PaO2 49. What is this client's P/F ratio?
49/0.4 The P/F ratio is an indicator of ARDS severity. This value corresponds to the PaO2/FiO2. This client's P/F ratio is 49/0.4, which is 122. This meets moderate ARDS criteria (P/F <200).
Simple mask- starts from how many L/min?
5L/min- 40% + 5-7% per 1L/min
What's the limit of the NC?
6L/min
O2 sat level for COPD
88-92%
A client has fluid in the pleural space and the nurse is preparing for a chest tube insertion. The nurse knows that the insertion site will be located at which of the following locations?
8th or 9th intercostal space When a client has a chest tube placed to remove fluid, the insertion site is around the 8th or 9th intercostal space.
BiPAP
Bi-level positive airway pressure two levels 1. inspiratory positive airway pressure (IPAP) 2. Positive end expiratory pressure (PEEP) benefit is to have a little more support on inspiration
A client who is newly diagnosed with asthma is learning about how to use a metered dose inhaler. Which information from the nurse is correct to use the inhaler correctly and to avoid medication errors?
Breathe out before administering the medication and then breathe in to inhale the drug A metered-dose inhaler may be used to deliver medication to a client who needs an inhaled dose of a drug. A metered-dose inhaler delivers a set amount of the medication and is designed to hold a specific number of doses per canister. It diminishes the potential for error because the amount is well controlled. The nurse can teach the client to breathe out before using the inhaler, then take a big breath in to pull the medication into the lungs
A client has had a chest tube placed for 10 hours and the nurse is assessing the color of the drainage. Which color would be most concerning to the nurse?
Bright red If the drainage is bright red, this could indicate active hemorrhage. This is an urgent situation, and the provider should be called.
A nurse is working in the emergency room and receives report on 4 clients. The nurse knows to see the client with which of the following first?
COPD; a pulse ox of 88% on 4L NC, now restless This client has increasing O2 needs. Increasing restlessness is a sign of hypoxia. This client may need to be placed on BiPAP to help open the alveoli so CO2 and O2 can exchange.
The nurse is caring for a client who is in the hospital for exacerbation of emphysema symptoms. The nurse notes shortness of breath and tachypnea. Which of the following actions is most appropriate in response to this?
Check the client's arterial blood gases A client who demonstrates shortness of breath and tachypnea as a result of a chronic disease needs further monitoring and intervention to help improve their ability to breathe. In this situation, the nurse should routinely check the client's arterial blood gases, as ordered, as these test results can identify whether there is enough oxygen in the bloodstream or if carbon dioxide levels are building.
A nurse must position the client prone after a diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply.
Decreased atelectasis The prone position reduces pressure on the lungs. When there is less pressure exerted on the lungs, atelectasis decreases. Mobilization of secretions Studies have shown that many clients in the prone position have increased lung secretions, which improves oxygenation. Decreased pleural pressure Prone positioning, or placing the client face down with the head turned to the side, helps with pulmonary function in the client diagnosed with ARDS. When the client is placed in prone position, the heart and diaphragm are not pressing against the lungs, which means that pleural pressure is reduced.
A 38-year-old client has been diagnosed with amyotrophic lateral sclerosis (ALS) and has subsequently developed breathing difficulties including shortness of breath and an inability to cough. Which best describes a nutritional challenge associated with this diagnosis?
Dysphagia Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that causes a decline in respiratory function, including shortness of breath and an inability to cough. The client is also at a nutritional risk because of muscle wasting and dysphagia. Other factors that may contribute to nutritional issues in the ALS client include constipation, increased metabolic rate, and difficulties performing activities of daily living.
The nurse is caring for a client diagnosed with influenza. Which of the following personal protective equipment does the nurse need to wear when entering this client's room?
Facemask Influenza requires droplet precautions which include standard precautions, plus a facemask when entering a client's room or when coming within three feet of the client. If the nurse anticipates coming into contact with body fluids that splash, the nurse will follow standard precautions as well, which would include a gown and gloves. However, these are not necessary if the nurse is simply entering the client's room.
The nurse is caring for a patient that is suspected to have a flail chest injury. The nurse know that is is best to position the client in which of the positions?
Flail side downward to stabilize flail segment and improve ventilation. This position will stabilize the chest and improve ventilation in the nin-injured hemothorax.
Absent breath sounds on auscultation
Fluid or air around the lungs, mass, means no air moving- notify
A nurse is caring for a client who has tuberculosis. The client is just completing a 9-month regimen of medication as part of treatment for the condition in which she responded well. Which of the following choices describes how follow-up is handled for the client who was treated successfully?
Follow-up is needed only if the client experiences symptoms of TB The standard form of treatment for tuberculosis is a 6 to 12 month regimen of medication, which is usually effective for most clients. After completing a therapeutic regimen, the client does not necessarily need routine follow-up unless he develops further symptoms of TB.
The nurse is caring for a client with acute pulmonary edema. Which of the following orders does the nurse anticipate?
Furosemide Furosemide is a diuretic that is given to rid the body of excess fluid. This is an important medication to help improve client lung function because it helps fluid to leave the lungs and allows the client to breathe more effectively
Area to auscultate
Important to auscultate the basis of the lungs where the water collects, if the pt is bed-ridden, listen to the dependent, posterior area.
