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Fundamentals Of Nursing > Exam 3 Part 1 > Flashcards

Exam 3 Part 1 Flashcards

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1
Q

What mechanism is used to rid the body of trapped air?

A

Pursed lip breathing

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2
Q

What nervous system promotes the body’s rest and digest response to conserve energy to be used later and regulate digestion, metabolism and urination?

A

Parasympathetic Nervous System

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3
Q

What system drives the flight or fight response in stressful situations?

A

Sympathetic nervous system

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4
Q

The lubricant made in the lungs that keeps the alveoli from collapsing during exhalation is called…

A

Surfactant

*if alveoli collapses, they’re harder to open back up

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5
Q

When either ventilation OR perfusion doesn’t happen effectively, adequate gas exchange cannot occur

True
False

A

TRUE!!!

*both ventilation and perfusion need to be effective for good gas exchange

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6
Q

What is the point to which a lung can expand in response to increased pressure within the alveoli?

A

Lung compliance

*the more compliant the lungs, the more they can expand

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7
Q

Airway resistance is the pressure that exists when the diameter of the airway is narrowed.

A client with asthma is having a flare up causing their airway to constrict leading to wheezing and rhonchi. What has happened?

A

Increased airway resistance

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8
Q

A client is using accessory muscles to breath because they are in respiratory distress and require immediate assistance. What two factors play a role?

A

Lung compliance and airway resistance

*both increase the work of breathing

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9
Q

Coughing and deep breathing help post op clients prevent pneumonia. How is this technique performed?

A
  • take a deep breath, hold it for several seconds and exhale slowly
  • repeat 5 times
  • brace incision with pillow and try to cough deeply
  • repeat exercise ever 1-2 hrs
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10
Q

Huff Coughing is for clients who have thick secretions and is used to clear mucus. How is this method performed?

A
  • inhale air and hold
  • forcefully exhale
  • repeat four to five huffs
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11
Q

When administering oxygen, you should start with…

A

Least restrictive method which is via nasal cannula

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12
Q

Nasal cannula administers low flow oxygen at…

A

1-6 L/min

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13
Q

What two masks administer medium flow oxygen?

A

Simple face mask and Venturi mask

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14
Q

The Venturi mask administers medium flow oxygen at…and…

A

4-10 L/min and it’s MORE PRECISE

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15
Q

These two masks administer high flow oxygen both at 10-15 L/min…

A

Partial rebreather mask and Nonrebreather mask

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16
Q

The simple face mask administers oxygen at…

A

5-8 L/min

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17
Q

This device is capable of delivering different amounts of oxygen but also provides pressure…

A

CPAP/BiPAP

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18
Q

This oxygen delivery device is commonly used for obstructive sleep apnea (OSA)

A

CPAP/BiPAP

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19
Q

This adventitious lung sound is severe wheezing and is a medical emergency…

A

Stridor

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20
Q

In COPD, this lung sound can be described as whistling due to air moving through constricted airways…

A

Wheezing

21
Q

Rhonchi sounds like…

A

rattling caused by obstruction of airway. May be heard in clients with asthma and COPD

22
Q

This adventitious lung sound is caused by fluids filling the air sacs sounds like popping or crackling…

A

Crackles
*seen in clients with pneumonia

23
Q

What are methods of nursing care provided to a client experiencing heart failure?

A
  • Monitor VS, monitor labs (BNP, ejection fraction, CXR), I&Os
  • check daily weights and notify if weight gain 2lb/24hr or 5lb/week
  • HOB up
  • conserve energy
  • administer oxygen PRN
24
Q

Atelactasis

A

This is when there is a lack of surfactant in the lungs and the lung tissue collapses leading to a loss of volume during expansion.

25
Q

Asthma is caused by chronic, intermittent reversible airway obstruction of bronchioles.

What are health promotion/prevention methods?

A

Smoking cassation
Vaccinations (flu, pneumonia)
Avoid triggers
Infection prevention
Regular exercise
Clean environment (household, work, etc)

26
Q

What are nursing care actions given to a client with Asthma?

A

Position client in High Fowler
Apply oxygen PRN as prescribed
Administer bronchodilator as directed
Monitor RR, rhythm, effort O2 sat
Provide rest periods for dyspnea
Educate to seek treatment early for infections
Educate on proper use of meds (inhalers, nebs)

27
Q

Explain the Heart and Blood Circulation System

A

Deoxygenated blood coming from the vena cava enters right atrium/right ventricle - goes up into pulmonary artery- enter lungs - goes out pulmonary vein - enters left atrium/ventricle - enters aorta - systemic circulation

28
Q

COPD is a chronic irreversible disease. What are health promotion/prevention methods?

