Respiratory Care

Presentation of Viral Pneumonia

-Less severe than bacterial -Low-grade fever -Non-productive cough -WBC's normal to low elevation -CXR shows minimal changes -Chills -Rhonchi -Wheezes -Decreased SpO2

TWO AA'S

-Mnemonic for chest tube assessment -Tidaling -Water seal -Output -Air leak -Ability to breath -SpO2

Lung stridor

-Narrowing of the large airways -Medical emergency -Loud and musical

Presentation of TB

-Night sweats -Weight loss -Fatigue -Fever, chills -Persistent cough

Chest tube tidaling

-Normal and expected finding -Water goes up with inspiration, down with expiration

How to use an inhaler

-Shake 10-15 times -Large breath, exhale -Spacer in mouth, seal with lips -Tilt head back slightly -Depress inhaler, breathe in slowly & deeply -Hold 5-10 seconds -Open mouth & breath slowly out -Rinse mouth

Presentation of Influenza

-Aches -Upper respiratory -High fever 102-104 -Sometimes GI upset

Treatment for TB

-Airborne Isolation -Place and read TB skin test -RIPE therapy (rifampin, isoniazide, pyrazinamide, ethambutol) 6-12 months -Support respiratory system

Treatment of pneumonia

-Antibiotics/antivirals -Antipyretics -Analgesics -Spulemetial O2 -Vaccines (Flu and Pnu for over 65) -Fluids (3L/Day) -Encourage activity -Chest expansion excersises

Flu treatment

-Antivirals -Bed rest -Fluids/nutrition -Oxygen

Who cant receive the flu vaccine

-Anyone with a severe allergy to eggs or latex (alternatives available) -Transplant in last 6 months -Current illness (fever) -No nasal spray for immune-compromised -HX of Guillain-Barre

Treatment of COPD

-Bronchodilators and corticosteroids -Monitor SpO2 and ABG -Chest Physiotherapy -Increase fluid intake to 3L/day -Pursed lip breathing -Small more frequent meals -Avoid triggers -Smoking cessation

How to diagnose Pneumonia

-CXR -Sputum culture -ABG

Lung crackles

-Caused by fluid in the alveoli -Popping sound, hair rubbing

Treatment for Atelectasis

-Chest physiotherapy -Incentive spirometry -Intermittent positive pressure breathing -Position changes

Atelectasis

-Collapsed lung -Deflated alveoli -After surgery usually -Excessive secretions can also be a cause

Presentation of Atelectasis

-Diminished breath sounds -Chest pain with breathing -Fever -CXR shows collapse -Decreased SpO2

Lung rhonchi

-Harsh gurgling noise -Fluid or sputum in airway passages

Presentation of Bacterial Pneumonia

-More severe than viral -High fever >101 -Productive cough -WBCs elevated -CXR shows infiltrate -Chills -Rhonchi -WHeexes -Decreased SpO2

How do we diagnose TB

-Sputum culture -CXR -Mantoux TB skin test -Quantiferon Gold

What should a chest tube pt always have?

-Two hemostats -Occlusive dressing -Tape

Presentation of asthma

-Wheezing/crackles -Diminished breath sounds -Restlessness -Tachypnea -Tripod position -Low peak flow rate

Lung wheezing

-Whistling sound -Narrowing of small airways

PPD thresholds

-anyone >15mm -high risk >10mm -Immunocompromised >5 mm

The nurse is caring for the following clients. Which client should be seen first? A) New tracheostomy, on a ventilator, SpO2 88% B) Thoracotomy, pain 10/10, screaming C) PRBC's just arrived from blood bank to transfuse, hemoglobin 6.8 mg/dL D) Actively vomiting green bile and food particles

A A) New tracheostomy, on a ventilator, SpO2 88% B) Thoracotomy, pain 10/10, screaming C) PRBC's just arrived from blood bank to transfuse, hemoglobin 6.8 mg/dL D) Actively vomiting green bile and food particles

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? A) "Milder and less contagious" B) "More severe and requires hospitalization" C) "Causes a highly pruritic rash" D) "Rare and requires airborne isolation"

A A) "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. B) "More severe and requires hospitalization" Influenza Type A and B are more contagious and usually the cause of epidemics. Type C is milder and less contagious. C) "Causes a highly pruritic rash" Type C will not cause a pruritic rash. D) "Rare and requires airborne isolation" Influenza Type A and B are more contagious and usually the cause of epidemics. Type C is milder and less contagious.

