Passpoint Flashcards
Clients chest tube disconnects from the drainage tube. What should the nurse do first
Put tube in water or clamp tube near the client
Which condition happens after severe multiple trauma to the body and is characterized by low blood gases that don’t respond to high levels of therapeutic oxygen
ARDS
Acute respiratory Distress syndrome
PPD Test
High risk:
Suspect TB
TB contact
Immunocompromised (HIV)
Positive Reading:
> 5mm
PPD Test
Medium risk:
Endemic country
Live/work in large-group setting
Healthcare settings
IV drug use4
<4 yrs old
Comodidades
Positive test
> 10mm
PPD Test
Low risk
Healthy Person
Doesn’t fall into other categories
Positive test
> 15
What is a high risk person for a PPD test
Suspected TB
Contact with TB
Immunocompromised (HIV)
Why must clients be weeded off steroids
To prevent Acute Adrenocortical insufficiency
Low cortisol levels
Shock
Low BP
Weakness confusion
What can a nurse teach a client with pneumonia who has severe pleuritic chest pain?
Splint the ribs when coughing
Type of diet appropriate for a COPDer
High protein
How to diagnose CF.
Sweat chloride test
> 60 millimoles per liter =POSITIVE
59 - 30 Borderline
<30 normal
Name an intervention that a nurse does to help clear the airway in a client with CF
Chest physiotherapy
What does a positive tuberculin skin test mean…
Client has produced an immune response
It means that they have come into contact with TB, either through vaccination or exposure
Vesicular, Bronchial, Tracheal, Bronchovescular
Harsh, discontinuous sounds over trachea (in & exhale)
Soft, low pitched Lower lobes of lungs
Loud,high pitched over trachea, discontinuous, loudest during expiration
Medium-pitched continous sounds during (in & exhale) upper third of sternum between scapula
Vesicular
Soft, low pitched Lower lobes of lungs
Bronchovescular
Medium-pitched continous sounds during (in & exhale) upper third of sternum between scapula
Tracheal
Harsh, discontinuous sounds over trachea
Bronchial
Loud,high pitched over trachea, discontinuous, loudest during expiration
Soft, low pitched Lower lobes of lungs
Vesicular
Medium-pitched continous sounds during (in & exhale) upper third of sternum between scapula
Bronchovescular
Harsh, discontinuous sounds over trachea
Tracheal
Loud,high pitched over trachea, discontinuous, loudest during expiration
Bronchial
What is the priority nursing diagnosis for a client with pneumonia
Risk for falls
Ineffective breathing pattern
Impaired tissue integrity
Ineffective Airway Clearance
Ineffective Airway Clearance
1 priority of New Tracheostomy
Tracheostomy care
Check tightness of ties
Fit 1 finger under ties
Which is incorrect with Tracheostomy care
Change soiled tied and replace with 1 finger width space
Suction Tracheostomy tube before preforming care
Remove inner cannula and clean using universal precautions
Replace inner cannula and clean stoma site
Remove inner cannula and clean using universal precautions
Use STERILE precautions
Is constant bubbling in the water seal chamber of a chest drain normal?
Is tidling (up & down levels of water) Normal in water seal area
Is constant bubbling in the water seal chamber of a chest drain normal?
No, slight intermittent bubbles normal
Is tidling (up & down levels of water) Normal in water seal area
Tidaling is normal in water seal area
Acid base imbalance associated with Status Asthmaticus
Respiratory Acidosis
Malignant hyperthermia (MH) ….
Occurs…
Rare but life-threatening condition
Severe reaction to anesthesia drugs
Rhabdomyosis is the breakdown of muscles from (Strenuous Activy, hyperthermia, crush & burn injuries)
The consequence is leakage of creatine kinase, muscle enzymes, and myoglobin into the bloodstream.
What severe consequence can happen and how can we prevent this.
AKI acute kidney injury
Isotonic fluids
