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Nursing Inter, Asses, & Comm Book > Exam 2 > Flashcards

Exam 2 Flashcards

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1
Q

Where does the airway begin & end?

A

Begins at nose, & ends at terminal bronchiole

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2
Q

Upper airway consists of

A

nose, larynx, pharynx, & epiglottis

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3
Q

Lower airway consists of

A

trachea, bronchial tree, R & L Bronchi, segmental bronchi & terminal bronchioles

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4
Q

Function of lower airway

A

conduct air, clear mucus by cilia, & produce pulmonary surfactant

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5
Q

Which is more anterior ? The trachea or the esophagus?

A

tracheae is anterior to the esophagus (hence back to sleep)

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6
Q

Trachea ends & becomes right & left lungs where?

A

at the 2nd intercostal space

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7
Q

Where do the lungs begin & end?

A

Apex of lungs extend above the clavicle

Base of lungs at the 6th rib

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8
Q

Posteriorly, lungs begin at ___

Base of lung at_?

A

Lungs begin @ T1
Base of lungs at T10
Deep breathing= T12

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9
Q

Right side of lung

A

Has 3 lobes, separated by Horizontal fissure

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10
Q

What are the other fissures of the lungs called?

A

Oblique fissure

ends at 6th rib

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11
Q

Right lower lobe

A

is practically under armpit

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12
Q

On the left anterior lobe we mostly auscultate

A

upper lobe

ends at 6th rib mid-clavicular, starts under armpit T3

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13
Q

Right thorax

A

5th rib mid axillary line unites all 3 lobes

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14
Q

Left thorax

A

Oblique fissure from T3 beginning -6th rib mid clavicular line

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15
Q

Factors that affect respiration

A

Hunchback of scoliosis
Air trapped in spaces
Copriised respiration

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16
Q

Right middle lobe

A

is not a part of posterior right lobe

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17
Q

Position

A

tripod position=can’t breathe–> drop diaphragm to try to expand their lung volume

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18
Q

Activity & exercise

A

promotes pulmonary exercise & respond better to respiratory distress

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19
Q

Pregnancy

A

3rd trimester

orthopnea: not able to be comfortable while laying flat

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20
Q

If patient is having a hard time breathing first thing you should do is

A

put the head of their bed up

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21
Q

Smoking

A

contributes to lung disease: macrophages in lung destroy the protein that allow the lungs to expand.
> mucus production

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22
Q

Air pollution

A

Room air is 21% oxygen

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23
Q

Asbestos & coal dust

A

cause lung disease

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24
Q

Cough is/signals

A

Cough is most important lung defense
Clears irritating substances in lungs
warning signal

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25
Q

Generation of cough

A

Histamine released due to irritated substance

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26
Q

Non-described, long standing cough

A

Something more serious is going on

Warning sign of HF, lung cancer, HTN

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27
Q

Productive cough has what characteristics

A

Produces sputum: volume, consistency, color & odor

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28
Q

Is shortness of breathe subjective?

A

Yes, you cannot tell just by looking at them. Explore degree with pt.

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29
Q

Word for subjective SOB

A

Dyspnea

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30
Q

What are the characteristics of central hypoxia?

A

confusion, anxiety, inability to follow direction

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31
Q

Signs of respiratory distress?

A

clubbed nails, tripod position, nasal flaring

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32
Q

breathing pattern characteristics

A

Rate, rhythm & depth

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33
Q

Signs of effort to breathe

A

distressed, diaphragmatic, labored, pursed lips

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34
Q

skin color

A

general color, lip color, nail bed

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35
Q

Hyperpnea

A

tachypnea but deeper

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36
Q

Hypoventiliation

A

breathing less than 12 bpm but more shallow

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37
Q

Cheyne-stokes

A

periods of apnea
Last 10-60 sec flowed by periods of hyperventilation
Common in people in comas or about to die

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38
Q

Pectus Excavatum

A

Congenital deformity
Hollow chest: internal cartilage & ribs are concave
Applies pressure to heart & lungs
Treatment: invasive surgery

