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Nursing School > NR 462: Exam 2 > Flashcards

NR 462: Exam 2 Flashcards

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1
Q

Hypoxia Signs/Symptoms

A

RAT BED

Early Signs:

  • Restlessness
  • Anxiety
  • Tachycardia/Tachypnea

Late Signs:

  • Bradycardia
  • Extreme Restlessness
  • Dyspnea
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2
Q

Important assessments obtained during a focused respiratory assessment include

A
  • auscultation of lung (breath) sounds.
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3
Q

as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration

A

Crackles

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4
Q

Presence of acid-fast bacilli in the sputum indicates

A

active tuberculosis.

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5
Q

decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath

A

Hypoxia

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6
Q

strongly binds to hemoglobin, making it unavailable for oxygen binding and transport

A

Carbon monoxide

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7
Q

When the body cannot meet the increased oxygenation need, what happens?

A
  • increased metabolic rate
  • breakdown of protein and wasting of respiratory muscles,
  • increasing the work of breathing.
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8
Q

Saline has been found to cause more side effects when…

A
  • suctioning and does not increase the amount of secretions removed.
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9
Q

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?

A

Incentive spirometer

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10
Q

What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia?

A

Fingernails and their base

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11
Q

is used to distinguish benign and malignant pulmonary nodules

A

Positron emission tomography (PET)

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12
Q

involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax.

A

Thoracentesis

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13
Q

Postoperatively there is an increased risk for

A
  • atelectasis from anesthesia
  • restricted breathing from pain.
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14
Q

he nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to a 35-year-old female employee. Which question should the nurse ask before administration of this vaccine?

A

Could you be pregnant now?

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15
Q

Clear nasal drainage suggests leakage

A
  • of cerebrospinal fluid (CSF), presence of glucose
  • A drip pad may be applied, but the patient should not be reassured that this is normal.
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16
Q

The patient seeks relief from the symptoms of an upper respiratory infection (URI) that has lasted for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis?

A

Maxillary Pain

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17
Q

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect?

A

Gastrostomy tube
because the effects of treatment make it difficult to take in enough nutrients orally

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18
Q

A patient with a history of tonsillitis complains of difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse?

A

Contraction of neck muscles during inspiration

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19
Q

The school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus?

A
  • Cover the nose when coughing.
  • Obtain an influenza vaccination.
  • Stay at home when symptomatic.
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20
Q

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do

A
  1. adequate fluid intake
  2. Splint the chest when coughing.
  3. Instruct patient to cough at end of exhalation
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21
Q

What precautions is influenza

A

Droplet

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22
Q

What is the perimeter of droplet

A

5’ perimeter

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23
Q

A flu patient developed crackles in the lungs, what have they developmed

A

Pneumonia

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24
Q

physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance?

A

Respiratory Rate 28

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25
Q

Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia?

A

Increased vocal fremitus on palpation, bronchial breath sounds, egophony, and crackles in the affected area

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26
Q

What is the priority nursing intervention in helping a patient expectorate thick lung secretions?

A

Increase fluid intake to 3 L/day if tolerated.

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27
Q

An increased risk of pulmonary embolism is associated with

A
  • obesity
  • malignancy
  • heavy cigarette smoking
  • prolonged air travel with reduced mobility
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28
Q

When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication?

A

Antibiotic

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29
Q

Hypertension- Nursing Care

A

DIURETIC

  • Daily Weight
  • Intake and Output (I & O)
  • Urine Output
  • Response of BP
  • Electrolytes
  • Take Pulses
  • Ischemic Episodes (TIA)
  • Complications:
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30
Q

Collapsed Alveoli

A

Atelectasis

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31
Q

Hyptertension Complications 4C’s

A
  • Coronary Artery Disease
  • Coronary Rheumatic Fever
  • Congestive Heart Failure
  • Cerebral Vascular Accident
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32
Q

Create labs for someone with metabolic acidosis

A

low pH low HCO3

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33
Q

Labs for someone with Metabolic Alkalosis

A

High pH High HCO3

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34
Q

Respiratory Acidosis Labs

A
  • pH Low
  • PCO2 High
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35
Q

Normal Value for HCO3

A

22-26

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36
Q

Normal Value PCO2

A

34-45

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37
Q

Lab values when only partially compensated

A

all three values will be abnormal. One value will be working harder to compensate.