A client arrives in the ED with rib fractures. Which rib fractures will be most concerning?
Right side, ribs 1&2: this location has a highest concern. The significance is the association with cervical spine trauma, multiple rib fractures or life-threatening vascular injuries. It is associated with injuries of the brachia prexus and jamor vessels.
Airborne precautions
TB, varicella, SARS Gown, gloves, particulate respirator, negative pressure room
Which situation best describes terminal weaning of a ventilator-assisted client?
The removal of assisted ventilation for a client that ultimately results in death Terminal weaning is a situation in which a client requests to have the support of a mechanical ventilator removed. In this way, the client will not live much longer without the ventilator support, but when a client is educated on all factors, it is their choice. Terminal weaning often occurs as an end-of-life process in which a client understands that he or she is going to die and accepts the process of withdrawing the help of the ventilator.
The nurse is administering a pneumococcal conjugate vaccine to a client. Which of the following is true regarding this type of vaccine?
This vaccine is given to prevent pneumonia The pneumococcal conjugate vaccine is used to prevent invasive pneumococcal disease in infants and children and is given several times in childhood. The vaccine is most commonly given to infants and children This is true of the pneumococcal conjugate vaccine. Side effects include erythema, swelling and pain at the injection site These are side effects that may be experienced when the vaccine is administered.
What is the special caution with C. Diff?
Wash hands with soap and water
Mode of transmission for TB
airborne
Causes of ARDS
inflammatory of immune response (sepsis, burns, trauma, near drowning
ProBNP test (brain natriuretic peptide)
used to diagnose or rule out HF. Test is done when the pt has symptoms such as SOB, fatigue, excessive fluid in abdomen, swollen ankles and legs after heart attack or during treatment for heart disease. Is released in response to changes in pressure inside the heart. Levels go up when HF develops or gets worse.
Symptoms of asthma
wheezing/crackles, diminished breath sounds, restlessness, tachypnea, tripod position, low peak flow rate
Therapeutic management for asthma
1. high fowler's position 2. Administer O2 3. Medications: bronchodilaters first, cortico steroid, leukotriene modulators
What happens with ARDS
1. increased capillary permeability- fluid in alveoli 2. cytokines release- damage tissue 3. decreased lung compliance- scarring
Pulmonary Edema pathophysiology
1. increased pressure in pulmonary vessels 2. increased pressure cause fluid to shift out of vessels 3. fluid in the lungs impairs gas exchange causing hypoxemia
3 causes of asthma
1. inflammation 2. bronchoconstriction 3. mucus production
Signs of TB
1. persistent coughs 2. Night sweat 3. weight loss 4. fever, chills 5. fatigue 6. hemoptysis
TB causes two main things
1. pneumonitis- inflammation of alveoli (impair gas ex) 2. granulomas- mass that contains WBC & scar tissue. At first, its a sold mass, then WBCs and scar tissues form around the mass and infection gets eaten up and dissapear leaving the cavity.
The nurse is providing education to the parents of a 10-year-old who has been diagnosed with the flu and is experiencing high temperatures. The nurse knows to include which of the following in teaching regarding how to treat the fever?
"Do not use aspirin to treat the fever because of the risk for developing Reye Syndrome" Aspirin administration is associated with the development of Reye's syndrome, a disease that affects the brain and the liver.
You are the nurse of a child who has been diagnosed with Influenza type C and the parents ask what this means. As the nurse, you accurately explain influenza C with which of the following statements?
"Milder and less contagious" Influenza Types A and B are more contagious and usually the cause of epidemics. Type C is milder and less contagious.
Pulmonary edema starts with increased pressure in the vessels. What causes this increased pressure?
1. Altered CO- CHF( when heart fails to pump the blood) 2. causes back flow of blood 3. Increased pressure in lung vessels
Expected Dr's order
1. CXR 2. ABGs 3. ProBNP test- asess the heart due to the overstretch 4. CT scan or echo to determine the cause of the pulmonary edema.
pneumonia diagnostic
1. CXR- 2. sputum culture- to identify organisms (bacterial/viral) 3. ABG- Monitor for ARDS- check P/F ratio
During shift report, the oncoming nurse is told that an assigned client has atelectasis. The nurse knows this could be caused by which of the following? Select all that apply.
1. Collapsed lung A person with a collapsed lung will have atelectasis in the affected area. 2. Intubation during general anesthesia When a client is intubated, a machine breathes for the client. Normally a person's diaphragm contracts, which increases the space in the chest cavity and causes air to enter the lungs. When intubated, a machine forces air into the lungs, which is the opposite mechanism for lung inflation than normal, and can cause a certain measure of obstruction. Clients who are intubated nearly always have some amount of atelectasis afterward.