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39
Q

Pectus Carintum

A

Pigeon chest–> sternum protrudes
Repair is easy
Develops during school age

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40
Q

Spinal Deformities

A

Hyphotic spine: more difficult to breathe,

< stature

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41
Q

Barrel Chest

A

Round chest configuration
Sternum pushed out
Common in COPD
1:1 ratio instead of normal anterior thorax is 2x as big as posterior

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42
Q

Normal chest configuration

A

Anterior/posterior diameter if chest is 1/2 the length of the transverse

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43
Q

Barrel chest

A

1:1 diameter of the chest

Commonly seen in: emphysema, cystic fibrosis, infants & elderly

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44
Q

Respiratory expansion

A

Palpation, assessing the symmetry of the chest expanding during inhale & exhale
Thumbs on T10 vertebrae with fingers spread apart, look for thumb movement & symmetry

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45
Q

Where to begin acultation?

A

on the back
Listen side–> side
Top to bottom
Compare to other side & look for asymmetry

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46
Q

Bronchial sound charactersitics

A

Over the trachea & larynx, LOUD, inspiration 1/3 of expiration

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47
Q

Bronchiovesicular

A

Over the sternum, 2-3 intercostal space
T3 & T4
I=

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48
Q

Vesicular sound

A

Everywhere else
Inspiration 2/3 expiration 1/3
GENTLE

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49
Q

When normal lungs are displaced?

A

Breathe sounds are diminished in intensity

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50
Q

Adventitious breathe sounds are…

A

Always abnormal but not always significant

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51
Q

The larger the airway

A

The louder the sound

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52
Q

Crackles

A

High pitched and discontinuous
Heard at the end of inspiration
Does not clear with coughing
Sign of buildup of phlegm & fluid in alveoli

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53
Q

Pneumonia crackles

A

Consolidation of alveoli
Airspace is filled with excaudate & anti-inflammatory modifirs
Crackles & bronchial breath sounds

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54
Q

Pulmonary Edema

A

Develop crackles due to excess of fluid in alveoli

Becomes more coarse over time

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55
Q

s/s of pulmonary edema

A

Dyspnea, SOB, lower, lower O2 saturation, air hunger, orthopnea, have productive cough

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56
Q

Wheeze

A

Heard on inspiration & expiration (usually louder on expiration)= continuous
High pitches/ musical

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57
Q

Asthma is…

What type of adventitious breathe sounds will you hear with it?

A

Wheeze

Chronic inflammation of the lungs: contact with allergen triggers- narrows airway & lungs swell

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58
Q

Stridor

A

Strong wheeze, obstructed airway associated with upper larynx & trachea

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59
Q

Croup is associated with ___ breathing

A

associated with stridor on inspiration, expiration sounds like barking seal
Swelling & inflammation of vocal cords & throat

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60
Q

Rhonchi

A

snoring, low pitched o
Heard on inspiration & expiration
May clear with coughing
Caused by air bubbling past secretions in large airways

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61
Q

Ronchi is associated with

A

Bronchitis
Inflammation of bronchi causing an > production of mucus on lining of upper airways
Air passing through mucus membrane causes bubbling rhonchi

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62
Q

Pleural friction rub

A

Low pitches, dry grating sound

Heard on inspiration & expiration

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63
Q

Pleural friction rub is associated with:

A

Pleurisy: inflammation of the lining of the lungs
-deeper breaths the more pain they experience
Breathe shallowly and < frequently
-hypotonia- (< muscle tone)
-hyperventilation

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64
Q

Pleural Effusion

A

Diminished or absent breathe sounds over effected area.

Collection of pleural fluids that is outside the lungs.

