Exam 1

Question 1

Describe ISBAR

Answer 1

Identify - yourself, role, task; the patient, name, DOB, why admitted

Situation - what is going on, dx, symptoms

Background - previous dx, concerns

Assessment/Action: what you have determined, what needs to be intervened

Recommendations: interventions, transfers, etc.

Question 2

Chronic Illness

Answer 2

Illness with symptoms that impede an individual’s daily life/QoL for more than 3 months

Question 3

Chronic Illness Management

Answer 3

More symptom management, education, alleviate to improve QoL

Question 4

Ageism

Question 5

Nursing Processs

Answer 5

Critical thinking, decision making process

Assessment
Nursing Dx
Planning
Implementation
Evaluation

Question 6

Objective Data

Answer 6

Signs; what the nurse observes

Vital signs
Diagnostic tests
Outward appearance of client
Physical Examination
- Inspection
- Auscultation
- Palpation
- Percussion

Question 7

Subjective Data

Answer 7

Symptoms; what the client explicitly tells the nurse

Pain
Nausea
Tenderness
Told through physical exam (pain upon auscultation)
Health hx - fam/past/current
Medication use
Substance use

Question 8

Nasal Cannula

Answer 8

Use when SpO2 slightly low but still okay
Can eat using this
Deliver <5L

Question 9

Simple Face Mask

Answer 9

Use when need to deliver more O2 than nasal cannula
5-10L

Question 10

Non-Rebreather Mask

Answer 10

Use when you need to deliver higher than 21% O2

Question 11

Focused Assessment

Answer 11

Abbreviated health hx and physical exam when pt indicates pain/dysfunction in a particular system
ex. chest pain -> focused chest assessment

Question 12

Comprehensive Assessment

Answer 12

Thorough documentation of health hx and physical examination of all systems
If issue arises, will continue on and perform a focused assessment

Question 13

How to Assess Adequate Oxygenation

Answer 13

WoB - increased
Adventitious breath sounds
SpO2
ABGs
Cyanosis
Respiratory rate increased
Heart rate increased

Question 14

Interventions for Inadequate Oxygenation

Answer 14

Administer oxygen
- higher flow/concentration
Determine what could be causing the impairment
- diffusion: pneumonia? COPD?
- airway bronchoconstriction/remodelling: COPD, asthma

Question 15

Vital Signs

Answer 15

HR: 60-100 bpm
BP: 120/80 mmHg
RR: 12-20 br/min
SpO2: >95%
Temp: 36.6-37.5
Pain

Question 16

Pneumonia - Manifestations (S/S)

Answer 16

Wheezing and crackling breath sounds
Fever
Increased respiratory rate
Increased heart rate
Productive cough
Decreased SpO2

Question 17

Pneumonia - Nursing Assessments

Answer 17

SpO2
WoB
Adventitious breath sounds - auscultate
Equal chest expansion
RR/HR/Temp

Question 18

Pneumonia - Nursing Interventions

Answer 18

Semi-fowler’s position
Productive coughing techniques
Incentive Spirometer
Antibiotics
Bronchodilator
Mucolytics

Question 19

Pneumonia - Nursing Teaching

Answer 19

Tripod/Semi-Fowler’s position - helps with lung expansion
Incentive spirometer
Cough techniques
Mask wearing/hygiene

Question 20

Pneumonia - Possible Complications

Answer 20

ARDs
Pleural effusion
Pneumothorax

Question 21

Asthma - Manifestation (S/S)

Answer 21

Wheezing
WoB increased
Cough
Increased RR, prolonged expiration

Question 22

Asthma Nursing Assessments

Answer 22

Dyspnea, WoB, accessory muscle use
Chest expansion
Decreased SpO2
Adventitious breath sounds - wheeze

Question 23

Asthma - Nursing Management

Answer 23

Assessment: subjective - previous exacerbations, exposure to triggers, medications, vital signs

Nursing Dx: Ineffective airway clearance as a result of excess mucus production; Ineffective

Planning: goal - improve QoL, management of attack,

Implementation - asthma control plan

Question 24

Asthma - Nursing Teaching

Answer 24

Health Promotion: fluid intake, exercise, anxiety control, trigger avoidance, nutrition
Device management - inhalers, medications, etc.
Education + resources

Question 25

Asthma - Possible Complications

Answer 25

Could evolve into severe obstruction which could totally impair gas exchange Untreated/uncontrolled could lead to airway remodelling and chronic inflammation Hypoxemia, poor organ perfusion ARDS

Question 26

COPD - Manifestations (S/S)

Answer 26

Chronic, persistent dry cough for >3 months in two years Mucus/sputum production Dynamic hyperinflation - barrel chest Increased WoB Pursed lip breathing Dyspnea, SoB Smoking/particulate matter exposure hx Weight loss/anorexia Prolonged expiratory, wheezes, decreased breath sounds Tripod position Accessory muscle use Hypoxemia, cyanosis

Question 27

COPD - Nursing Assessments

Answer 27

Subjective: respiratory infections/illnesses, medications, pack years & smoking hx, dyspnea, exhaustion, irritability, exposure to particulate matter, restlessness, unable to fully exhale, anorexia/weight loss/difficulty eating, dyspnea, fatigue Objective: height/weight/BMI, anxiety, increased WoB, compensatory breathing mechanisms, depression/restlessness, cyanosis, peripheral edema, increased RR, prolonged expiration Equal chest expansion/retraction; body composition - thin? Adventitious breath sounds - wheeze, crackles Productive cough - sputum produced

Question 28

COPD - Nursing Teaching

Answer 28

Health Promotion: smoking cessation, exercise/walking, fluid & nutritional intake,

Question 29

COPD - Possible Complications

Answer 29

Pulmonary hypertension, right heart hypertrophy, cor pulmonale