Donning PPE
1. Gown 2. Mask 3. Goggles/face shield 4. Gloves
Pneumonia assessment for viral
1. Less severe than bacterial 2. Low grade fever 3. Non-productive cough 4. Normal WBC or small elevation 5. CXR shows minimum changes 6. Chills, rhonchi, wheezes, decreased SpO2
Therapeutic management for pneumonia
1. Meds: antibiotic, antiviral, antipyretic, analgesics 2. supplemental O2 3. Flu vaccine 4. Fluids up to 3 L per day 5. Monitor respratory status 6. encourage activity 7. chest expansion exercises- TCDB( turn, cough, deep bresthe_, IS, CPT 8. Hand hygiene
Pneumonia assessment for viral
1. More severe than viral 2. High fever > 101 3. Productive cough 4. Elevated WBCs 5. CXR shows infiltration 6. Chills, rhonchi, wheezes, decreased SpO2
Atelectasis
1. Occur after surgery- shallow breath, drowsy, pain 2. excessive secretions
Contraindication for flu vaccine
1. People with severe allergy to eggs/latex 2. History of Guillain Barre 3. Recent transplant (<6 months) 4. current illness (fever)-their immune system is preoccupied,
Atelectasis assessment
1. diminished breaths sounds 2. chest pain with breathing 3. fever 4. CXR shows collapse 5. decreased SPO2
A 46 years old client was involved in a motorcycle accident and comes in to the ED with rib fracrures and a flail chest. The provider orders to set up for treatment utilizing pneumatic stabilization. Which actions would be included as part of this treatment?
1. endotracheal intubation: a flail chest occurs with rib fractures when three or more portions of the ribs are broken. causing floating pieces of ribs in the chest cavity. Pneumatic stabilzation involves stabilizing the internal lung tissue to support ventilation. This includes endotracheal intubation and mechanical ventilation with PEEP. 2. Mechanical ventilation: 3. Use of PEEP with ventilation: decrease chance of alveoli collapsing.
Patient education for pulmonary edema
1. follow fluid restriction 2. take medications as ordered.
2 methods to protect airway
1. head-tilt chin lift 2. Jaw thrust (for C-spine)
TB diagnostic tests
1. sputum culture- gold standard- to see the actual organisms in the culture (more expensive and takes time) 2. Acid Fast Baccili smear (AFB smear)- more common 3. CXR 4. Mantoux TB skin test-PPD is placed interdemally. Looking for induration (it's not the redness that creates positive but its actual induration) If the induration is more than 15mm, if the induration is >10mm for high risk population (including nurses), >5mm for immunocompromised population are considered positive. 5. If inconclusive, Quantinferon Gold-
A school is offering tuberculosis testing for all of its employees. The health nurse administers the injections to each of the employees using a tuberculin syringe. At which angle does the nurse administer the injections into the skin?
10 degree When a nurse administers an intradermal injection to test for tuberculosis, she should insert the needle at a 5 to 15-degree angle (or nearly flat against the skin). Inserting the needle at this angle will allow the nurse to inject the solution just under the skin to create a wheal for testing.
Non-rebreather- what % per 1L/min
10% 10L/min= almost 100% for example, 6L/min= 60%
A nurse is caring for a client with ARDS. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply.
A PaO2 level below 60 mmHg Respiratory failure occurs when the body cannot remove enough carbon dioxide, and/or cannot take in enough oxygen to be sustainable. Clinical indicators of respiratory failure include pulse oximetry of less than 90% on room air, PaO2 level less than 60 mmHg, and a pCO2 level of over 50 mmHg. A pCO2 level over 50 mmHg A pCO2 level of over 50 mmHg indicates respiratory failure.
The nurse is assessing a client with COPD at the healthcare clinic. Which of the following would most likely increase this client's risk of suicide?
A concomitant diagnosis of mental illness A chronic condition such as COPD is often associated with mental health issues, including diagnoses of depression and anxiety. A client with depression may be at increased risk of suicide, which the nurse should assess for when visiting with the client. A client who has attempted suicide in the past, a person with another mental health diagnosis, and someone with a history of substance abuse are all at higher risk of suicide.
A client is in distress with a diagnosis of acute pulmonary edema. Which of the following actions by the nurse is contraindicated?
Administer a fluid bolus as ordered A client with pulmonary edema has too much fluid building up in the pulmonary venous system. Administering a fluid bolus would worsen the pulmonary edema. If there was an order for a fluid bolus, the nurse should clarify the order with the provider.
A nurse who works in a long-term care facility has learned that one of the residents has developed active tuberculosis. What should the nurse do to protect the other residents?
Allow the client to remain in the nursing home but provide isolation precautions and treat the active disease A client with active tuberculosis has the potential to transmit the infection to others and is considered contagious. In a long-term care facility, the client should receive treatment for the disease and should be isolated from other residents until the potential for the spread of the infection is past, which is one to two weeks after treatment is started. Other residents should be tested for exposure to tuberculosis using the Mantoux skin test.
Breathe out before administering the medication and then breathe in to inhale the drug A metered-dose inhaler may be used to deliver medication to a client who needs an inhaled dose of a drug. A metered-dose inhaler delivers a set amount of the medication and is designed to hold a specific number of doses per canister. It diminishes the potential for error because the amount is well controlled. The nurse can teach the client to breathe out before using the inhaler, then take a big breath in to pull the medication into the lungs
Apply a non-rebreather In this case, applying oxygen is urgent because it is apparent that the client is struggling from the information you already have. It may be prudent to obtain an oxygen saturation for a baseline if this can be done without delay. However, there is enough information in the stem to demonstrate a clear breathing problem, so you can move on from 'assessment'. In a real life clinical setting, getting an O2 sat, auscultating lung sounds, and applying O2 will all happen by multiple nurses within 1-2 minutes. **Test-taking tip: Think of priority questions this way - if I could literally ONLY do one of these things for the client....what would happen if I DON'T ____.