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65
Q

Pleural effusion is associated with:

A

Pneumothorax: Lung has collapsed, air around the lung cannot contract
You will hear normal breathe sounds on one side & none on side that is collapsed

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66
Q

Hemothorax

A

collection of blood outside the lungs

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67
Q

Chest Physiotherapy

A

Percussion called clapping! Also can do vibrations= manual compression & tremor on chest wall
Purpose: to loosen & mobilize secretions & cause clearance. Use gravity

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68
Q

People with _____ illnesses have large secretions & don’t have productive cough

A

pneumonia, cystic fibrosis, COPD

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69
Q

Chest X-ray

A

can see fluid/air in pleural space
Collapsed or under-inflated lung. Consolidation
Position of catheter tube

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70
Q

Peak flow meter

A

measure peak EXPIRATION
Reflects size of airways, severity of illness= how constricted

male expires ~600mL/min
Female expires ~475mL/min

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71
Q

Incentive spirometry

A

Measures maximal inhalation
8-10 breaths/Hr w/a

Male inhales ~3200mL

Females inhale ~2600mL
Prevents pneumonia & collapsed lung
Get secretions in lungs at level to be coughed out

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72
Q

aerosol therapy:

small volume nebulizers:

A

Add moisture to O2 delivered

Hydrates thick sputum (delivered to deep area of respiratory tract)

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73
Q

side effects of bronchodilators

A

> HR, BP, RR, agitation, anxiety, fluid retention

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74
Q

Aerosol therapy: steroids

A

Pt uses 4/5 L of O2
Inhale slowly, or hold breathe, exhale through nose, inhale
Keep in mouth until all medication is gone
Mouth care after they finish
Assess pt before & after pt uses med

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75
Q

Sputum culture

A

lab test (30 min) or C&S both tell you which antibiotics to order

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76
Q

after surgery there’s a risk for

A

lung collapse since cough reflex was suppressed, after surgery= pt in pain, alveoli not inflating secretions being retained

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77
Q

Types of cough

A

Deep cough: no pain, take a deep breathe & forceful expiration

Stacked cough: in pain
Series of short, quick coughs
Take in deep breathe in but force out is quick

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78
Q

Pursed lip breathing

A

Pt is having a difficult time breathing, keeps bronchial expanding
breathe through nose (for count of 2)
Exhale through the lips (for count of 4)

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79
Q

Lowest possible oxygen saturation & gas pressure in blood

A

93% o2 stat

68% gas pressure in blood

80
Q

at what point should oxygen be humidified

A

5mL

always used during high flow oxygen

81
Q

Nasal cannula has how much O2 dispersion?

A 
24-44%
2L=28%
3L=32%
4L=36%
5L=40%
6L=44% (MAX AMOUNT)
82
Q

Simple mask

A

40-60% oxygen
Most common but not specific, put oxygen at 5L and they receive 40-60% oxygen
contraindicated for people who need specific amounts of oxygen

83
Q

Venturi

A 
Delivers 24%-50% oxygen. Has potential to give more than nasal cannula, but can control unlike simple mask
Blue=24%
Yellow= 28%
White= 31%
Green= 35%
Pink= 40%
Orange= 50%
84
Q

Reservoir mask

1st type

A 
Rebreather mask (50-70% of oxygen)
Non-specific
85
Q

reservoir mask 2nd type

A

Non- rebreather mask (80-90% oxygen)
Bag attached to bottom: stays inflated all the time
White disks on each side of the patients mask
Disks off: patient rebreathing little CO2
Flow meter 10-15mL

86
Q

Pts with COPD

A

no more than 32% oxygen

have humidor gently bubbling

87
Q

Artificial Oral airway

A

for patients who are unconscious, extends t back of tongue & throat
prevents tongue from blocking airway
NEVER TAPE

88
Q

Ambu Bag

A

Delivers artificial respiration
Use at normal RR
Never depress bag fully

89
Q

how to keep oral secretions thin?

A

drink fluids

90
Q

breathes sounds that are moderate “blowing” with I=E are

A

Bronchovesicular

91
Q

What category of medications may be administered via nebulizer to open airways?

A

Bronchodilators

92
Q

s/s f hypoxia

A

dyspnea, tachycardia, cyanosis

93
Q

What question might the nurse ask to assess for orthopnea

A

How many pillows do you sleep with at night?