A nurse is educating a client who had a tracheostomy placed yesterday about the need for humidified oxygen. Which statement by the client reflects appropriate education was provided? A) "This will keep my trach from clogging up." B) "I'll use the oxygen if I feel short of breath." C) "I only need it because my oxygen levels are low." D) "I will need this oxygen the rest of my life."

A A) "This will keep my trach from clogging up." Humidified oxygen in clients with a new tracheostomy tube is used to prevent mucous plugs from forming. If the secretions dry out, then can clog and occlude the tracheostomy tube. This is a correct statement by the client. B) "I'll use the oxygen if I feel short of breath." The client should use the humidified oxygen continuously to prevent mucous plugs, not only as needed for shortness of breath. This statement would require more teaching by the nurse. C) "I only need it because my oxygen levels are low." D) "I will need this oxygen the rest of my life."

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? A) 10 degree B) 90 degree C) 60 degree D) 25 degree

A A) 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. B) 90 degree This angle is too great to create a wheal or bleb. 90 degrees is an appropriate angle for an IM injection. C) 60 degree This angle is too great to create a wheal or bleb. D) 25 degree This angle is too great to create a wheal or bleb.

A nurse is caring for a client who is unconscious after a head injury. The client is breathing on his own but has increased oral secretions that require frequent suctioning. The nurse prepares to suction secretions from his mouth and nose. Before starting the suction process, the nurse turns on the suction machine and sets the pressure at which of the following? A) 120 mmHg B) 60 mmHg C) 100 mmHg D) 220 mmHg

A A) 120 mmHg When setting suction levels prior to suctioning a client, whether it is oral, nasal, or endotracheal suctioning, the nurse should not set the suction level higher than 150 mmHg for adults and 120 mmHg for children. Any higher pressure than this can cause trauma, hypoxemia and atelectasis, all without providing increased suction effectiveness. B) 60 mmHg C) 100 mmHg D) 220 mmHg

A nurse works in a rehabilitation facility that cares for clients of various ages and medical backgrounds. Which of the following situations would the nurse encounter as the biggest risk for aspiration? A) A client who uses a mechanical ventilator B) A client who uses a jejunostomy tube C) A client with hypoglycemia D) A client who sleeps in the prone position

A A) A client who uses a mechanical ventilator Aspiration involves breathing in fluid or particles that are not meant to enter the respiratory tract. Unmanaged, aspiration can lead to pneumonia, in which an infection develops in the lungs. Certain clients are at higher risk of aspiration and illness, including those who use mechanical ventilators, those with nasogastric feeding tubes, and those who have dysphagia. In the mechanically ventilated client, there is a risk for microaspiration, even if the tube cuff is inflated properly. This client is at the greatest risk of aspiration. B) A client who uses a jejunostomy tube While any feeding tube carries a risk of aspiration, the further down the GI tract the tube terminates, the less likely aspiration becomes. C) A client with hypoglycemia D) A client who sleeps in the prone position

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) A concomitant diagnosis of mental illness B) Recent weight loss of 5 percent of body weight or more C) A condition that requires close dietary monitoring, like diabetes D) Malnutrition

A A) 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. B) Recent weight loss of 5 percent of body weight or more This is not correlated with a risk of suicide in clients with COPD. C) A condition that requires close dietary monitoring, like diabetes This is not correlated with a risk of suicide in clients with COPD. D) Malnutrition This is not correlated with a risk of suicide in clients with COPD.

A nurse is caring for a client who requires a ventilator for breathing assistance. Which of the following practices would most likely reduce the risk of the client developing ventilator-associated pneumonia? A) Elevating the head of the bed B) Wearing a protective gown while providing patient care C) Injecting 1 mL of saline flush into the endotracheal tube prior to suctioning D) Changing the ventilator circuit every 12 hours

A A) Elevating the head of the bed B) Wearing a protective gown while providing patient care This intervention does not reduce the risk for developing VAP in the intubated client. C) Injecting 1 mL of saline flush into the endotracheal tube prior to suctioning This practice used to be a common way to thin secretions just prior to suctioning, but the purpose was not to reduce the risk of VAP. D) Changing the ventilator circuit every 12 hours Changing the ventilator circuit frequently will increase the chance of the client developing ventilator-associated pneumonia rather than decrease the risk.

