Resp Problems

Question 1

Laryngeal cancer recieving radiation therapy. Patient complains voice is hoarsed. What is best nurse response.

1. Let’s elevate HOB and see if that helps
2. Your voice should improve in 6 - 8 weeks after radiation is done
3. Dry mouth & Difficulty swallowing are also SE of radiation.
4. I will call your HCP and let him know.

Answer 1

2. Your voice should improve in 6 - 8 weeks after radiation is done

In the meantime ice chips & saline gargles will help.

Elevating HOB will help with oxygenation not sore throat

Question 2

COPD patient on 6L/min has RR of 8. What serious condition can happen as a result

Answer 2

Respiratory Arrest

Question 3

T or F

Darker skin can lower the reading of a pulse ox reader by 3%- 5%

Answer 3

T

Question 4

Can UAP take specimens to the lab?

Answer 4

Yes, as well as gather supplies

Question 5

Which requires intervention

1. Suctioning trach tube before giving trach care
2. Removing old dressing and cleaning off excess secretions
3. Remove inner cannula and cleaning using standard precautions
4. Replacing the inner cannula and cleaning the stoma site

Answer 5

3. Remove inner cannula and cleaning using standard precautions

Sterile procedure

Question 6

Anterior Epitaxis
Which are correct procedures

1. Supine posistion and turned to side
2. Apply direct lateral pressure to nose for 5 minutes
3. Maintain standard body substance precautions
4. Apply ice or cool compress
5. Instruct not to blow nose for several hours

Answer 6

2. Apply direct lateral pressure to nose for 5 minutes
3. Maintain standard body substance precautions
4. Apply ice or cool compress
5. Instruct not to blow nose for several hours

Question 7

MSG can both asthma

T or F

Answer 7

T

Question 8

Elderly unactivated (Flu& pneumonia) which vital sign is most important

1. BP 152/84
2. RR27
3. HR 92
   4 TEMP 101.3

Answer 8

TEMP 101.3

Question 9

Post-op thoracotomy (Surgical procedure to gain access into thepleuralspace of thechest, access heart,lungs)

What action should a nurse delegate to UAP

1. Instruct patient to alternate rest & periods of activity
2. Encourage, monitor, and record nutritional intake
3. Monitor cardiorespirtory response to activity
4. Planning activities for periods when the patient has the most energy

Answer 9

Encourage, monitor, and record nutritional intake

UAP are trained to handle feedings not the other activities

Question 10

Nurse is initiating nurse care plan for a patient with pneumonia. What intervention for cough enhancement should they Delegate to UAP

1. Teach patient importance of adequate fluid intake
2. Assist patient to sitting posistion with neck flexed, shoulder relaxed, and knees flexed.
3. Remind patient to use spirometer every hour or two
4. Encourage patient to take deep breath, hold for 2 seconds, cough 2 or 3 times in succession

Answer 10

3. Remind patient to use spirometer every hour or two

UAP can remind patients to preform actions that are already part of their care plan.

If UAP & Patient were both shown how to posistion for cough this is also appropriate. But it will still fall under the supervision OF RN

Question 11

UAP feeding most important for late stage COPD

1. Encourage high protein high calorie foods
2. Feed quickly to avoid early satiety
3. Offer lots of fluids between bites
4. Attempt to get them to eat everything on their tray

Answer 11

1. Encourage high protein high calorie food

COPD causes food intolerance, nausea, early satiety, poor appetite, meal related-dyspnea

It’s important they eat the most dense foods possible because their body burns a lot of calories trying to breathe

Question 12

Which is the greatest risk for developing PE

1. Motorcycle crash
2. Participation in exercise class 6 months ago
3. Gave birth 1 year ago
4. Bed rest for 6hrs after diagnostic procedure

Answer 12

Motorcycle crash.

Trauma increases chance for DVT & PE
Long time in bed recovering.

Question 13

ARDS (acute respitory distress syndrome)

Oxygen nonrebreather but ABG show poor oxygenation. What does the nurse anticipate

1. Endotracheal intubation and initiate mechanical ventilation
2. Immediately begin CPAP via patients nose & mouth
3. Administer furosemide 100 mg IV push STAT
4. Call code for respitory arrest

Answer 13

1. Endotracheal intubation and initiate mechanical ventilation

Non breather deliver nearly 100% oxygen. When patients don’t respond to this Refactory Hypoxemia is present.

Will go into respitory arrest unless intubated

Question 14

Which describes incorrect procedure. For ARDS patient who will receive a Endotracheal Tube

1. Assess for bilateral breath sounds and symmetrical chest movements
2. Use end-tidal carbon dioxide detector to confirm Endotracheal Tube placement
3. Marks 1 cm from where it touches incisors or nares
4. Orders chest x-ray to verify placement is correct

Answer 14

Marks 1 cm from where it touches incisors or nares.

Mark directly where Tube touches incisors or nares - to verify it hasn’t shifted.

End-tidal CO² detector is gold standard for placement

Question 15

UAP reading VS on a intubated patient. Which VS should they report immediately?

1. HR 98
2. RR 24
   3.BP 168/90
3. Tympanic membrane temp 101.4

Answer 15

4. Tympanic membrane temp 101.4

Ventilator is likely to cause infection & due to oxygen going directly to lungs with out the body’s filters

Question 16

50 yr old diagnosed with right leg DVT & PE. Back home now from hospital and prescribed Enoxaparin SQ. Which assessment will the nurse need to communicate immediately?

1. Right leg aches all night
2. Right calf is warmer & larger than left calf.
3. Unable to remember husband’s name
4. Multiple ecchymotic areas on abdomen

Answer 16

Unable to remember husband’s name

Possible sign of intracranial bleeding from the lovenox.

The signs that related to the DVT are normal and will resolve themselves

Ecchymysis bruising is normal with lovenox

Question 17

1.7 L of fluid removed from thoracentesis. Which assessment Findings is most important

1. Cry and stating can’t go on with treatment much longer
2. Sharp, stabbing, chest pain with every deep breath
3. BP 100/48 HR 103
4. Dressing at thoracentesis site has 1 cm of bloody drainage

Answer 17

3. BP 100/48 HR 103

After removal of fluid from pleural cavity fluid may shift from intravascular space to the pleural space. IV maybe needed

Question 18

Which action is most important for reducing ventilator-associated pneumonia.

1. Admin antibiotics as ordered
2. Hyperoxygenate patient before suctioning
3. Maintain HOB 30 - 45
4. Suction airway when course crackles appear

Answer 18

Maintain HOB 30 - 45

Other actions are standard care but will not prevent VAP