94
Q

crackles are caused by

A

moisture in airway

95
Q

How often should nurse check pt for effective coughing?

A

Q2hr

96
Q

Postoperative pt can cough more effectively by:

A

holding a pillow or folded bath blanket over the incision

97
Q

wheezes occur during

A

inspiration & expiration

98
Q

The nursing process includes

A

Assessing, Diagnosing, Outcome Identification, Implementation, & Evaluation

99
Q

The purpose of an assessment is to

A

Establish baseline VS & function
Determine normal fxn
Determine presence of dysfunction (maintain prior level f functioning)

100
Q

Appraisal of the total patient situation

A

Physical, psychological, emotional, sociocultural, spiritual

101
Q

Do you validate nursing diagnosis with the pt?

A

Yes

102
Q

Assessment Data

A

Directly from patient or patient’s significant other (if impaired)

103
Q

Secondary source of data:

A
  • Family members, significant other from patient not impaired
  • Health records
  • Lab values, diagnosed test
104
Q

Objective Data

A

BP, Vomiting, Age

105
Q

Nursing Diagnosis is based on

A

Our assessments provide basis for nursing diagnosis

Identified pt problem

106
Q

Actual Diagnosis has 3 factors

A

1) Diagnostic label
2) Relatable factors (etiology causing factor)
3) Defining characteristics (s/s, validates diagnosis)

107
Q

how do you make a diagnosis stateent for risk?

A

2 part statement:

Diagnostic label related to etiology causes

108
Q

Patient goals are written

A

As behavioral statements from patients POV

109
Q

Cognitive

A

pt understands or has knowledge

110
Q

Psychomotor

A

pt demonstrates that they can perform a skill

111
Q

Psychologic:

A

Physical change in parameter

112
Q

Affective

A

indicates change in pts attitude, values, and beliefs

113
Q

Goal Outcome criteria

A

Pt will do what action, how well, & by when

114
Q

What is an example of an affective outcome?

A

Mother will verbalize the benefits of following discharge instructions

115
Q

Nursing Interventions

A

Independent nursing actions, physician initiated interventions, & collaborative interventions

116
Q

Intervention and Rationales for Pain

A

Intervention: teach patient correct dosage, time frame, and precaution for taking analgesia
Rationale: knowing when and how to take pain medication will maximize pain relief and minimize adverse effects

117
Q

Evaluation

A

Indicate if the outcomes/goals were met or unmet
Indicate actual behavior as supporting evidence
If goal was not met , make recommendations for revising the plan of care

118
Q

What activity is carried out during the implementing step of the nursing process?

A

Planned nursing actions (interventions) are carried out.

119
Q

A nurse writes down the following outcome for a depressed patient: “By 6/9/12, the patient will state three positive benefits of receiving counseling.” This is an example of which of the following types of outcomes:

A

affective

120
Q

Who or what is the primary source of information for a nursing history:

A

the patient

121
Q

Which of the following are verbs that are helpful in writing measurable outcomes:

A

Define, list, verbalize

122
Q

A student identifies Fatigue as a health problem and nursing diagnosis for a patient receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this patient problem:

A

I think fatigue is a problem for you; do you agree?

123
Q

What type of data would you call nausea and abdominal pain?

A

subjective

124
Q

Which of the following patient care concerns is clearly a nursing responsibility:

A

Monitoring health status changes

125
Q

This is an example of a:The patient will be able to list five symptoms of infection on discharge

A

well written outcome

126
Q

Which part of this diagnosis is considered the problem statement?
Processes related to Alzheimer’s disease as evidenced by incoherent language.

A

Disturbed thought process

127
Q

Can you give a pt’s spouse info over the phone w/o their permission?

A

No

128
Q

HIPPA

A

1 Provides provision for patient: they can see and copy medical records at any time
2 Viewing medical records: patient is allowed, cannot review medical record unless that is your patient for that day
3Telephone conversation: who ru talking 2? Do u have permission to talk w them?
4Hallway/waiting room conversation: not talking about patients, keep patient conversation confidential
5Information to family members and friends: need to get patient’s permission

129
Q

Goals of documentation?