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? A) Facemask B) Gloves, gown, and N-95 mask C) Facemask and gown D) N-95 mask

A A) 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. B) Gloves, gown, and N-95 mask These personal protective items are used if the client is on airborne precautions and the nurse anticipates coming into contact with body fluids. C) Facemask and gown Only a facemask is necessary upon entering the room of a client on droplet precautions. If the question stated that the nurse anticipates coming into contact with body fluids, then the correct answer would be facemask, gown, and gloves. D) N-95 mask

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? A) He should get the flu shot because he can have worse symptoms from influenza compared to another child B) He should not get the flu shot because he is too high risk from his medical condition C) You should avoid giving him the flu shot. Instead, keep him indoors and practice good hand hygiene D) He should get the flu shot because there is a chance of death from influenza infection

A A) 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. B) He should not get the flu shot because he is too high risk from his medical condition A stable neurological condition is not a contraindication for the flu vaccine. C) You should avoid giving him the flu shot. Instead, keep him indoors and practice good hand hygiene The client with CP benefits from the flu vaccine. D) He should get the flu shot because there is a chance of death from influenza infection There is a chance of increased complications for a child with cerebral palsy if the child contracts influenza, but saying the word 'death' to the parents would cause alarm and should be avoided.

Which of the following nursing interventions would be the priority to prevent tracheal necrosis in a client with an endotracheal tube in place? A) Maintaining adequate cuff pressure B) Performing trach care every 4 hours C) Providing oral care every 2 hours D) Optimizing hemodynamics

A A) Maintaining adequate cuff pressure The cuff at the end of the endotracheal tube sits in the trachea and allows for the use of positive pressure ventilation. If this cuff is overinflated, clients are at risk for tracheal necrosis. The pressure in this cuff should be at or below 20 mmHg. B) Performing trach care every 4 hours Trach care is for clients with a tracheostomy tube, not an endotracheal tube. C) Providing oral care every 2 hours Clients who are intubated should receive oral care every 2 hours to help prevent Ventilator Associated Pneumonia - this will NOT prevent tracheal necrosis. However, this q2hr intervention is the perfect time to verify your cuff pressure! D) Optimizing hemodynamics This is essential, but does not have an effect on tracheal necrosis, therefore this is not the priority intervention.

After his endotracheal tube has been removed, a client develops breathing difficulties. He has wheezes upon auscultation and exhibits intercostal retractions with each breath. The nurse suspects post-extubation swelling in the airway. Which medication would most likely be administered to correct this situation? A) Nebulized epinephrine B) Albuterol C) Cromolyn sodium D) Acetylcysteine

A A) Nebulized epinephrine Nebulized epinephrine is an inhaled solution that relieves shortness of breath and wheezing. It can be used for the treatment of post-extubation swelling and breathing difficulties in a client who was recently extubated and who is showing signs of respiratory distress. Nebulized epinephrine is inhaled through an atomizer and facilitates easier breathing by widening the size of the airway passages. B) Albuterol C) Cromolyn sodium D) Acetylcysteine

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? A) Notify the provider and request an EKG B) Discontinue theophylline administration immediately C) Reassure the client that this is a side effect of the medication and continue to monitor D) Titrate the dose down and reassess the client's symptoms after 15 minutes

A A) 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. B) Discontinue theophylline administration immediately Discontinuing the drug could compromise the client's airway. Getting an EKG is the most appropriate action. C) Reassure the client that this is a side effect of the medication and continue to monitor. D) Titrate the dose down and reassess the client's symptoms after 15 minutes The question does not specify that there is a titratable range, so this would be an inappropriate action.

A female client presents to the ER reporting difficulty breathing. Upon assessment, the client reports "it feels like it's squeezing all around my ribs when I try to take a deep breath and it's making me nauseous." What is the priority nursing intervention for this patient? A) Obtain a 12-lead EKG B) Apply oxygen C) Auscultate lung sounds D) Check a blood pressure

A A) Obtain a 12-lead EKG The priority will be to obtain a 12-lead EKG. Because female clients tend to report atypical cardiac symptoms when having a myocardial infarction, it is imperative to rule out MI in this client. B) Apply oxygen Oxygen should not be given without assessing an SpO2 first. C) Auscultate lung sounds The client has a patent airway and is not significantly short of breath enough to prevent speaking in full sentences. Therefore the priority is to rule out an MI. D) Check a blood pressure This is not a priority at this time. The priority is to rule out an MI.