A multidisciplinary team is working together to help a client who has decreased pulmonary function as a result of COPD. The team members perform a functional assessment on the client. Which action would be a component of this assessment?
Assessing for dyspnea on exertion An evaluation of a client's functional ability helps the team members determine how well a client will adhere to treatments and be able to perform exercise. The functional assessment determines if the client is able to perform various activities of daily living and exercise and how much effort these tasks require. The assessment also determines if the client becomes short of breath while trying to perform everyday activities.
While caring for a client who has a chest tube, the nurse takes measures to prevent a tension pneumothorax. Which of the following interventions would the nurse most likely employ?
Avoid clamping the chest tube A client with a chest tube is at increased risk of developing a tension pneumothorax, in which air builds up in the pleural cavity and further collapses the lung. The chest tube is in place to remove air in the intrapleural space using a water seal and gentle suctioning, but complications can arise. An air leak in the chest tube system can cause air to enter the pleural space, further worsening a pneumothorax. If the tube is clamped, any air that has accumulated cannot escape from the pleural space. The nurse can avoid causing a pneumothorax in the chest tube client by not clamping the tube.
The nurse assesses a client and notices that the lungs have coarse crackles and the client is struggling to breath, and the client's legs are edematous. The nurse should implement which of the following orders first?
Check vital signs The nurse should check the client's vital signs first to determine if the client needs oxygen or any other treatment. The vital signs will also be needed to report to the healthcare provider.
An ambulance arrives at the emergency department with a client who has audible sucking noises on both inspiration and expiration and diminished breath sounds on one side. Which of the following procedures should the nurse anticipate?
Chest tube insertion These signs and symptoms are consistent with an open pneumothorax. The client needs an occlusive dressing to stop airflow at the site of the sucking sound, and will require placement of a chest tube to reinflate the lung on the affected side.
Clumping the chest tube
Clamping the chest tube creates pressure and puts the client at risk for tension pneumothorax. This is done by very specific circumstances, and often by an advanced practice provider.
The nurse is caring for a client with a chest tube. During report handoff, the incoming nurse notes that the fluid in the tube is moving up the tube with inspiration, and down the tube with expiration. Which of the following actions is most appropriate for the nurses in this situation?
Continue with report, as this is a normal finding This finding is referred to as tidaling, and is a normal occurrence with a chest tube system with inspiration and expiration. If the nurse notes that there is no tidaling, then either the client's lung has completely re-expanded, or there's an occlusion in the tubing, such as a clot.
A client is ventilated with acute respiratory distress syndrome following infection of COVID-19. Which of the following are priority actions by the nurse? Select all that apply.
Frequent oral care Frequent oral care should be performed on the client, because this helps prevent ventilator-associated pneumonia. Elevating the HOB This is a priority action by the nurse. When the client is supine, the head of bed should be elevated >30 degrees, and ideally 45 degrees. This is part of the ventilator-associated pneumonia (VAP) bundle used in hospitals to prevent pneumonia in ventilated clients.
The nurse is assessing a client who presented to the emergency room for shortness of breath. The client states, "I just cannot breath deeply, it feels like there is someone holding my ribs tight." What is the priority for this client?
Get an EKG (ECG) Chest pressure can indicate a myocardial infarction. This client is able to speak a complete sentence, so the client has an airway and is breathing. The nurse will need to contact the provider for an EKG (ECG) right away.
Standard Precautions
Hand hygiene, gloves
The parents of a 4-year-old child with cerebral palsy have brought him in for a routine physical exam. The parents ask the nurse about vaccinations for their child and if the child should get the annual flu shot. Which response from the nurse is correct?
He should get the flu shot because he can have worse symptoms from influenza compared to another child Neurological disorders can worsen the symptoms of influenza. A client with a stable neurological disorder like controlled seizures or cerebral palsy should still be counseled to receive the flu shot.
After developing influenza, a 75-year-old client is suffering from severe diarrhea and dehydration. The nurse is providing help and guidance over the phone to the client's family. Which information should the nurse give to the family that would best help this client?
Help the client to drink fluids by taking frequent spoonfuls or small sips An older adult who is suffering from severe diarrhea and dehydration at home should take in oral fluids if able. In this case, the nurse should encourage the family to help the client take small, frequent sips of fluid in order to provide hydration and prevent further complications associated with illness. Re-hydration needs to be attempted much more frequently than every four hours.
A nurse needs to assess posterior lung sounds in a client. In which position would it be most appropriate to place this client?
High Fowler's To assess the back and listen to posterior lung sounds, the nurse should place the client in the high Fowler's position. In this position, the client is sitting up with the head of the bed at a 90-degree angle. The high Fowler's position is used for performing an assessment that would require the client to sit up, such as the face and head, chest, and back.
A nurse is working in the ED and has just received a client with an asthma exacerbation. Which of the following positions would be the most conducive to effective gas exchange for this client?
High-Fowler's High-Fowler's is the client sitting straight upright, which would best facilitate breathing and gas exchange in a client with an asthma exacerbation.
A healthcare office provides immunizations for children and adults in the community. The nurse is preparing vaccine information sheets (VIS) to give to clients about the vaccines. Another nurse says, "Those forms are optional. You do not have to give those out if you do not want to." Which response from the nurse is accurate?