A 
Delivery of quality patient care
Continuity of care
Communication of treatment goals
Progress toward goals
Interdisciplinary consistency
130
Q

Pt transfer should be done:

A

face to face, give synopsis of pt

131
Q

SBAR

A

S= situation, what is occurring at the time
B=background, what lead up to current situation
A= assessment, what is going on
R=recommendation, what do we want/expect to correct current problem

132
Q

Quality inferential statement

A

Seemed/appeared statement: not inappropriate
We can infer things based on knowledge and relationship of patient
But must provide reason why you think this is occurring
Documentation Errors

133
Q

How to document errors on hard copies

A

Single line in the error
Write word ERROR
Take accountability (name, credential, time)

134
Q

SOAP Notes

A

Subjective
Objective: measurable
Analysis
Plan: what should be done

135
Q

DAR Note

A

Data, Action, Response

136
Q

Charting By Exception

A

Conclusive to electronic record
Identify what hospital course should look like and critical pathway toward getting better
Much of it is a checklist
Variable chart

137
Q

Electronic Heath Record

A 
The patient is focus of the chart
Report the facts
New/change information and objectives
Support subjective data with objective feeds
Chart things done for the patient
Avoid personal opinions and biased statements
Chart problems with actions taken
Chart patient response and reaction
138
Q

In which of the following cases should a progress note be written:

A

When admitting a patient, When receiving a patient postoperatively, When a procedure is performed

139
Q

What is evaluated when conducting a nursing audit

A

Patient records

140
Q

Decode versus encode

A 
decode= pt understanding the message
recode= encoded message that nurse must decode
141
Q

Genuineness

A

present yourself honestly and spontaneously

142
Q

Empathy

A

ability to perceive another person’s’ situation and view it from that perspective

143
Q

Concreteness

A

Promote understanding & sensibility

144
Q

Vocal paralanguage

A

Our words & how we deliver them: Tone, pitch, volume, rate of speech

145
Q

3 elements of communication

A

words 7%
tone 38%
body language 55%

146
Q

Validating

A

You state the words as you heard them

147
Q

Clarifying

A

You make sure you understand what the pt said

148
Q

Reflection

A

repeating what the person said or describing the person’s implied feeling–> restate emotional component

149
Q

Directing/focusing: ask for elaboration on the topic

A

asking for elaboration on a topic

Tell me more about _______

150
Q

What term describes a nurse who is sensitive to the patient’s feelings but remains objective enough to help the patient achieve positive outcomes:

A

empthetic

151
Q

Narrow index of therapeutic & toxicity

A

Liver
Kidney
GI

152
Q

Height + weight can be used pharmokinetically

A

Body surface areas (BSA) used for drug dose calculations

153
Q

FDA

A 
Responsible for public safety of drug
Responsible for sales and marketing (effectiveness)
controls drug advertisement
Control what drugs need prescriptions
Prevents unsafe drugs for being marketed
154
Q

Class 2

A

most perscribed drugs, usually narcotics, highly reguated, require 2 nurses

155
Q

Class 5 drugs

A

OTC drugs

156
Q

Drug order components

A 
Patient name
Date and time written
Medication name
Medication dose
FREQUENCY OF ADMINISTRATION
Route of administration
SIGNATURE WHO GAVE THE ORDER
157
Q

One time order

A

usually a loading dose

158
Q

repeat order

A

use judgement with your assessment, usually a time parameter and may be ordered to give but otherwise use your judgement

159
Q

1 grain=

A

60 mg

160
Q

1mg=

A

1000mcg

161
Q

1000mg

A

1,000,000mcg

162
Q

1mL

A

15 gtts (drops)

163
Q

15mL=

A

3tsp= 1TBL

164
Q

30mL =

A

1 fl oz

165
Q

240mL

A

8fl oz= 1 cup

166
Q

How to pour liquid meds

A 
Pour liquid medication at eye levels
Read dose at the base of meniscus
Pour away from label
Drug calculation:
Drug on hand/quantity on hand= dose required/ X quantity desired
167
Q

