Nursing 1310 Exam 2
What are the electrolyte lab values for sodium (Na+)?
135-145mEq/L
A nurse has received report on four clients. Which client would the nurse visit first? 1.) a client with congestive heart failure who has gained 2 pounds overnight 2.) a client with tuberculosis who raised 50mL of sanguineous sputum over the past 2 hours 3.) a client with C.diff who continues to have loose, fouling smelling stools 4.) a client with COPD whose last report of oxygen saturation was 91%
2
What percentage of atmospheric air is oxygen?
21%
What are the electrolyte lab values for Bicarbonate (HCO3-)?
22-26mEq/L
What are the electrolyte lab values for potassium (K+)?
3.5-5mEq/L
What is the normal pH?
7.35-7.45
What are the electrolyte lab values for Calcium (Ca+)?
8.5-10.5mg/dL
What are the risk factors for getting pneumonia?
Age, not receiving the pneumococcal vaccine in the last five years or ever, did not get their influenza vaccine the previous year, chronic health problems, recent exposure to respiratory infections, smoking/second hand smoke
What type of precautions would be in effect for a client with Pulmonary Tuberculosis?
Airborne Precaution
What hormone regulates water excretion from the kidneys (also known as the "no pee hormone")?
Antidiuretic Hormone (ADH)
How long should patients stay on the medications to treat Pulmonary Tuberculosis?
Anywhere from 6 months to 2 years
What does using the Incentive spirometry prevent?
Atelectasis
What are some sources where you can get potassium from?
Bananas, spinach, tomatoes, meat, milk, oranges
Which electrolyte is not found in food but produced through metabolic processes?
Bicarbonate
The nurse is caring for a client with bacterial pneumonia. The effectiveness of the client's oxygen therapy can be best determined by which indicator of oxygenation? A.) absence of cyanosis B.) client's respiratory rate C.) arterial blood gas values D.) client's level of consciousness
C
Which electrolyte regulates muscle contraction and relaxation?
Calcium
What are the four categories for Infectious Pneumonia?
Community Acquired Pneumonia (CAP), Hospital Acquired Pneumonia (HAP), Health Care Acquired Pneumonia (HCAP), Ventilator Associated Pneumonia (VAP)
What adventitious breath sounds are associated with: Bronchitis Pneumonia Tumors Pulmonary Edema?
Course crackles, low pitched crackles
What adventitious breath sounds are described as sounding like course rattling sounds?
Course crackles, low pitched crackles
What adventitious breath sounds is likely to change with coughing or suctioning?
Course crackles, low pitched crackles
What normally occurs during an advanced state of Pulmonary tuberculosis?
Hemoptysis
Which oxygen therapy device can go between 40L/min and 60L/min and is also known as vaprotherm?
High-Flow Nasal Cannula
What are the Signs & Symptoms of Pneumonia?
Increased respiratory rate/dyspnea, hypoxemia, Purulent/rust colored sputum, fever, pleuritic chest pain, confusion in older clients
What are the two medications that are given to treat Pulmonary Tuberculosis?
Isoniazid (INH) and Rifampin (RIF, Rifadin)
What is Hypoxemia?
Low levels of oxygen in the blood
What is counted as intake?
Oral fluids, IV fluids
As oxygen is an atmospheric gas, does it have to be prescribed or can the nurse give it freely if it is necessary?
Oxygen must be prescribed as it is a prescribed drug
Which electrolyte regulates ECF?
Sodium
Which of the diagnostic assessments for Pulmonary Tuberculosis is done to confirm the diagnosis?
Sputum Culture
What are some orders that can be given to diagnose pneumonia?
Sputum culture, Chest X-Ray, ABG's
What is the most common diagnostic assessment done to diagnose Pulmonary Tuberculosis?
TB Skin Test
What are the diagnostic assessments that can be done for Pulmonary Tuberculosis?
TB Skin Test, Chest X-Ray, Sputum Culture, and Lab Draw
What are some treatments for a patient who was diagnosed with Pulmonary Tuberculosis?
TB medications, decreased activity, and respiratory isolation until sputum culture comes out as negative
A patient is going home while continuing oxygen, what should the nurse make sure to educate the patient before being discharged?
