O2, Perfusion, and Cardiac Flashcards
The nurse is reviewing client education with a parent and their teenager. Which interventions should help minimize the occurrence of sickle cell crisis? Select all that apply.
- Receive a yearly pneumonia vaccination.
- Always wear socks and gloves when outside on cold days.
- Engage in vigorous aerobic exercise at least 3-4 times a week.
- You should drink at least 3-4 liters of non-caffeinated liquid a day.
- Avoid cigarettes and/or tobacco products and second hand smoke.
2, 3, 5
Rationale
In order to help minimize the occurrence of a sickle cell crisis, the client should be instructed to: drink 3-4 liters of non-caffeinated liquid/day; avoid alcoholic beverages; avoid cigarettes and/or tobacco to include second-hand smoke; receive an annual flu shot; a pneumonia shot every 5 years or according or the CDC guidelines; avoid being too hot or cold; wear socks and gloves outside on cold days; avoid high altitudes; avoid strenuous exercise; and engage in mild, low impact exercise 3xs/week when not in a crisis.
The nurse reviews in the client’s medical history the following: congestive heart failure, weight gain of 15 pounds (6.8kg) in the last 72 hours, crackles in lungs bilaterally, shortness of breath at rest, respiration at 24 breaths per minute, O2 saturations 96% on 2 lpm of oxygen (O2), and pedal edema +3. The admitting lab values are Na: 139mEq/L, K: 2.9mEq/L, Cl : 98mEq/L, and Mg: 1.7mEq/L. Which client outcomes indicate that spironolactone is effective?
- Respiration at 18 breaths per minute.
- Pedal edema +1.
- Potassium level of 5.2mEq/L.
- Weight loss 5 pounds (2.3kg).
- O2 saturations 96% on 3 lpm O2.
1, 2, 4
Rationale
Spironolactone is a potassium-sparing diuretic. Positive outcomes include less pedal edema, improved respiratory effort, and weight loss indicating fluid volume decrease.
Which assessment finding should the nurse anticipate in a client experiencing an acute asthma exacerbation?
- Decreased nasal secretions.
- Frequent productive cough.
- Answering questions in full sentences.
- Prolonged phase of forced expiration.
4
Rationale
The nurse should expect to observe a prolonged phase of force expiration, frequent unproductive cough, increased nasal secretions, and breathlessness in the client experiencing acute asthma exacerbation.
The nurse writes the following goal for the unit: “Within 3 hours of the start of shift, the temperature, pulse, respirations, and blood pressure for all 15 clients will be documented, reviewed, and signed in the electronic medical record.” Which category of SMART goals is missing from this statement?
- Specific.
- Measurable.
- Time-bound.
- Realistic.
3
SMART goals are specific, measurable, achievable, realistic, and time-bound. To make this statement a SMART goal, the nurse should note that the temperatures, pulses, respirations, and blood pressures (specific vital signs) should be documented (achievable) and reviewed between 7 a.m. and 10 a.m. (time-bound) for 15 clients (realistic). The nurse is delegated a task and specifying what is to be done and the time frame it should be completed.
A client’s admitted to the intensive care unit diagnosed with stage 5 chronic kidney disease assessment includes crackles in the lungs, periorbital edema, anuric, muscle cramps and paresthesia. The nurse should anticipate the health care provider to prescribe which treatment?
- Renal dialysis.
- Nitroglycerin.
- Albuterol inhalation.
- Furosemide intravenously.
1
Diuretics can be used in clients with chronic kidney disease stages 1-4. Clients who have advance to stage 5, diuretics will not work; these clients will need to receive renal dialysis treatment to remove the excess fluids from their system.
A client is diagnosed with restrictive cardiomyopathy. Which should the nurse identify as a known cause of this condition?
- Radiation therapy.
- Myocarditis.
- Hypertension.
- Genetic disorder.
1
Rationale
Restrictive cardiomyopathy is a heart disease characterized by abnormal filling of the ventricles. Radiation therapy of the chest can cause restricted cardiomyopathy.
A client is scheduled for an echocardiogram the next morning. What instructions should the nurse communicate to the client about this test?
- A large bore IV will be inserted.
- Pain medication will be administered.
- No food or drink will be allowed after midnight.
- No special preparation is necessary
4
An echocardiogram is a noninvasive test that does not require pre-procedure interventions or preparation.