3 administration checks

A

check drug matches, MARS when retrieve medication
Re-check ever med after retrieval against MAR
Before give each med, check MAR

168
Q

Document

A

As soon as given, & give reason, document response to medication, 15-30 min after given

169
Q

AD AS AU

A 
AD= right ear
AS= Left ear
Au= both ears
170
Q

NOC

A

night

171
Q

DS

A

Double strength

172
Q

ung

A

ointment

173
Q

Write out daily, every other day, write out unit, use mL, use international units
tid is not as accurate as Q8hr

A

No QD or anythin

174
Q

Do not use transdermal patch if

A

pt has temp > 102

175
Q

when administering oticlly in adults

A

pull pinna up and back.

after giving meds, massage tragus

176
Q

when administering otically in kids

A

pull pinna down and back

177
Q

Intradermal injection locations:

A

inner forearm, upper arm, across scapula

178
Q

technique for bevel needle in intradermal injection

A

Control depth
DO NOT BEVEL DOWN,Bevel down will push into subcutaneous tissue.
Inject at 5-15 degree angle

179
Q

Measure induration of intrdermal injection

A

hardening of bleb is a positive reaction

180
Q

Subcutaneous injection

A 
0.5-1.0mL
small gauge 25-28 gauge
Sites: abdomen, upper arm, back of thigh
Needle length
Needle insertion angle 
1 inch bunch: 45 degrees
2 inch bunch: 90 degrees
181
Q

Insulin

A 
agitate suspension
Observe for lipodystrophy: depression of the skin due to bad rotation and cold insulin injection
Use one inch rule
25-30 gauge
1/2-5/8 in needle
Draw from NPH last
182
Q

Heparin

A

25-28 gauge
5/8-7/8 needle length
insert away at 90’

183
Q

Intramuscular Injection

A

use 3-5mL injection
19gauge-25 needle
5/8in-3in needle
Z-tracking recommended for all IM injections

184
Q

Deltoid IM

A 
Max 2mL
midaxillary line
2.5-3cm below acromion process
5/8-1.5 in needle
Close to radial nerve &amp; brachial artery
185
Q

Vastus Lateralis

A

Best for toddlers
Not around nerves or vessels. Inject into outer middle third
5/8 -1.5 needle

186
Q

Ventrogluteal

A 
Free of blood vessels &amp; major nerves
Considered safest &amp; least painful
Not recommended for older adults
typically 1.5 in 
up to 3 mL
Landmark: greater trochanter (heel of hand), anterior superior iliac ===spine (pointer), iliac crest (middle finger)
187
Q

Dorsogluteal

A

Not recommended
Close to sciatic nerve
Superior gluteal artery
Thick layer of fat

188
Q

Draw up orders

A

Draw up vial before ampule
Draw up multi-dose before ampule
Prefilled syringes are norally overfilled

189
Q

Actovial

A

when you press down to the top, the diluent mix with the powder

190
Q

Which parts of the needle should be kept sterile?

A

The needle, the inside of the barrel & the part of the plunger entering the barrel

191
Q

What should you do if your needle is coated with liquid?

A

change needle
Viscous that can’t be in subcutaneous tissue change needle
Always change for z-tracking

192
Q

Tuberculin Syringe (Tb)

A 
Small and narrow
Holds 1 mL
.01 marking
¼ or ½ needle
change needle for SL or IM use
193
Q

Factors to consider for needle length

A

¼ - 3 inch)
Muscle mass
Adipose tissue
Look at patient and make judgment

194
Q

Factors to consider for needle diameter

A

14-29
Lower number: the larger diameter
Considered by viscosity or medication to be administer

195
Q

Contaminates the plunger after the medication is drawn into the syringe do you have to discard it?

A

No, administer as prescribed

Nursing Inter, Asses, & Comm Book (6 decks)

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