I have to give them out to clients when I give them a vaccine Vaccine Information Sheets (VIS) are informational forms that consist of a single sheet of paper with the information the client needs to know about the vaccine they receive. The VIS contains information about how the drug is given and potential side effects of the drug, as well as other pertinent information. When administering a vaccine, a nurse is required to give the client a copy of the VIS.
The nurse is discharging a client with tuberculosis. The client asks if it is possible to stop taking the tuberculosis medication once she feels better. Which of the following is the most appropriate response?
If you don't finish the entire treatment course, it can lead to drug resistance and complications in the future" Noncompliance with treatment may lead to drug resistance (MDR-TB), therefore strict adherence to the regimen is important. This statement by the nurse is most accurate, and offers the most amount of information for the client.
A client with COPD has developed malnutrition and weight loss since his diagnosis 8 years ago. Which describes the most likely reason why a COPD client is at higher risk of malnutrition?
Increased energy expenditure used to maintain adequate breathing A client with advanced COPD is at risk of malnutrition and weight loss because of the high-energy expenditure he requires for breathing. A COPD client may spend a large amount of his time working to breathe, which uses up many calories. Intake is also reduced if the client has such difficulties with breathing that it is too challenging to try to eat and breathe at the same time. Consequently, many clients with COPD lose weight over time and become malnourished or cachexic.
Pneumonia
Inflammation- alveoli filled with fluid or pus Infectious (both viral and bacterial) Noninfectious (aspiration, post-op)
Droplet precautions
Influenza, pertussis, meningitis, MRSA pheumonia with coughing Gown, gloves, standard mask, face shield recommended
A nurse is teaching a client how to take a deep breath and cough during postoperative care after abdominal surgery. The nurse has helped the client to a sitting position. What step should the nurse have the client perform next?
Inhale slowly through the nose Deep breathing and coughing techniques help expand the lungs postoperatively. This is important to allow the alveoli to expand, because atelectasis occurs with general anesthesia, and can lead to pneumonia if not addressed. The nurse would instruct the client to inhale slowly at first, because coughing will ensue which is uncomfortable for the post-op client. Inhaling slowly also allows maximum time for the lungs to re-inflate, and more time allows for more alveoli to be inflated when the client moves air in slowly.
The nurse is caring for a client who is post-op day 1 following abdominal surgery. The nurse notes that the client is taking shallow breaths and is guarding the incision site. The client has a temperature of 38.5 C, pulse 80, O2 88%, respirations 20, BP 110/86, and a WBC count of 10. The nurse assesses the client's incision site and notes no redness or warmth. Which of the following interventions is most appropriate?
Instruct the client on use of the incentive spirometer When a client develops a fever between post op days 1-3, it is likely due to atelectasis progressing to pneumonia. Since the client does not have other signs of infection and is a relatively fresh post-op, this client is likely experiencing post-op atelectasis. The nurse would check to see if the client was given an incentive spirometer and if so, make sure they are using it 5-10 times per hour while awake. If no IS is present at the bedside, the nurse will need to provide one and instruct the client on how to use it.
If a pneumothorax is present and the client has a chest tube, what type of bubbling would be expected in the water chamber?
Intermittent Intermittent bubbling is noted when a pneumothorax occurs. As long as there is air in the pleural space, there will be intermittent bubbling in the chamber.
A client who had a bronchospasm was given ipratropium for treatment. The client asks the nurse how the medication works. Which of the following responses is accurate?
It reverses the action of acetylcholine, causing smooth muscle relaxation Ipratropium is an anticholinergic bronchodilator, which reverses the action of acetylcholine. This causes airway smooth muscle relaxation.
A nurse is caring for a client who is in respiratory distress because of ARDS. Which of the following conditions would most likely be present in this client?
Lack of tissue perfusion Acute respiratory distress syndrome (ARDS) is a life-threatening condition that affects the lungs and prevents the client from getting enough oxygen. This client will most likely be unable to effectively perfuse the tissues because decreased oxygen from lung disease prevents adequate oxygen from reaching the bloodstream and therefore peripheral tissues.
An asthmatic client requires a short-acting bronchodilator medication during an attack to quickly resolve wheezing and to facilitate easier breathing. Which of the following medications is considered to be a short-acting bronchodilator?
Levalbuterol (Xopenex) A short-acting bronchodilator is a medication used for temporary but rapid relief of symptoms of respiratory distress an asthma attack. These are often referred to as 'rescue inhalers' or 'reliever' medications. While this type of drug helps to facilitate easier breathing, it does not control inflammation or other factors that caused the attack in the first place. Examples of short-acting bronchodilators include levalbuterol, metaproterenol, and pirbuterol (Maxair).
The student nurse is assessing a client with acute pulmonary edema. Which of the following are expected findings?
Lung crackles Pulmonary edema occurs when there is fluid buildup in the lungs. This is caused by increased pulmonary venous pressure, usually originating in the heart. When a client's lungs fill with fluid, the nurse will hear crackles upon auscultation. Dyspnea Dyspnea, or difficulty breathing, is common for the client with pulmonary edema. Because of the fluid buildup in the lungs, gas exchange is impaired, and the client has trouble getting enough air into and out of the lungs. Tachypnea Tachypnea, or rapid breathing, is an expected finding for a client with pulmonary edema. These clients feel anxious and have extreme shortness of breath, so breathing rapidly is a way to compensate. The client may also express a feeling of drowning, and demonstrate profuse diaphoresis (sweating).
