respiratory

Question 1

low o2 stat, mild to moderate tachypnea is expected in COPD

Answer 1

true

Question 2

position that helps you breathe better

Answer 2

Fowler, high fowler, tripod
they promote maximum lung expansion

Question 3

hemothorax vs tension pneumothorax symptoms
side effects?
interventions?

Answer 3

both causes hypotension, tachycardia, unilateral diminished breath sounds (or on the affected side), in addition tension pneumothorax causes subcutaneous emphysema

another sign is unilateral chest expansion
first intervention is: insert chest tube (lifesaving intervention, do immediately to save patient.

in hemothorax, air goes in destroying that negative pressure, causing the lungs to collapse partially or completely

in tension peumothorax, the air enters lung but cannot escape the pleural space.

Question 4

with chest tube insertion, how much drainage is too much

Answer 4

the nurse should monitor for >100ml/hr
that would be too much drainage and can cause hemorrhage.

Question 5

triage
large wound on head and glascow coma scale is 3

absent right pedal pulse and a fractured tibia (in lower leg)

Answer 5

unlikely to survive 1st patient

patient pedal pulse 1+ is more likely to survive

black: apneic (not breathing), pulselessness, full thickness burns that’s >60% of total body area, severe Neuro trauma

Question 6

what breaches confidentiality
social media page for rns in a hospital, select all that applies questions
a. client in room 5 has influzenza so remember to take your vaccines
b. wash your hands if you cared for client in room 5, he has cdiff
c. cute dementia patient in our unit
d. high acuity patients lately, great job everyone

Answer 6

all of the above expect for high acuity patients lately, great job everyone

you cannot share private information on social media
don’t give room number, or nickname

non specific info can still share clients info to a third party

Question 7

what is a big risk after a thoracentesis

Answer 7

thoracentesis: needle is inserted in the pleural space b/w chest wall and lungs, to remove excess fluids. risk is air going inside of lungs.

big risk is pneumothorax
patient is expected to cough (up to 1hr after procedure, 2hrs and coughing is a sign of possible pneumothorax, if it is chest tube immediately.
other s/s of pneumothorax: chest pain, shortness of breath, etc..