The nurse should educate the patient on how oxygen should not be around open flames due to it being combustible
What mechanism is the primary regulator of fluid intake?
Thirst Mechanism
Why should the nurse make sure to educate the patient who is taking Isoniazid for TB to report any darkening of urine, yellowish skin, yellowing sclerae, as well as bleeding tendencies?
This is because these are signs and symptoms of liver failure or liver toxicity
What is counted as output?
Urine, watery stools, emesis
What adventitious breath sounds are associated with: Inflammation Bronchospasm Edema Secretions Pulmonary Vessel Engorgement?
Wheeze
What adventitious breath sounds usually does not clear with coughing?
Wheeze
Which family member exposed to tuberculosis would be at highest risk for contracting the disease? 1.) 45 year old mother 2.) 17 year old daughter 3.) 8 year old son 4.) 76 year old grandmother
4
A community care nurse is assessing risks for pneumonia in a patient population of the elderly. Which of the following patients would have the lowest risk for developing pneumonia? Which patient would have the highest risk for developing pneumonia? A.) a male patient diagnosed with atrial fibrillation B.) a female patient treated post-op perforated bowel C.) a male patient with a CVA who exhibits signs of dysphagia D.) A homeless woman who is an alcoholic
A would be the lowest risk and C would be the highest risk
Which information is most important for a nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy? A.) "Report darkening or reddening of the urine while taking Rifampin" B.) "Do not drink alcohol in any quantity while taking Isoniazid" C.) Restrict fluid intake to 2 quarts of liquid a day on pyrazinamide" D.) "Temporary visual changes while taking ethambutol are not serious"
B
Which is an expected finding for a client who has been treated for bacterial pneumonia? A.) a respiratory rate of 25 to 30 breaths/min B.) the ability to perform activities of daily living without dyspnea C.) a maximum loss of 5 to 10 lb of body weight D.) Chest pain that is minimized by splinting the rib cage
B
A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes Rifampin. Which instruction should the nurse give the client about potential adverse effects of rifampin? Select all that apply. A.) Have eye examinations every 6 months B.) Maintain follow-up monitoring of liver enzymes C.) Decrease protein intake in the diet D.) Avoid Alcohol intake E.) The urine may have an orange color
B, D, E
Which electrolyte regulates acid-base balance?
Bicarbonate
What normal breath sounds is described as being high pitched, having a loud amplitude, the quality is harsh, hollow, and normally located in the trachea and larynx?
Bronchial (Tubular, Tracheal)
What normal breath sounds is described as being moderate pitched, having a moderate amplitude, a mixed quality, and located over major brooch where fewer alveoli are located?
Bronchovesicular
What are some signs of Hypoxia?
Cyanosis, confusion, tachycardia, and you will see a low pulse-ox
Which nursing action would most likely be successful in reducing pleuritic chest pain in a client with pneumonia? A.) Encourage the client to breathe shallowly B.) Have the client practice abdominal breathing C.) Offer the client incentive spirometry D.) Teach the client to splint the rib cage when coughing
D
What is Hypoxia?
Decrease in tissue oxygen
When taking Isoniazid to treat Pulmonary Tuberculosis what should the nurse make sure to educate the patient on?
Do not drink alcohol, avoid antacids, take the medicine on an empty stomach, take a daily multivitamin that contains B-complex vitamins, and to report any darkening of urine, yellowish skin, yellowing sclerae, as well as bleeding tendencies
When taking Rifampin to treat Pulmonary Tuberculosis, what should the nurse make sure to educate the patient on?
Do not drink any alcohol while taking this medication, it is normal for their to be orange-reddish staining of the skin and urine and also staining of contact lenses, report darkening of urine and a yellow appearance to the skin or the sclerae, this medication may reduce the effectiveness of certain contraceptions
What are the signs & symptoms of Pulmonary Tuberculosis?