A student nurse is discussing ARDS with the preceptor and correctly describes the progression of ARDS as which of the following?
Lung trauma releases cytokines which damage lung tissue ARDS occurs when lung trauma leads to the release of cytokines into the lung tissue. This damages the lung tissue. The inflammatory response also leads to increased capillary permeability which allows fluid to enter the alveoli. Lung tissue becomes scarred, and a hyaline membrane forms, decreasing lung compliance which severely impairs gas exchange. This is a respiratory emergency, and can lead to irreversible lung damage and/or respiratory failure.
contact precautions
MRSA, VRE, C. Difficile Gown, gloves
The nurse providing care to a child with influenza knows to give top priority to which of the following interventions?
Monitoring for signs of secondary infection The most common complication of influenza is a secondary infection, like pneumonia. The priority intervention would be to monitor for signs of secondary infection.
Diagnosis of ARDS
No specific biomarker or lab test Look at clinical signs, then CXR and ABG for confirmation 1. Evidence of underlying condition 2. Increasing O2 needs (even with increase in FiO2, O2 sat won't improve) 3.Diffuse bilateral infiltrates on CXR (white out) 4. Refractory (not responding) hypoxemia- look at p/f ratio
A nurse is assessing a client with a chest tube. The nurse notes that the client once had a moderate amount of light yellow drainage coming out of the tube and the drainage is now red. Which action should the nurse perform in response?
Notify the healthcare provider If the chest tube drainage is greater than 70 to 100 mL/hr, increases suddenly or becomes bright red, the nurse must notify the provider. Chest tube drainage color may vary, but any sudden change in the appearance or consistency of the drainage could indicate hemorrhage which should be immediately reported to the provider.
A client with acute bronchospasm and a history of diabetes mellitus, coronary artery disease, and chronic obstructive pulmonary disease is admitted to the unit and started on IV theophylline. The client begins to complain of a fluttering feeling in the chest. The nurse checks the client's vital signs and notes a pulse of 135, blood pressure 130/88, respiratory rate 22, oxygen sat 90%. Which action by the nurse is most appropriate?
Notify the provider and request an EKG Theophylline is a xanthine derivative, which should be used with caution in clients with cardiac issues, including coronary artery disease. The palpitations may just be tachycardia, but with this client's history, the most appropriate action is for the nurse to notify the provider and get an EKG. The drug should not be discontinued because this could cause the client to regress to bronchospasm, which compromises the airway.
Chronic dyspnea occurs when a client has difficulty breathing over a period of weeks or months. Which of the following is an example of a cause of chronic dyspnea?
Obesity Dyspnea, also known as breathlessness, is a state in which a person is unable to get enough air. Dyspnea may be acute, such as after an injury affecting the lungs or a panic attack, or it may be chronic in nature. Causes of chronic dyspnea include such conditions as heart disease, arrhythmias, asthma, COPD, bronchiectasis, and obesity.
A nurse in the ICU is caring for a client that has been ventilated for 2 weeks due to Acute Respiratory Distress Syndrome (ARDS). The client's FiO2 has been at 60% for the last 48 hours. What is the nurse's immediate priority concern at this time?
Oxygen toxicity Clients with ARDS require high levels of oxygen. Levels above 50% FiO2 for prolonged periods of time can cause oxygen toxicity. This is why the SpO2 goal for these clients tends to be approximately 92-94%. If a client has an SpO2 of 100%, the FiO2 needs to be decreased!
The nurse receives report on a client who presented to the emergency department the day before following a near-drowning incident. Upon presentation to the ED, the emergency responders stated that the client's oxygen needs increased from 6 LPM to 8 LPM on a simple face mask while en-route. The client is now at 12 LPM. Based on this information, which of the following findings will most likely lead the nurse to suspect ARDS?
P/F ratio 120 A P/F ratio of 120 indicates moderate refractory hypoxemia, which means the client is not able to exchange adequate oxygen despite an increased FiO2. This is a classic sign of ARDS. The P/F ratio is found by dividing the PaO2 by the FiO2. The lower the number, the more severe the ARDS.
P/F ratio
PaO2/FiO2 ratio- if <300- mild ARDS, <200- moderate, <100- severe In normal person, it is expected to be higher than 300.
Atelectasis followup
Pneumonia can develop in the area of atelectasis. Worsening SOB, cough, fever, chills, seek medical attn.
A nurse is providing instructions to a client who is undergoing a thoracentesis to assess for malignant tissue. Which of the following interventions are appropriate related to this procedure?
Position the client upright with trunk slightly forward A thoracentesis involves the removal of fluid, air or tissue from the pleural space. It involves aspiration using a needle. The nurse should position the client sitting upright and slightly forward with arms resting on a bedside table. The client should be provided pain medication as needed, and encouraged not to cough, deep breathe, or move during the procedure. After the procedure, the puncture site must be dressed with a pressure dressing and monitored for bleeding and crepitus. Ensure client does not cough or deep breathe during the procedure The client should be encouraged not to cough, deep breathe or move during the procedure. Assess the site for crepitus post-procedure After the procedure, the puncture site must be dressed with a pressure dressing and monitored for bleeding and crepitus. The client should be instructed to breathe normally while the puncture site heals for one hour to avoid any stress on the area. The puncture side will heal rapidly and the client should be able to resume normal activity in one hour.
