Nursing Diagnoses

Question 1

Ineffective Airway Clearance Causes

Answer 1

Ineffective cough
Foreign object aspiration
Respiratory muscle fatigue
Severe Bronchospasm
Thick/ tenacious secretions

Question 2

Ineffective Airway Clearance Signs and Symptoms

Answer 2

Abnormal Breathing sounds
Abnormal RR, Rhythm, Depth
Dyspnea
Excessive Secretions
Hypoxemia
Ineffective or Absent cough
Orthopnea

Question 3

Ineffective Airway Clearance Interventions if due to tenacious secretions?

Answer 3

Encourage Fluids
Humidifier
Mucolytic
CPT

Question 4

Ineffective Airway Clearance Interventions if due to cough?

Answer 4

Teach proper coughing technique
Quad and Huff techniques
If both are ineffective, require suctioning

Question 5

Ineffective Airway Clearance Intervention if due to foreign body aspiration?

Answer 5

Abdominal Thrusts

Question 6

Impaired Gas Exchange Causes

Answer 6

Conditions that causes collapse of alveoli
Altered oxygen carrying capacity of the RBCs
High altitudes
Hypo/ Hyperventilation

Question 7

Impaired Gas Exchange Signs and Symptoms

Answer 7

Hypoxemia
Hypoxia
Abnormal Breathing pattern
Altered ABG
Restless
Cyanosis
Dyspnea
Coughing
Nasal Flaring
Use of accessory muscles

Question 8

Impaired Gas Exchange Interventions

Answer 8

Raise HOB to high fowler’s position
Administer O2
Ambulate as tolerate
TCDB
Position in tripod if acute distress occurs

Question 9

Ineffective Breathing Pattern Causes

Answer 9

Trauma
Brain damage
Pain
Obstruction
Anxiety
Ascites
Fluid overload

Question 10

Ineffective Breathing Pattern Signs and Symptoms

Answer 10

Abnormal rate and rhythm
Bradypnea/ Tachypnea
Nasal Flaring
Orthopnea
Pursed Lip Breathing
Accessory Muscle use

Question 11

Ineffective Breathing Pattern Interventions

Answer 11

Position Upright
IS
Diaphragmatic Breathing
Suction as Needed
Mechanical Ventilation may be required
Pursed lip breathing

Question 12

Impaired Tissue Perfusion Causes

Answer 12

Arterial Disease
Venous Insufficiency
Heart failure
Local injury
Embolism
Compartment Syndrome
Hypovolemia

Question 13

Impaired Tissue Perfusion Signs and Symptoms Cardiopulmonary

Answer 13

Chest pain
Acute Respiratory distress
Dyspnea
Pallor
Decreased O2 Stats

Question 14

Impaired Tissue Perfusion Signs and Symptoms Cerebral

Answer 14

ALOC

Question 15

Impaired Tissue Perfusion Signs and Symptoms GI

Answer 15

Decreased Peristalsis

Question 16

Impaired Tissue Perfusion Signs and Symptoms Peripheral

Answer 16

Pallor
Cyanosis
Motting
Decreased/ Absent pulse
Increased Cap Refill
Gangrene

Question 17

Impaired Tissue Perfusion Signs and Symptoms Renal

Answer 17

Decreased Urine Output

Question 18

Impaired Tissue Perfusion Interventions if Hypovolemic

Answer 18

IV fluids

Question 19

Impaired Tissue Perfusion Interventions if Shock

Answer 19

IV fluids and possible need for pressors

Question 20

Impaired Tissue Perfusion Interventions for Cardiopulmonary

Answer 20

O2 and Nitro

Question 21

Impaired Tissue Perfusion Intervention for Peripheral

Answer 21

Keep Warm

Question 22

Decreased Cardiac Output Causes

Answer 22

Alterations in heart rate and rhythm
Cardiac muscle disease
Decreased Oxygenation
Impaired Contractility
Increased Afterload
Decreased Preload

Question 23

Decreased Cardiac Output Signs and Symptoms

Answer 23

Abnormal Heart sounds
Angina
Anxiety
ALOC
Crackles
Orthopnea
Fatigue
Decreased Peripheral pulses
Decreased Perfusion
Hypotension

Question 24

Decreased Cardiac Output Interventions if Decreased Preload

Answer 24

Limit Fluids

Question 25

Decreased Cardiac Output Interventions if Hypovolemic

Answer 25

Fluid Resuscitation
(carefully monitor for fluid overload)

Question 26

Decreased Cardiac Output Interventions

Answer 26

Position Upright
Supplemental O2
Monitor HR and BP