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38
Q

Lab Value when fully compensated

A

pH will be normal

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39
Q

Diseases that can cause Acid Base Imbalances

A
  • COPD
  • Pulmonary Edema
  • Pneumonia
  • Hyperkalemia-Acidosis,
  • Hypokalemia Alkalosis,
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40
Q

Step 1: Blood has cicrulationg through the body, lost its oxygen and collected CO2, where does it enter?

A
  • Right Atrium of the heart through the Vena Cava
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41
Q

Step 2: Right Atrium Contracts and pumps blood through which valves?

A

Tricuspid valve and right ventricle

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42
Q

Step 3 of 9: The Right Ventricle pumps blood where?

A
  • Through the pulmonary artery into the lungs
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43
Q

Step 4: What do the tiny blood vessels (capillaries) in the lungs do?

A

absorb CO2 from blood and replace it with oxygen

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44
Q

Step 5: oxygenated blood flows through the pulmonary vein and into where?

A
  • Left Atrium
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45
Q

Step 6: Oxygenated blood pumps throu the mitral valve and into where?

A

Left Ventricle

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46
Q

Once the blood has gone through the aortic arch, what are the option for where blood can be pumped?

A
  • thru carotid artery into the brain
  • auxiliary arteries into the arms
  • aorta and into the torso/legs
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47
Q

Step 8: Blood moves through the arteries, then through capillaries, where does it return?

A

Veins

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48
Q

Step 9: What is the last step of the cardiac cycle?

A

Deoxygenated blood will return to the heart

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49
Q

this pumps blood to pulmonary circulation

A

right ventricle

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50
Q

pumps blood to the systemic circulation

A

left ventricle

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51
Q

this is a valve between LA & LV

A

Mitral Valve

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52
Q

Valve betwee RV & Pulmonary Aorta

A

pulmonic valve

53
Q

Contraction of Myocardium

A

Systole

54
Q

Relaxation of Myocardium

A

Diastole

55
Q

Normal Value for Mean Arterial Pressure

A

Must be greater than 60

56
Q

as the average pressure in a patient’s arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure (SBP).

A

Mean Arterial Pressure

(CO X Systemic Vascular Resistance) + Central Venous Pressure

57
Q

Amount of blood ejected from the left ventricle with each beat

A

Stroke Volume

58
Q

How much output of blood does the heart put out

A

4-6 liters

59
Q

peptide hormone secreted by the cardiac that in pharmacological doses promotes salt and water excretion and lowers blood pressure

A

natriuretic peptide

60
Q

this hormone lives in the Atria

A

a- natriuretic peptide

61
Q

This hormone lives in the ventricle

A

B-natriuretic peptide

62
Q

What happens to heart function in older adults?

A
  • the heart muscles decrease
  • become stiff
  • Need for pacemakers
63
Q

What drug are older adults are less sensitive to?

A

Beta Adrenergic Agonist Drugs

64
Q

Define Preload

A
  • How much the heart stretches before it contracts
  • higher the preload, the harder the heart has to work
65
Q

What is another name for preload

A

End Diastolic Volume

66
Q

Define Afterload

A
  • the tension developed in the wall of the left ventricle during ejection.
67
Q

Good Cholesterol

A

HDL

68
Q

Bad Cholesterol

A

LDL

69
Q

Why would you test CBC for a patient with Anemia?

A
  • would have low red blood cells
  • would have a hard time carrying oxygen
  • Tachycardia
70
Q

Define Hypertension

A

Force exerted by the blood against the walls of the blood vessel. No symptoms. (sys above 140, diastole above 90)

71
Q

Modifiable Risk factors of hypertension

A
  • sodium intake
  • smoking
  • stress
72
Q

Non Modifiable Risk factors for hypertension

A
  • Family History
  • African American
73
Q

Symptoms of Hypertension

A
  • “silent killer”
  • Any damage from high BP
  • dizziness
  • Headache, pressure in the brain
  • Fatigue
  • Dyspnea
  • Problems w/ retina
74
Q

Assessing someone with Hypertension

A
  • Health HX
  • Phys Exam
  • BP in both arms
  • Manual BP
  • Patient should be seated quietly for 5min
  • Take 2 Measurements
75
Q

Goal for patient with Hypertension

A
  • Control BP
  • Reduce CVD Risk Factors
76
Q

Nursing Inverventions for someone with Hypertension

A
  • empathy
  • motivation/adherence to therapy
  • consider cultural beliefs
  • Taking meds
77
Q

Menu for someone with Hypertension

A
  • DASH diet
  • Fish every week
  • Fruits, Vegetable
  • Lots of Water
  • Potassium
  • Low Sodium
78
Q

What is a hypertension Crisis?

