RESPIRATORY Flashcards
What statement from the COPD client indicates an increase in dyspnea?
I prop myself up at night to sleep
What is the priority nursing action for a client with asthma and a red zone PEF reading?
Administer rescue drugs
What symptoms are anticipated in an older adult client suspected of having pneumonia?
- Fever
- Cough
- Confusion
- Weakness
Which order will the nurse implement first for the pneumonia client?
Blood cultures and urinalysis
What risk factors for VTE are present in the 61-year-old female client?
- Recent surgery
- Prolonged bed rest
What finding indicates that the heparin infusion is therapeutic?
aPTT is 1.5 to 2.5 times the control
What teaching points should the nurse include for the client being discharged on warfarin?
- Be sure to have follow-up INR laboratory tests done.
- Report any bruising or bleeding to your provider.
- Use a soft toothbrush to brush your teeth and an electric razor to shave your legs.
What client response indicates a need for further teaching regarding warfarin therapy?
I should drink more green tea and cranberry juice
What is a potential extrapulmonary cause of ventilatory failure?
Opioid analgesic overdose
What is the appropriate nursing action if vagal stimulation occurs while suctioning a client?
Oxygenate with 100% oxygen
What is the process of inhaling and exhaling called?
Ventilation
Define respiration.
The exchange of oxygen and carbon dioxide at the cellular level.
What are the components of the upper respiratory system?
Nose and mouth.
What comprises the lower respiratory system?
Neck and thoracic cavity; trachea is the entrance to the lungs.
What is the relationship between oxygen concentration in the alveoli and capillaries?
Oxygen concentration is greater in the alveoli than in the capillaries.
What do stretch receptors in the lungs control?
The volume of air inhaled with each breath.
What is the significance of the quality of breathing?
Refers to the effort involved when taking a breath and the sounds that may occur.
What changes occur in the respiratory system as an aging adult?
Pulmonary function declines, chest walls and airways lose elasticity, and effort to breathe increases.
What is hypoxemia?
Decreased level of oxygen in blood.
What is the early sign of hypoxemia?
Retractions or drawing in of the chest wall.
What is dyspnea?
Labored breathing or shortness of breath (SOB).
What is a pneumothorax?
Lung collapse caused by the collection of free air in the pleural space.
What is atelectasis?
Collapse of all or part of a lung.
What can decreased levels of O2 lead to?
Respiratory acidosis.
What are adventitious breath sounds?
Abnormal sounds heard in the lungs, including crackles, rhonchi, wheezing, and pleural friction rub.
What does the presence of crackles indicate?
Fluid, inflammation, exudates, or atelectasis.
What is the purpose of deep breathing exercises?
To promote lung expansion and oxygenation.
What is the purpose of hyperoxygenation before suctioning?
To increase oxygen flow before and between suction attempts.
What does the Venturi mask do?
Delivers the most accurate percentage of oxygen.
What is the role of bronchodilators in respiratory therapy?
To relax smooth muscle of the airway and decrease mucus secretions.
What are common pharmacologic therapies for chronic respiratory problems?
- Long-acting beta-agonists (LABA)
- Inhaled corticosteroids
- Short-acting beta-agonists (SABAs)
What does the presence of diminished breath sounds indicate?
Possible airway obstruction or lung collapse.
What are modifiable risk factors for respiratory conditions?
- Hypertension
- Atherosclerosis
- Obesity
- T2 Diabetes
- Smoking
- Stress
- Anxiety
What is the recommended positioning for optimal breathing?
Fowler’s position.
What interventions can be used to promote secretion clearance?
- Deep breathing and coughing
- Suction
- Chest percussion
- Postural drainage
What should be monitored in a patient receiving oxygen therapy?
- O2 saturation
- Breath sounds
- Pain
- Restlessness
- Anxiety
What is the purpose of suctioning in respiratory care?
To clear secretions when a patient is unable to cough them up.
What is the goal of nursing interventions for patients with respiratory issues?
To ensure adequate oxygenation and comfort.
What is Continuous Positive Airway Pressure (CPAP)?
Applies positive pressure to the airway of a client who is breathing spontaneously
What is Bilevel Positive Airway Pressure (BiPAP)?
Provides inspiratory positive airway pressure and airway support during expiration
What is Positive End-Expiratory Pressure (PEEP)?
Maintains positive pressure in the airways during exhalation and between breaths
What are common ventilatory alarms?
- High-pressure * Low-pressure
What does a high-pressure ventilatory alarm indicate?
Increased secretions, wheezing, bronchospasm, displaced or obstructed endotracheal tube, or client anxiety
What does a low-pressure ventilatory alarm indicate?
Disconnection or leak in the ventilator or client’s airway cuff, or client stops spontaneous breathing
What are complications from mechanical ventilation?
- Hospital-acquired pneumonia (HAP) * Barotrauma (volutrauma) * Pneumothorax * Decreased cardiac output * Stress ulcers
What is chest physiotherapy?
A treatment that involves chest percussion and postural drainage to promote lung clearance
Fill in the blank: The expected assessment for the older adult related to the natural aging process of the respiratory system includes _______.
Decrease in respiratory muscle strength
What is the expected finding related to the aging process of the respiratory system?
- Tightening of the vocal cords * Decrease in residual volume * Decrease in anteroposterior diameter * Decrease in respiratory muscle strength
What are some risk factors for obstructive sleep apnea?
- Obesity
- Large uvula
- Short neck
- Smoking
- Large tonsils or adenoids
- Oropharyngeal edema
These factors can contribute to airway obstruction during sleep.
What are common assessment cues for obstructive sleep apnea?
- Persistent daytime sleepiness
- Snoring
- GERD
- Physical assessment of height, weight, jaw, neck, chin, oral cavity
- Irritability and personality changes
- Depression
A thorough assessment is crucial for diagnosis.
What is epistaxis and what are its common causes?
Nosebleed resulting from trauma, hypertension, blood dyscrasia, etc.
Often occurs after sneezing or blowing the nose.
What is the usual treatment for epistaxis?
Nasal packing; cauterization may be necessary
Posterior nasal bleeding is considered an emergency.
What types of interventions are commonly used for head and neck cancer?
- Radiation therapy
- Chemotherapy
- Biotherapy
- Surgical intervention
These treatments aim to manage the cancer effectively.