A nurse is caring for a client who had a tracheostomy placed 2 days ago. The nurse enters the room and makes the following observations during a safety check. Which of the following observations would be the MOST concerning? A) Oxygen tubing connected directly to flow meter B) Obturator on the bedside table C) Trach ties are soiled with dried mucus D) Hydrogen peroxide bottle on the counter

A A) Oxygen tubing connected directly to flow meter Any client who recently received a tracheostomy tube (and oftentimes even chronic tracheostomy clients) should always be receiving humidified oxygen to prevent a mucous plug from forming. If the tubing is connected directly to the flow meter, that means there is no humidifier attached. There should be a water bottle that the oxygen flows through before going to the client in order to humidify the oxygen. The nurse should notify the respiratory therapist to obtain a humidifier for this client. B) Obturator on the bedside table C) Trach ties are soiled with dried mucus D) Hydrogen peroxide bottle on the counter

A nurse is caring for a client who has a chest tube. While turning the client in bed, the tube is accidentally removed. Which of the following should be the nurse's first response? A) Place a gloved hand over the site B) Tell the client to stay still while you go to retrieve an occlussive dressing to cover the site C) Place the tip of the catheter near the opening and secure it D) Turn the client so that the affected side is up

A A) Place a gloved hand over the site If a client's chest tube becomes dislodged and is pulled out, the nurse should immediately cover the site with an occlusive dressing and tape. If these supplies are not immediately available, the nurse should cover the site with a gloved hand, stay with the client and call for help. Occluding the site with dressing or manually acts as a one-way valve to prevent the development of a tension pneumothorax until the condition can be treated by the provider. B) Tell the client to stay still while you go to retrieve an occlussive dressing to cover the site Not covering the site immediately could result in a tension pneumothorax. The nurse should cover the site with a gloved hand or occlusive dressing to prevent air from entering the pleural space. C) Place the tip of the catheter near the opening and secure it D) Turn the client so that the affected side is up

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? A) The client should be monitored during exercise to address safety B) The client should wear a Holter monitor when exercising at home C) The client should log exercise hours and bring in a copy to the rehab center D) The client will need to receive nebulizer treatments prior to starting exercise

A A) 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. B) The client should wear a Holter monitor when exercising at home C) The client should log exercise hours and bring in a copy to the rehab center D) The client will need to receive nebulizer treatments prior to starting exercise If a client needed a respiratory treatment, they may receive one but would cease exercising. There would not be planned nebulizer treatments prior to exercising.

A client is being admitted to the hospital from home with complications of tuberculosis. When making a room assignment, the nurse would most likely consider which of the following factors? A) The hospital's isolation procedures B) Whether the client will have someone staying with him C) The nurses assigned to work during the shift D) Whether a nursing assistant is available to help the client

A A) The hospital's isolation procedures Most client room assignments are made based on the client's condition and the availability of staff. In this situation, the client has an infectious condition and needs a specific room that has a negative pressure air system. Therefore in this case, the client's assignment is based on the hospital's isolation procedures for a client with an airborne illness. B) Whether the client will have someone staying with him The room assignment does not take into consideration whether the client will have someone staying with them in the case of an airborne illness. Rather, the type of room needed is considered, based on the fact that the client has an illness that can be transmitted through the air. C) The nurses assigned to work during the shift D) Whether a nursing assistant is available to help the client

A client is being seen in the emergency department after a spinal cord injury. The client initially states an inability to feel anything below the shoulders. At which point would this client need to be intubated with an endotracheal tube? A) The point at which the client has a Glasgow Coma Score of 8 B) The point at which the client has a respiratory rate of 10/minute C) The point at which the client's oxygen saturation is 88 percent on room air D) Upon discovering that the client has a pneumothorax as seen on x-ray

A A) The point at which the client has a Glasgow Coma Score of 8 B) The point at which the client has a respiratory rate of 10/minute C) The point at which the client's oxygen saturation is 88 percent on room air D) Upon discovering that the client has a pneumothorax as seen on x-ray

