Week 6: Gas Exchange, CF

Admit the patient to the ICU

A 70 year old patient presents to the emergency Department with a cough producing yellow sputum, fever, chills, and shortness of breath. An examination the nurse finds that the patient is confused, has a respiratory rate of 42/minute, in a blood pressure of 80/50. The nurse expects that what will be indicated in the patient's treatment plan.

The disease process and breathing exercises

A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and would begin with which aspect of care?

Staohylococcus aureus

A four-year-old child with cystic fibrosis (CF) experiences a cough associated with viscous, purulent, and greenish sputum. The nurse expects that which organism will be found in the patients sputum?

Explain that antibiotic are not required for the patient

A nurse is caring for a pediatric patient who has experienced a cough, clear and watery sputum, headache, and muscle aches for the past two weeks. The nurse auscultates wheezes during expiration. There is no other abnormality found. The patient's parent asks why an antibiotic has not been prescribed. How should the nurse respond?

High resolution computer tomography

A patient experiences pleuritic chest pain, dyspnea, wheezing, clubbing of digits, weight loss, and blood streaked sputum. The nurse anticipates that which test will be prescribed?

A significant indication that the patient has been exposed to tuberculosis

A patient had an intradermal tuberculin skin test (Mantoux) administered 48 hours ago. The nurse assesses the injection site and identifies a 12-mm area of palpable induration. How should the nurse interpret this result?

It discourages the development of resistant strains of the TB organism

A patient who has tuberculosis (TB) is being treated with combination drug therapy. The nurse explains that combination drug therapy is essential because of what reason?

Apply oxygen and place the patient in a semi-Fowler's position.

A patient with asthma who has undergone a total hip replacement complains on the third postoperative day of shortness of breath and slight chest pain and notes that "something is wrong." Temperature is 98.8° F, blood pressure 168/98 mm Hg, pulse 96, respirations 32, and oxygen saturation is 89% on room air. What is the priority nursing action?

Pancrelipase before each meal

A patient with cystic fibrosis (CF) experiences oily, irregular bowel movements and has a fat-soluble vitamin deficiency. The nurse anticipates what prescription?

Pleural abrasion

A patient with cystic fibrosis (CF) experiences wheezing, coughing, and frequent pneumonia. The patient's computer tomography shows bullae and blebs of 1 to 2 cm in the lungs. The nurse anticipates tat what will be included on the patients plan of care?

-Elevate the head of the bed -Immediately contact the healthcare provider -Place the patient in a side-lying position; suspected bleeding side down

A patient with cystic fibrosis admitted for treatment of bronchiectasis has begun coughing up bloody sputum. Which nursing interventions are priority?

-Get adequate rest -Avoid alcohol and smoking -Take every dose of the prescribed antibiotic.

A patient with pneumonia is being treated at home and has reported fatigue to the nurse. What instructions should the nurse include when teaching the patient about care and recovery at home?

Emaciated appearance of the extremities

A patient with wheezing, coughing, and frequent pneumonia experiences large, oily, and frequent bowel movements. The patients medical history reveals poor absorption of fats and proteins. The nurse anticipates what assessments finding?

"I have abnormal hemoglobin."

After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has corrected understanding of the condition?

"I should take antibiotics for all upper respiratory infections."

The nurse determines that additional discharge teaching is needed for a patient with pneumonia when the patient states what?

-Protuberant abdomen -Emaciated appearance of the extremities

The nurse expects what assessment findings in a patient with cystic fibrosis and bronchiectasis?

Bronchial artery embolization

The nurse identifies that which treatment strategy will be beneficial for a patient that has a hemoglobin level of 7.8 mg/dL, inflammation, hemoptysis, and elastic and muscular structural changes to the bronchial wall?

Hyperthermia related to infectious illness

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4 F, a productive cough with yellow sputum, and respiratory rate of 20. which is the most appropriate nursing diagnosis is based upon this assessment?

6 AM

The nurse is caring for the patient with a productive cough. The nurse collects a sputum specimen for an acid-fast bacillus (AFB) smear. What collection time by the nurse is most appropriate?

Restlessness and sudden complaint of dyspnea

The nurse is monitoring a patient who is having a thoracentesis for recurrent pleural effusion. Which of these assessment findings would be of most concern?

White blood cell count 4500/mm3

The nurse is reviewing the laboratory reports for the patient receiving cefuroxime. The nurse determines that the medication is having the intended effect by noting which laboratory result?

Formation of bullae & blebs in lungs

The nurse observes that a patient with cystic fibrosis (CF) has a body temperature of 102 F, shortness of breath, sore throat, and purulent mucous. The nurse expects what other assessment finding?

Drain secretions from specific segments of the lungs and bronchi into the trachea

This is providing postural drainage therapy on a patient who has cystic fibrosis. Postural drainage is used to do what?

-Steatorrhea -Low body mass index

What are complications associated with pancreatic insufficiency?

Increase fluid intake to 3L/day if tolerated

What is the priority nursing intervention in helping a patient expectorate thick lung secretions?

Administering antibiotic therapy

When caring for a patient with pertussis, what will the nurse prioritize?

Sarin gas

Which agent of terrorism can cause death within a few minutes?

3.0 L

Which amount is the normal value of a clients inspiratory reserve volume?

Sweat test

Which diagnostic test will help determine the condition of a patient that has a productive cough, perfuse sweating, local hypoxia, and arteriolar vasoconstriction?

Difficulty swallowing medication

Which factor placed a conscious patient at risk for pneumonia?

Meconium ileus

Which finding helps to diagnose cystic fibrosis in a newborn?

Checking that a bag-valve mask is available during the transfer

Which nursing action is highest priority when preparing to transfer an unconscious patient who sustained a head injury from the emergency department to a neurological trauma unit?

Carina

Which part of the respiratory system would the clients radiology report refer when identifying the angle of Louis?

-Consume more fluids and caloric supplements -Learn about central venous access devices (CVAD) that may be used for long-term medication administration

Which should the nurse include when providing information related to health promotion and disease prevention to a patient with cystic fibrosis?

Slow, weak cry

Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration?

"During general anesthesia, the upper airway obstruction risk is less in pediatrics."

Which statement by the nurse regarding anesthetic drugs in pediatric clients requires correction?

Medications must be used even when the child is asymptomatic

Which statement must the nurse emphasize to the family when preparing a school-aged child with persistent asthma for discharge?

Mild soap and water

Which substance will the home care nurse nurse instruct a client to use after laryngectomy to cleanse the stoma site?

-Mold -Cold air -Pet dander -Air pollution -Cigarette smoke

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks?

1 day

At which interval are humidified oxygen systems placed to prevent infection?

Purulent sputum that has a foul odor and taste

Patient has been admitted with a suspected lung Abscess during the assessment the nurse is aware that the most common manifestation of a lung Abscess is which of these?