Fatigue, lethargy, nausea, anorexia, weight loss, irregular mensus, low grade fever, nigh sweats, chest tightness, chest pain, blood tingled sputum, crackles in lung fields or bronchial breath sounds
What adventitious breath sounds are associated with: Asbestosis Atelectasis Interstitial Fibrosis Bronchitis Pneumonia Chronic Pulmonary Disease?
Fine crackles, fine rales, high-pitched rales
What adventitious breath sounds are described as sounding like velcro?
Fine crackles, fine rales, high-pitched rales
What does FiO2 stand for?
Fraction of Inspired Oxygen
Oxygen that is transported to all cells, tissues, and organs is known as what?
Gas Exchange
What organ is the primary regulator of fluids and electrolytes in the body?
Kidneys
What are some sources where you can get Calcium from?
Milk, milk products, leafy green vegetables, canned salmon
Which oxygen therapy device delivers between 24% and 44% of FiO2 at a flow rate between 1L/min and 6L/min?
Nasal Cannula
Which oxygen therapy device(s) is good for long term use?
Nasal Cannula
What are the five oxygen therapy devices?
Nasal Cannula, high-flow nasal cannula, simple face mask, non-rebreather face mask, and a Venturi mask
Which oxygen therapy device delivers between 60% and 90% FiO2 at a flow rate between 10L/min and 15L/min?
Non-Rebreather face mask
What type of pneumonia is caused by inhaling toxic, chemical flames, and/or aspiration of vomitus or food?
Noninfectious Pneumonia
What structure in the respiratory tract is known as cranial nerve #1?
Nose
Who is at risk for getting Pulmonary Tuberculosis?
People who have constant contact with an untreated infected person, those who have a reduced immune system or have HIV disease, adults who live in crowded areas, older homeless adults, people of lower socioeconomic groups
Arterial blood flow through tissues and the blood that is pumped by the heart is known as what?
Perfusion
What adventitious breath sounds are associated with: Pleurisy Tuberculosis Pulmonary Infarction Pneumonia Lung Cancer
Pleural Friction Rub
What adventitious breath sounds are described as loud, rough, scratching sounds?
Pleural Friction Rub
What adventitious breath sounds are heard in the lateral lung fields?
Pleural Friction Rub
What disease causes an obstruction of bronchioles, a decreased gas exchange, and an increase of exudate (fluid)
Pneumonia
Which electrolyte regulates cardiac contraction?
Potassium
What would be a noninvasive oxygen monitor?
Pulse Oximetry
What hormone increases blood volume (and renal perfusion) through Na+ and H2O retention?
Renin Angiotensin Aldosterone System
What arterial blood gas is the following? pH = 7.30 PaCO2 = 48 HCO3 = 26
Respiratory Acidosis
What adventitious breath sounds are associated with: Thick Tenacious Secretions Sputum Production Obstruction by Foreign Body Tumors
Rhonchus (Rhonchi)
What adventitious breath sounds are described as lower pitch that is course and sounds like continuous snoring?
Rhonchus (Rhonchi)
What adventitious breath sounds arises from large airways?
Rhonchus (Rhonchi)
Which oxygen therapy device delivers between 35% and 50% FiO2 at a flow rate between 6L/min and 12L/min?
Simple Face Mask
What electrolyte maintains blood volume?
Sodium
What are some sources where you can get sodium from?
Table salt, cheese, canned foods, processed meats
When you get chronic lung disease, what part of the respiratory system gets compressed?
Terminal Bronchioles
True/False. If a patient had Pulmonary Tuberculosis, after 3 months their sputum culture will be negative.
True
True/False. Oxygen therapy is prescribed at the lowest FiO2. Explain your answer.
True because you have to have an acceptable blood oxygen level that does without any negative side effects
The movement of air higher in oxygen into lungs and the removal of carbon dioxide produced during metabolism is known as what?
Ventilation
Which oxygen therapy device delivers adjusted rates of either 24%, 28%, 31%, 35%, 40%, and 50% FiO2?
Venturi Mask
Which oxygen therapy device is used for someone who has a trach?
Venturi mask
What normal breath sounds is described as being low pitched, having a soft amplitude, and a rustling quality?
Vesicular
What adventitious breath sounds are described as sounding squeaky and arises from small airways?
Wheeze