A nursing student observes a nurse performing cupping on a client. The student correctly understands which of the following as the reason for this? A) To loosen secretions and fluids B) To expand the lungs and inflate the alveoli C) To hydrate the client in order to thin mucus D) To dilate the airways to facilitate greater air movement

A A) To loosen secretions and fluids Cupping is the action of rhythmic percussion, or hitting the chest to loosen secretions and fluids. It forces these substances to move from smaller to larger airways where they can be expelled. B) To expand the lungs and inflate the alveoli Expanding the lungs and inflating the alveoli is achieved when the client takes deep breaths. Cupping helps loosen secretions, but the client must take deep breaths on their own. C) To hydrate the client in order to thin mucus Cupping involves percussing the chest. While hydration does help to thin mucus, cupping isn't related to hydrating the client. D) To dilate the airways to facilitate greater air movement Dilation of airways is achieved through administering bronchodilators such as albuterol. Cupping does not assist with this.

A nurse is caring for a client who is 68-years-old and has been diagnosed with chronic lung disease. The client already has a diagnosis of heart failure and has been in the hospital for breathing difficulties. The nurse wants to gather an interdisciplinary team to talk about this client's care. In this situation, the most likely reason for meeting with an interdisciplinary team is which of the following? A) To shift the focus from acute care to ongoing care B) To help the nurse feel a sense of professional satisfaction C) To motivate other staff members to focus on their jobs D) To make the best use of the client's time in the hospital

A A) To shift the focus from acute care to ongoing care Part of the work of an interdisciplinary team is to coordinate efforts for care when the client has a chronic illness that will need to be managed after receiving acute care in the hospital. B) To help the nurse feel a sense of professional satisfaction The reason for assembly of this team is to facilitate a potential change in approach to care from acute to ongoing management. C) To motivate other staff members to focus on their jobs The reason for assembly of this team is to facilitate a potential change in approach to care from acute to ongoing management. D) To make the best use of the client's time in the hospital The reason for assembly of this team is to facilitate a potential change in approach to care from acute to ongoing management.

A nurse is caring for a client with influenza who requires droplet precautions. Which of the following activities is part of maintaining droplet precautions? A) Wear a mask when going into the room B) Do not transport the client outside of the room C) Avoid letting visitors enter the client's room D) Wear a gown, gloves, and shoe covers whenever touching the client

A A) 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. B) Do not transport the client outside of the room The client may be transported outside of the room if a surgical mask is placed on the client. C) Avoid letting visitors enter the client's room Visitors are allowed if they wear a mask. D) Wear a gown, gloves, and shoe covers whenever touching the client Illnesses that require droplet precautions infect a person by entering the respiratory tract, so other than a mask, personal protective equipment is not necessary

A 6-year-old is being discharged from the hospital following an appendectomy. The parents have asked to have the flu vaccine administered via nasal spray, prior to discharge. The nurse knows that which of the following are contraindications for administering this immunization? Select all that apply. A) History of asthma B) Siblings undergoing treatment for leukemia C) History of enuresis D) Doses of ibuprofen in the last 24 hours E) Sibling diagnosed with type 1 diabetes

A&B A) History of asthma Children who have asthma or a history of any reactive airway disease should not be given the nasal spray flu vaccine because it is a live virus. B) Siblings undergoing treatment for leukemia The nasal spray flu vaccine is a live virus and should not be given to clients with a weakened immune system like in leukemia. C) History of enuresis The nasal spray influenza vaccine is not contraindicated in clients with enuresis. D) Doses of ibuprofen in the last 24 hours The nasal spray influenza vaccine is not contraindicated with the administration of ibuprofen. E) Sibling diagnosed with type 1 diabetes The nasal spray influenza vaccine would not be contraindicated in this scenario.

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? Select all that apply. A) The wall suction should be set at > 80 mmHg B) The nurse should note tidaling when the client breathes C) The nurse should notify the provider if there is a sudden increase in drainage D) The apparatus should make a sucking sound at the insertion site E) Suction is always at low-intermittent suction with a chest tube, never continuous suction

A,B&C A) 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. B) The nurse should note tidaling when the client breathes C) The nurse should notify the provider if there is a sudden increase in drainage D) The apparatus should make a sucking sound at the insertion site If there is a sucking sound at the insertion site, this is a medical emergency and must be addressed immediately. E) Suction is always at low-intermittent suction with a chest tube, never continuous suction While low-intermittent suction is most common, it is not the only suction setting used.