A

Smoking cessation
Avoid second-hand smoke
Use mask for exposure to irritants
Vaccinations (flu, pneumonia)

29
Q

Nursing care for clients with COPD:

A

Position in high fowlers or tripod
Encourage coughing and deep breathing, use IS
Administer neb or inhalers
Supplemental O2 to maintain 88-92%
Promote adequate hydration and nutrition
Educate on breathing techniques to control dyspnea (pursed lip, diaphragmatic)

30
Q

What is the pathway for electrical conduction of the heart?

A

SA Node - AV node - Bundle of His - Left Bundle Branch - Purkinje Fibers

31
Q

What is the process of physical examination of the respiratory system?

A

Inspection
Palpation
Percussion
Auscultation

32
Q

A client has left sided heart failure and this involves…

A

the lungs
* crackles can be heard

33
Q

A client has right sided heart failure and edema in the extremities. How does the edema progress?

A

Starts with feet, legs and ankles

34
Q

What are the types of Angina and describe them…

A

Stable Angina - relieved by rest and nitroglycerin. Last < 15 minutes

Unstable - may occur at rest or exertion. Increases in occurrence, severity and duration over time

Variant - usually at rest. Caused by coronary artery vasospasm

35
Q

What is done to help care for a client with angina?

A
  • Have client rest and administer nitroglycerin q5min x 3 doses. If unrelieved, ER/911/RapidResponse
  • Prepare for tests/exams. Stress test, cardiac cath (NPO, check for allergies)
36
Q

What health promotion/prevention methods help with Angina?

A

-physical activity
-have BP and cholesterol checked regularly
-heart healthy diet low in saturated fat and sodium
-smoking cessation
-educate on medications (nitro, beta blockers)

37
Q

Myocardial Infarction is a medical emergency. In assessment of MI, what can you see?

A

irregular HR, diaphoresis, anxiety, nausea, epigastric distress, dyspnea, lightheaded, dizzy, chest pain with radiation (not relieved by nitro/rest), SOB

Increased RR and HR

Females may experience pain between shoulder, ache in jaw or sensation of choking with exertion

38
Q

What care is provided to a client with Myocardial Infarction?

A

Monitor vital signs
12 lead ECG, telemetry
Monitor labs
Oxygen at 2-4l via NC
Prepare for test or possible procedures
Promote energy conservation
Administer meds (nitro, aspirin, morphine)

39
Q

What are health promotion and disease prevention methods for a client with heart failure?

A

Exercise
Heart healthy diet
Smoking cessation
Follow prescribed medication regimen

40
Q

What does left sided heart failure look like?

A

Cough, crackles, wheezes, tachypnea, tachycardia, confusion, orthopnea, fatigue, cyanosis, exertional dyspnea, restless, blood tinged sputum

41
Q

What does right sided heart failure look like?

A

Weight gain, JVD, fatigue, enlarged liver and spleen, ascites, anorexia, GI distress, increases peripheral venous pressure, dependent edema

42
Q

Symptoms of oxygen toxicity are:

A

Seizures, muscle twitching, eye problems, tinnitus, respiratory problems

43
Q

What is advised if administering 4 liters of oxygen?

A

Use humidifier for dryness

44
Q

What are important oxygen safety considerations?

A

NO smoking, no open flames
Keep heat sources >5ft away
NO flammable liquids or aerosols nearby
Let hand sanitizer dry completely before O2
Use 100% cotton
DON’T use petroleum, oil, grease based products on face and chest
Keep O2 cylinders upright
Keep O2 concentrators away from curtains/walls
Keep tubing <50 ft in length
Keep fire extinguisher nearby

45
Q

Some therapeutic nursing interventions are:

A

Pursed lip breathing, flutter valve, incentive spirometer, percussion using cup shaped hand

46
Q

How is an incentive spirometer used?

A

Used in 10 reps per hour with each breath held for 3 to 5 sec

47
Q

How is pursed lip breathing done?

A

Breathe in 2 counts and breathe out 4 counts

48
Q

How is a flutter valve used?

A

Client seals mouth around mouthpiece and inhales, exhales for at least 3 to 4 sec, breaths should be 10 reps, client coughs up to 3 times

Fundamentals Of Nursing (2 decks)

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