A 47-year-old client has been brought to the emergency department after falling from a roof. He has absent breath sounds on his right side, crepitus, and sharp chest pain with tracheal deviation to the left. Which of the following nursing interventions is appropriate?
Prepare client for chest tube placement This client has the assessment findings of a pneumothorax. This occurs when the client's intrapleural space is compromised, either from a blunt chest injury or an opening in the chest wall. Intrathoracic pressure rises, and the affected lung collapses. For this condition, the nurse will administer oxygen, place the client in Fowler's position, and prepare for chest tube placement.
influenza management
Since its viral, need to let it run the course,. 1. Antiviral medication (take within 48 hrs oseltamivir/tamiflu) 2. bed rest 3. fluid/nutrition 4. oxygenation
The nurse caring for a client with pulmonary edema notes a fluid restriction. Which of the following is a potential reason for this?
Pulmonary edema is a condition of too much pulmonary system pressure, so the client needs to limit fluid intake A fluid restriction is necessary with pulmonary edema because the client is fluid overloaded. Limiting PO intake and IV fluids, along with administering diuretics and ensuring the client is adequately oxygenated are the main treatments for this condition.
A client with chest trauma has ABGs drawn. The nurse anticipates which scenario upon ABG analysis?
Respiratory acidosis Chest trauma usually correlates with breathing difficulties. The nurse would anticipate respiratory acidosis upon analysis of the client's ABG results.
While caring for a client who is recovering from surgery, the nurse finds out that the client is infected with active tuberculosis. Prior to this discovery, the nurse had only been using standard precautions. Which action of the nurse is most appropriate for providing proper precautions in this situation?
Start using precautions right away by placing the client in a negative pressure room and using a respirator mask Isolation precautions are used for different types of infectious conditions to prevent the transmission of illness. A client with active TB requires airborne precautions, which include isolation in a negative-pressure room and the use of a specialized filter mask when providing care. Airborne precautions should be implemented right away, even if this nurse was unaware of the condition before.
A 60-year-old client is going through pulmonary rehabilitation for COPD. The nurse understands that an expected outcome of pulmonary rehabilitation is which of the following?
The client has an easier time performing activities of daily living Pulmonary rehabilitation is designed to help a client with lung disease to improve their ability to perform activities of daily living and overall quality of life. The program may provide education about oxygen therapy and medications, offer tips for the client to exercise more, and often provides social support.
A 25-year-old client in the ICU is being treated for acute respiratory distress syndrome (ARDS). The client is on a ventilator and requires 80 percent FiO2. Which information would the nurse most likely need to report about the client to the respiratory therapist assigned to this case?
The client needs an arterial blood gas drawn Respiratory therapists have multiple duties in the healthcare facility and they frequently monitor and work out many technical details of the client's care when a ventilator is being used. A respiratory therapist would most likely change the ventilator settings but the nurse is able to increase the oxygen level on the ventilator and the nurse can suction the client. It is common for the respiratory therapist to draw arterial blood gas levels.
A 68-year-old client with COPD is being seen for pulmonary rehabilitation. The nurse is instructing the client on exercise guidelines for managing the disease. Which information must the nurse include as part of exercise guidelines for this client?
The client should be monitored during exercise to address safety Part of pulmonary rehabilitation is to educate the client about guidelines for activity levels. While it is important for a client with COPD to get enough exercise, the nurse also needs to address the client's safety to prevent harm from exercise that is too intense. When starting pulmonary rehab, the client will most likely need to be monitored while exercising.
A 68-year-old client has been diagnosed with chronic monocytic leukemia. The nurse is teaching the client about the best methods of staying healthy. Which information should the nurse provide about influenza vaccination related to leukemia?
The client should receive a seasonal flu shot A client with cancer is in an immunocompromised state, and if exposed to influenza, the client has less of a chance of fighting off the infection. The client should be counseled to receive the flu shot, which contains an inactivated virus, versus other methods of vaccination. The flu shot will give the client more immunity against infection.
A nurse has just received report on 4 patients who all have chest tubes in place. Which client is the priority to see first?
The client with continuous bubbling in the drainage chamber- continuous bubbling in the chamber reflects an air leak, meaning there could be a hole in the tubing or it could be dislodged. This client is the proirity to be seen first. A client with pneumothrax will have bubbling in the chamber during breathing, which is a normal, expected finding. But it will flucuate with breathing, not be continuous.
A nurse is caring for a client who has a chest tube because of a pneumothorax. The nurse can tell the certified nursing assistant to check which of the following?
The client's respiratory rate When caring for a client who has a chest tube, the nurse cannot delegate its care to unlicensed assistive personnel due to the assessment required for management. The only measure the certified nursing assistant can perform in this case is to check the client's respiratory rate, as this is part of obtaining vital signs.
A nurse is working with a client who requires a mechanical ventilator for breathing support. The client uses SIMV ventilation at a rate of 16, PEEP 6, PSV 10. In this example, the PEEP is described as which of the following?