The nurse is caring for a client who has pneumonia. Which of the following are warning signs that the client may be going septic? Select all that apply. A) Hypotension B) Chills C) Decreased urination D) Tachypnea E) Bradycardia

A,B,C&D A) Hypotension Hypotension is a sign of sepsis. B) Chills Chills indicate fever, which is a sign of infection. This can indicate sepsis. C) Decreased urination A septic client will demonstrate decreased urination due to hypoperfusion of the kidneys. D) Tachypnea A respiratory rate above 20 per minute is a sign of sepsis. E) Bradycardia Tachycardia is a sign of sepsis, but not bradycardia.

A nurse is caring for a client who has developed ventilator-associated pneumonia while in the hospital. Which of the following strategies could the nursing unit apply that would best prevent hospital-acquired infections? Select all that apply. A) Promote appropriate hand hygiene B) Wear the same pair of gloves during multiple client contact C) Use standard precautions at all times when providing client care D) Wash hands with soap and water when visibly soiled E) Utilize invasive devices to gather important data, such as vital signs

A,C&D A) Promote appropriate hand hygiene B) Wear the same pair of gloves during multiple client contact C) Use standard precautions at all times when providing client care D) Wash hands with soap and water when visibly soiled E) Utilize invasive devices to gather important data, such as vital signs

A nurse is caring for a client who has a tracheostomy. The nurse decides to perform a tracheal cuff-pressure measurement. Which of the following are considerations regarding this process? Select all that apply. A) The cuff should exert the minimum amount of pressure to avoid damaging the airway B) The ideal pressure is the highest amount needed to seal the airway C) The actual ideal cuff pressure varies with each client D) Measurement of the pressure requires a stethoscope and a cuff pressure manometer E) Cuff pressure should be measured every 24 hours

A,C&D A) The cuff should exert the minimum amount of pressure to avoid damaging the airway The cuff should be inflated enough that it keeps the tube in place and seals the airway, but at the minimum level so as to avoid affecting the blood supply to the tracheal mucosa. B) The ideal pressure is the highest amount needed to seal the airway The cuff should be inflated only to the minimum level at which a seal is made, but damage to the tracheal mucosa is avoided. C) The actual ideal cuff pressure varies with each client Tracheal-cuff measurement involves checking the size of the cuff inflation within the tracheal wall. D) Measurement of the pressure requires a stethoscope and a cuff pressure manometer The nurse performs cuff measurement using a cuff pressure manometer and stethoscope. E) Cuff pressure should be measured every 24 hours The pressure should be measured every 8 hours to avoid overinflation.

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? Select all that apply. A) "Do not use aspirin to treat the fever because of the risk for developing Reye Syndrome" B) "You should administer acetaminophen every 4 hours around the clock until the fever goes away" C) "Sponge your child down with ice water to help them stay cool" D) "Dress your child in light clothing and keep the room cool" E) "Contact your provider if your child's temperature is 104F or greater"

A,D&E A) "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. B) "You should administer acetaminophen every 4 hours around the clock until the fever goes away" While acetaminophen can be dosed every four hours it should not be given more than 4 times in 24 hours. C) "Sponge your child down with ice water to help them stay cool" This method is too severe and may bring the child's temperature down too rapidly causing more problems. D) "Dress your child in light clothing and keep the room cool" It is appropriate to use moderate cooling techniques like dressing the client in light clothing and keeping the room cool to help with the client's comfort level. E) "Contact your provider if your child's temperature is 104F or greater"

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? A) Call the healthcare provider C) Check vital signs D) Give PRN hydralazine 25 mg IV E) Palpate the client's pulses in the legs

B A) Call the healthcare provider The nurse should call the healthcare provider after a set of vital signs are taken. Vitals are the priority. B) 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. C) Give PRN hydralazine 25 mg IV There is no indication to give hydralazine to this client. The blood pressure was not taken to determine if it is high and hydralazine is a blood pressure medication. D) Palpate the client's pulses in the legs The nurse should check the client's vital signs. Palpating the pulses would not help in this situation.