A
  • Diastolic blood pressure above 140.
  • Not taking meds or undermedicated.
  • Treat it with IV. Monitor bp.
79
Q

1 Drug for Hypertension

A

Diuretics

80
Q

Right Sided Heart Failure

A
  • Chronic Respiratory Problems
  • Ascites
  • Cor Pulmonal
  • Weight Gain
  • MI
  • Ab Pain
  • JVD
  • Hepatomegaly
  • Peripheral Edema
81
Q

Left Sided Heart Failure

A
  • Most Common
  • Pulmonary Congestion
  • Crackles
  • Poor Oxygenation
  • S3, Increase Afterload
  • Irregular Palpitations
  • Pulmonary Edema
  • Diastolic and systolic dysfunction
  • Blood backing up into right atria
82
Q

Diastolic Failure

A
  • Ventricles become stiff, cannot relax
  • Normal Ejection Fraction
  • Low BP
  • Low Cardiac Output
  • Pulmonary Congestion
  • Poor Exercise Tolerance
83
Q

Systolic Fairure

A
  • Ventricles Swell
  • Decrease in left ventricular ejection fraction
84
Q

Normal Ejection Fraction

A

55%

85
Q

Difference between Left Sided Heart Failure Vs. Right Sided Heart Failure

A
  • RT- Peripheral Edema
  • LF- Pulmonary Edema
86
Q

Diagnostic Testing for Heart failure

A
  • BNP
  • ANP
  • Creatnine Kinase
  • Troponin
  • Fibronogen
  • Chest Xray
  • EKG
  • Coronary Angiogram
  • Echogram
87
Q

What is the exercise stress test for heart failure

A
  • Put them on a treadmill 5 min
  • walk test
  • pass/fail
88
Q

Clinical Manifestation of Acute Decompensated Heart Failure

A
  • Dyspnea,
  • orthopnea
  • fatigue
  • Paroxysmla Nocturnal dyspnea
  • Waking up feeling like their suffocations, because of reabsorption of fluid.
  • Persistent dry cough.
  • Frothy (bubbly) blood tinged sputum (pink).
  • Cyanoisis
  • Clammy Skin
89
Q

sample list of vital signs for a patient in distress ADHF

A
  • Irregular pulse
  • low urine put
  • Weight gain
  • Fluid retention
  • Anorexia
90
Q

Nursing Diagnosis for a patient with heart failure

A
  • Activity Intolerance
  • Fluid Volume Excess
  • Impaired Gas exchange.
91
Q

Goals for a patient with Heart Failure

A
  • Decrease Intravascular Volume (diuretics)
  • Decrease Preload
  • Decrease After load (vasodilation)
  • Reduce Anxiety
92
Q

Patient positions for a patient with high fowlers

A

High Fowlers

93
Q

Aneurism Definition

A

weakend blood vessel

94
Q

What are outcomes of ventricular dysfunction

A
  • Diminished Quality of Life
  • Reduced Exercise Tolerance
95
Q

Ejection Fraction Definition

A
  • Fraction of blood pumped out for the ventricle with each heart beat
  • Applies to right and left
  • SV/End Diastolic Volume
96
Q

Complications of Heart Failure

A
  • Pleural Effusion
  • Fatal Dysrrythmias
  • AFib
  • Respiratory Acidosis
97
Q

Define Ventilator Acquired Pneumonia

A
  • 48 hours after intubation, before the onset of the event
98
Q

Aspiration Pneumonia Definition

A
  • Aspirated something into their lungs
  • Decreased LOC
99
Q

Hospital Acquired Pneumonia

A
  • Occurring 48 hours or longer after admission
  • Not incubating at time of hospitalization
100
Q

Causes of Pneumonia

A
  • Smoking
  • Secondhand smoke
  • Asthmna
  • Genes
  • pollution and fumes
101
Q

COPD Patient Assessment

A
  • Use Pursed Lipped Breathing
  • Use Oxygen as prescribed
  • Close ended question
  • High Fowlers, Orthopnea, Tripod
  • Chest percussions
  • Respiratory Rate
  • Lung Sounds
  • Heart Rate increased
  • Sputum culture in the morning
  • 6-8 wks deep breathing exercises
102
Q

Nutrition w/ COPD patient

A
  • adequate fluid intake
  • Small meals more frequently
  • Avoid foods that cause gas
  • High Calorie
  • High Protein diet
  • Instructo to cough at end of exhalation
103
Q

Signs of COPD

A
  • productive cough for 3 or more months in each of 2 successive years
  • Dyspnea
  • Chronic Fatigue
  • Bluish Red Color Skin
  • Pulmonary Hypertension
104
Q

Describe the patient with advance COPD and Cor Pulmonale

A
  • Damaged to lung tissue
  • Acute respiratory failure
  • Depression/anxiety.
  • Anger.
  • Pulmonary Hypertension.
105
Q

right sided heart failure caused from pulmonary hypertension. Caused from COPD

A

Cor Pulmonale

106
Q

nursing diagnosis for a patient with advanced respiratory diseases.