The increase in end-expiration volumes to prevent atelectasis When using assistive devices that administer oxygen, PEEP refers to positive end expiratory pressure, which is the volume of air in the lungs after exhalation. PEEP settings prevent the alveoli from collapsing and causing atelectasis, which can worsen respiratory symptoms. The PEEP setting on most adult ventilators may range from approximately 5 to 20 cm H2O.
A nurse must use a N95 respirator for protection against tuberculosis with a client. Which of the following considerations should be used while the nurse is utilizing this mask?
The mask must be fitted specifically for the nurse An N95 respirator is a special type of mask worn by the nurse to filter out airborne particles of microorganisms. The respirator is designed to protect the wearer against pathogens of a specific size, such as tuberculosis. It must be fitted specifically for the nurse to ensure there is a tight seal against the face. The N95 respirator is not the same as a surgical mask and the two are not interchangeable.
A nurse is caring for a client who has a chest tube after a motor vehicle accident. The provider has ordered low suction for the chest tube. Which interventions would the nurse utilize when managing suction on this chest tube?
The wall suction should be set at > 80 mmHg When a wet suction control unit is used, the level of water determines the amount of suction inside the chest cavity. The wall suction should be set at >80 mmHg for a suction level of -20 mmHg. The nurse should note tidaling when the client breathes Tidaling in the water-seal chamber means that the client is breathing, and is normal. However, intermittent or continuous bubbling in the water-seal chamber means there is an air leak. The leak should be located and fixed immediately, and the provider needs to be notified if the nurse is unable to find the leak. The nurse should notify the provider if there is a sudden increase in drainage If there is a large increase in the amount of output from the chest tube, the provider must also be notified right away, because this could indicate hemorrhage.
A client with asthma has started a new prescription for albuterol (Proventil HFA). What side effects are associated with use of this drug?
Tremor in the extremities Albuterol is a drug used to open the airways and facilitate easier breathing. It may also have negative side effects that causes tremor in thRestlessness Shakiness, and restlessness are also the side effects of Albuterol.e extremities. Pounding heart rate It may also have negative side effect that causes a pounding heart rate.
A nurse is caring for a client with influenza who requires droplet precautions. Which of the following activities is part of maintaining droplet precautions?
Wear a mask when going into the room Droplet precautions are needed when a client is infected with a condition that can be spread by droplets, such as influenza, pertussis and mumps. The nurse should wear a mask when entering the room because germs that are spread by droplets can travel up to three feet if the client coughs or sneezes.
If noncompliant for TB treatment
causes drug resistance (MDRTB) Later develop latent TB
CPAP
continuous positive airway pressure positive pressure, one level throughout breaths
Rhonchi, Wheezing, Stridor
crackles- water in alveoli, rhonchi- fluid/secretion in airway passage, gurgling sound, wheezing- narrowing of the smaller airway, whistling sounds (need to identify if inspiratory wheeze or expiratory wheeze), stridor- narrowing of the larger airway (usually heard on inspiration), musical sound
Reverse isolation (neutropenic isolation)
neutropenia, post-transplant, burns Hair bonnet/mask, gown/gloves, No fresh flowers or home-cooked meal, hand hygiene
A nurse is caring for a 55-year-old client who needs a thoracentesis after a cancer diagnosis. The nurse stays with the client during the procedure. Which of the following interventions will the nurse employ to assist with this procedure?
nstruct the client not to talk during the procedure Thoracentesis involves placing a needle into the wall of the chest to drain fluid or air, instill medication, or to take a sample of tissue. During a thoracentesis, the nurse should stay with the client, as the client will be awake and may become anxious. The nurse should help the client to lie still while the needle is in place and instruct him not to talk, cough, or breathe deeply during the procedure.
An 88-year-old client presents to the emergency department who is diaphoretic, tachypneic, and dyspneic. The nurse immediately obtains vital signs and administers oxygen via facemask at 6 liters per minute based on an O2 sat of 78%. The provider suspects pulmonary edema and orders a chest X-ray, ABGs, and a BNP. What is the purpose of the BNP?
o determine if the client has heart failure BNP, or B-type natriuretic peptide, is a protein released into the bloodstream when the ventricles are stretched in clients with congestive heart failure. This helps the provider determine the source of the client's pulmonary edema, as this condition is usually caused by congestive heart failure.
The nurse is caring for a client with a chest tube. While assessing the tubing, the nurse notes a clot in the tubing. What action is appropriate on order to reduce the clots from the tubing?
squeeze by sections moving from the cient to the chest tube chamber. Squeeing with one hand then releasing before squeezing further down is the best EB way to clear the chest tube of a clot. Chest tube should never be milked because this causes negative pressure and can cause the patency of the tube to become compromised.
Influenza symptoms
sudden onset, aches everywhere( HA, muscle, joints), upper respiratory symptoms (runny/stuffy nose, sore throat, coughing), high fever(102-104)
Atelectasis treatment
the goal is to re-inflate the lungs If fluid (pleural effusion) or air leak (pneumothorax), then needs to be drained, percussion of the chest (CPT and cupping) Incentive spirometry Bronchoscopy: manually remove the blockage Postural drainage: removing the mucus by changing the position PEP
4 normal sounds at
tracheal, bronchial, Broncho vesicular, vesicular