The nurse providing care to a child with influenza knows to give top priority to which of the following interventions? A) Encouraging small, frequent meals B) Monitoring for signs of secondary infection C) Assessing the child's skin for signs of breakdown D) Monitor for signs of hearing loss

B A) Encouraging small, frequent meals The child should be encouraged to eat small, frequent meals as tolerated but this would not be given top priority. B) 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. C) Assessing the child's skin for signs of breakdown While it is important to monitor skin integrity, it would not be top priority. D) Monitor for signs of hearing loss While hearing loss can occur from influenza is very rare and monitoring for it would not be given top priority.

A nurse is working in the recovery room and caring for a client who was just brought in following surgery. The nurse removes the client's endotracheal tube and the client begins to have a laryngospasm. Which responses of the nurse are most appropriate? Select all that apply. A) Provide supplemental oxygen via nasal cannula B) Perform a chin lift C) Apply a blood pressure monitor D) Place the client flat and supine

B&E A) Provide supplemental oxygen via nasal cannula Supplemental oxygen should be given, but at 100% via face mask in the situation of laryngospasm. B) Perform a chin lift A laryngospasm occurs after extubation when the client's vocal cords freeze up, making it difficult for the client to breathe. The nurse may insert an oral airway or perform a chin lift to keep the airway open. Midazolam or propofol is sometimes administered to relax the larynx and facilitate easier breathing. C) Apply a blood pressure monitor A blood pressure monitor is not relevant to treating laryngospasm. D) Place the client flat and supine This increases the work of breathing. Elevating the head of the bed for ease of breathing is more appropriate. E) Administer midazolam as ordered

The nurse is caring for a client whose chest x-ray shows pneumonia. The provider has placed the following orders: vancomycin IV, piperacillin/tazobactam IV, blood and sputum cultures, vitals now and every 4 hours. Which order needs to be completed first? A) Blood and sputum cultures B) Vancomycin C)Piperacillin/tazobactam D) Vitals

D A) Blood and sputum cultures Vital signs are first, because the order reads, "vitals now". However, blood and sputum cultures must be drawn before starting any antibiotics. B) Vancomycin Antibiotics are given after cultures are drawn. C) Piperacillin/tazobactam Antibiotics may not be started until after cultures are drawn. D) Vitals The order reads "vitals now", which means vital signs should be taken first. After vital signs, the nurse would draw blood cultures, then the antibiotics would be administered. It is essential to draw cultures prior to antibiotic initiation, because the antibiotics will impact culture results.

Risk Factors for TB

-High-Risk countries -Tight quarters -Past exposure -Immunocompromised

Management of asthma

-High-fowler's -Administer 02 -Medications (Bronchodilators, corticosteroids, Leukotriene modulators)

Presentation of COPD

-Accessory muscle use -Adventitious breath sounds -Barrel chest -COngestion on CXR -ABG = high pCO2 and low pH

What level should the water seal in a chest tube be at?

2 cm

What is the maximum L/min for COPD patients?

2L/min

How old do children need to be to get the flu vaccination?

6 months

A client with asthma has started a new prescription for albuterol (Proventil HFA). What side effects are associated with use of this drug? Select all that apply. A) Depression B) Tremor in the extremities C) Pounding heart rate D) Restlessness E) Vomiting

B,C&D A) Depression The incidence of depression was not reported as side effect with Albuterol use. B) 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 the extremities. C) Pounding heart rate It may also have negative side effect that causes a pounding heart rate. D) Restlessness Shakiness, and restlessness are also the side effects of Albuterol. E) Vomiting This is not also reported as a side effect of Albuterol.

The nurse knows that which of the following are risk factors for hospital-acquired pneumonia? Select all that apply. A) Not getting the pneumococcal vaccine B) Not getting the influenza vaccine C) Advanced age D) Aspiration E) Mechanical ventilation

C,D&E A) Not getting the pneumococcal vaccine Getting vaccinated reduces the risk for community-acquired pneumonia, not hospital-acquired pneumonia. B) Not getting the influenza vaccine Getting vaccinated reduces the risk for community-acquired pneumonia, not hospital-acquired pneumonia. C) Advanced age A person of advanced age is more likely to get hospital-acquired pneumonia. D) Aspiration Aspiration in the hospital can lead to HAP. E) Mechanical ventilation Hospital-acquired pneumonia (HAP) risk factors include advanced age, chronic lung diseases, aspiration, mechanical ventilation, decreased level of consciousness, and a suppressed immune system.

What does an air leak in a chest tube look like?

Continuous bubbling

Precautions for Influenza

Droplet