A
  • Hyperthermia Related to Infectious Illness,
  • ineffective airway clearance,
  • pneumonia
  • pulmonary embolism
  • Activity Intolerance
  • Inadequate Nutrition
  • Social Isolation
  • Impaired Gas Exchange.
  • Anxiety.
  • Risk for Infection
  • Ineffective Coping
  • Fatigue.
  • Ineffective Breathing Pattern
  • Insomnia
107
Q

movement of air into and out of lungs

A

Ventilation

108
Q

Movement of blood through the lungs. Blood clot blocks

A

Perfusion

109
Q

movement of gases between the lung and blood. Heart Failure.

A

Diffusion

110
Q

Maximum airflow rate during forced expiration.

A

Peaked Expiratory Flow rate, (every asthma patient)

111
Q

the greatest volume of air that can be expelled from the lungs after taking the deepest possible breath

A

vital capacity

112
Q

measures how much air a person can exhale during a forced breath.

A

Forced Expiratory Volume

113
Q

Define Stage 1 Hypertension

A

SBP between 140 and 159 mm Hg or DBP between 90 and 99 mm Hg.

114
Q

Define Stage 2 Hypertension

A

SBP 160 mm Hg higher or DBP 100 mm Hg or higher.

115
Q

Treating Heart Failure Mneumonic

A
  • Upright
  • Nitrates
  • Lasix
  • Oxygen
  • Ace Inhibitors
  • Digozin
  • Fluids (decrease)
  • Afterload (decrease)
  • Sodium Restriction
  • Test (Dig, ABG, K)
116
Q

CORE measures x4

A
  1. Angiotensin Converting Enzyme Inhibitor LVSF
  2. LVG assessment
  3. Smoking cessation counceling
  4. HF discharge instructions
117
Q

A patient with an acid-base imbalance has an altered potassium level. The nurse recognizes that the potassium level is altered because:

A

Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells.

118
Q

A patient has the following arterial blood gas (ABG) results: pH 7.48, PaO2 86 mm Hg, PaCO2 44 mm Hg, HCO3 29 mEq/L. When assessing the patient, the nurse would expect the patient to experience:

A

Hypertonic muscles with cramping.

119
Q

What is elastic recoil

A

Negative pressure in the lungs. Suctioning

120
Q

Acid Base imbalances from Lung Diseases

A
  • COPD
  • Pneumonia
  • Pulmonary Edema
  • Pulmonary Embolism
121
Q

Acid Base Imbalances From Kidney Disease

A
  • DiabetesHypertension, kidney disease, nephrotoxic drugs, congenital renal disease
122
Q

myocardial muscle protein released after injury or infarction

A

Troponin

123
Q

What happens to a patient’s acid base imbalance when in cardiac arrest

A

Acidosis

124
Q

Describe the purpose of pursed lip breathing in the COPD Patient

A

To reduce overall work of brathing

125
Q

A patient with heart disease has developed pulmonary edema w/ difficulty breathing. The nurse notes that the patient is breathing at a rate of 28/min and has oxy sat of 90% on room air. Which best describes the first response of the nurse?

A

administer oxygen through a face mask to correct saturation levels

126
Q

Causes for dyspnea

A
  • obesity
  • Heart Disease
  • Arrhythmias
  • Asthma
  • COPD
  • Bronchiectasis
127
Q

A nurse is reviewing principles of good nutrition for a patient w COPD. What suggestion regarding nutrition would support the health of the patient w/ COPD

A

Achieve and maintain a healthy weight

obesity contributes to complications of COPD

128
Q

This is a type of heart catheterization procedure. A type of dye that’s visible by an X-ray machine is injected into the blood vessels of your heart.

A

Coronary Angiogram

129
Q

This is an enzyme found in the heart, brain, skeletal muscle, and other tissues. Increased amounts are released into the blood when there is muscle damage.

A

Creatnine Kinase

Nursing School (33 decks)

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