What should the nurse anticipate will be prescribed for a client with a warfarin (Coumadin) overdose?
- Heparin.
- Albumin.
- Vitamin K.
- Protamine sulfate.
3
Vitamin K is used in the treatment of a warfarin (Coumadin) overdose. The nurse should be aware that it takes 4 to 6 hours for vitamin K to reverse the properties of warfarin. Plasma, prothrombin complex concentrates, or recombinant factor XII may need to be given until the effects of the vitamin K take effect.
The nurse is caring for a client receiving oxygen via a Venturi mask at 6 L/min. Which nursing intervention ensures that the client is receiving adequate oxygenation?
- Keeping the orifice for the Venturi adapter open.
- Observing for a mist during inspiration and expiration.
- Placing a nasal cannula on the client during mealtimes.
- Making sure the valves are patent and rubber flaps are functional.
1
The orifice for the Venturi adapter should be kept open and uncovered. If the Venturi orifice is covered, the adapter cannot function properly, and the prescribed amount of oxygen delivery may vary.
Which medication would the nurse anticipate to be prescribed for a client who suffers rhinitis as a result of seasonal allergies?
- Fluticasone (Flonase).
- Cyclosporine (Restasis).
- Ranibizumab (Lucentis).
- Brimonidine/timolol (Combigan).
1
Fluticasone (Flonase) is a medication that is prescribed for the treatment and management of nasal symptoms of seasonal and perennial allergies.
The nurse is preparing a class about the use of over-the-counter (OTC) medications. Which population of clients does not required special dosing of OTC antitussives and expectorants?
- Infants.
- Children.
- Adult.
- Geriatric.
3
The dose of antitussives and expectorants should be decreased when used by geriatric clients because of their slower metabolism. According to the FDA, special consideration needs to be taken for children as the age span is quite broad. Medications which are safe for a school-age child may not be safe fo an infant.
A client was prescribed acetylcysteine (expectorant) inhalation therapy for treatment of cystic fibrosis. Which data would indicate the medication has been an effective therapeutic?
- The client has decreased amount of secretions suctioned from client’s lungs.
- The client coughed up a moderate amount of liquefied secretions.
- Client’s breath sounds and wheezing are diminished on auscultation.
- Client’s appetite is increased with decreased amount of steatorrhea present.
2
The action of acetylcysteine is to decrease the viscosity of secretions making it easier for clients with cystic fibrosis to cough up the thickened secretions from their lungs.
The nurse is caring for a client who is at risk for developing pneumonia. Which action should the nurse take to decrease the risk of infection?
- Encourage the client to stay in bed and rest.
- Maintain an option suction system when suctioning the client.
- Teach the client how to cough and deep breathe.
- Implement protective isolation precautions.
3
Pneumonia occurs due to an infection in the lungs as the result of consolidation of pulmonary secretions in the lobes of the lungs. In order to reduce the risk of pneumonia infection, the nurse should teach the client how to cough and deep breathe to aid in the removal of these secretions from the lungs.
The nurse is caring for a client in acute respiratory failure. Which goal should the nurse include in the care plan?
- Respiratory rate will be 30 breaths/min within 24-48 hours after initiation of treatment.
- The client will be weaned from the ventilator within 24-48 hours after initiation of treatment.
- Blood pH will be between 7.50-7.60 within 2-4 hours after initiation of treatment.
- The client has a PaO2 greater than 80 mmHg within 2-4 hours of initiation of treatment.
4
Acute respiratory failure generally results from a primary lung dysfunction. When treating a client with acute respiratory failure, the client should have adequate gas exchange within 2 to 4 hours of initiating treatment. A PaO2 greater than 80 mmHg indicates adequate ventilation.
The nurse is assessing a client who is experiencing shortness of breath, intercostal retractions, nasal flaring, inspiratory and expiratory wheezing, who has not not shown any respiratory improvement after two administrations of albuterol nebulizer treatments. Which is a common trigger for acute asthma exacerbation?
- Ingested allergen.
- Exposure to warm air.
- Hypocapnia.
- Inactivity.
1
Specific triggers for acute asthma exacerbation vary from client to client. In general, sudden changes in weather (especially exposure to cold air), allergens in the environment or food, expression of intense emotion, and exercise may all trigger acute asthma exacerbation.
