Respiratory (Exam One) Flashcards
List the primary respiratory assessment techniques.
- Auscultation of lung sounds
- Palpation of thoracic cavity
What is tactile fremitus?
Vibration of the chest wall
How is tactile fremitus assessed?
Posterior chest is palpated while the patient says “99”
List conditions in which fremitus is increased?
- Pleural effusion
- Pneumonia
- Tumors
- Thick secretions
Will fremitus be increased or decreased if the lungs are hyper-inflated?
Decreased
How would a patient with low or decreased fremitus appear?
Barrel chested
The absence of fremitus is indicative of what condition(s)? What should the nurse do if fremitus is absent?
- Pneumothorax
- Atelectasis
-Auscultate for breath sounds
List the priority nursing interventions for a patient with increased respirations.
- Apply oxygen
- Administer medications
Describe clear/vesicular lung sounds.
- Breath sounds are normal
- No adventitious noises heard
Describe course crackles. What is the cause of this sound? Is this sound heard upon inspiration or expiration? What disorders are associated with this sound?
- Moist, low pitch bubbling sound
- Caused by fluid in airway
- Heard upon inspiration
- Pulmonary edema, bronchitis, pneumonia
Describe fine crackles. What is the cause of this sound? Is this sound heard upon inspiration or expiration? What disorders are associated with this sound?
- Sound of velcro being town apart
- Sound of hair being rolled between fingers
- Caused by alveoli popping open on inspiration
- Heart failure and atelectasis
Describe wheezes. What is the cause of this sound? Is this sound heard upon inspiration or expiration? What disorders are associated with this sound?
- High pitched, squeaky, musical sound
- Caused by narrow airways
- Heard upon inspiration or expiration
- Asthma
Describe pleural friction rub. What is the cause of this sound? Is this sound heard upon inspiration or expiration?
- Creaking or grating sound
- Caused by rough, inflamed pleural surfaces rubbing together
- Heard on inspiration or expiration
What does serum/metabolic CO2 measure?
Amount of carbonic acid and bicarbonate dissolved in the blood
Why is serum/metabolic CO2 often inaccurate?
Results are altered if the sample is exposed to air
List the different methods used to obtain a sputum sample.
- Expectoration
- Tracheal suction
- Bronchoscopy
Who is responsible for obtaining a sputum sample?
The nurse
When is the best time of day to obtain a sputum sample?
Morning
Describe sputum induction.
Patient inhales an irritating hypertonic solution that causes them to cough
What type of solution is used during a sputum induction?
Hypertonic solution
A sputum culture cannot contain _________.
Saliva
The nurse should observe the patients sputum for what?
- Color
- Amount
- Consistency
- Presence of blood
A culture and sensitivity (C&S) study is used to diagnose what? What does a culture and sensitivity (C&S) study help identify?
- Diagnoses bacterial infection
- Identifies infecting organism
When would an acid fast bacteria smear (AFB) be obtained?
- Culture and sensitivity (C&S) study is positive for organisms
- Diagnose TB
Cytology is utilized to determine the presence of what? What might this indicate?
Abnormal cells that may indicate cancer
How are gram stain results utilized in relation to patient therapy?
Guide patient treatment until culture and sensitivity (C&S) results are complete
A skin test determines if the patient has been exposed to what disease?
Tuberculosis (TB)
When might a skin test give a false reading?
Serum is injected too deep into the skin
List nursing responsibilities prior to a bronchoscopy procedure?
- Obtain signed consent
- Baseline respiratory assessment
- NPO for 6-12 hours prior to test
- Administer sedative
What is the priority nursing care management for a patient following a bronchoscopy procedure?
- NPO until gag reflex returns
- Semi-fowlers position
List nursing responsibilities for a patient who has had a transthoracic needle aspiration (TTNA)?
- Monitor lung sounds every four hours for 24 hours
- Monitor incision for signs and symptoms of infection
A patient who has had a transthoracic needle aspiration (TTNA) is at an increased risk for developing what condition?
Pneumothorax
List nursing responsibilities for a patient who has had a video-assisted thoracic surgery (VATS)?
- Monitor chest tube
- Monitor lung sounds
- Encourage deep breathing
Why would a patient have a chest x-ray following a video-assisted thoracic surgery (VATS) or transthoracic needle aspiration (TTNA)?
Verify a pneumothorax has not occurred
The nurse must ensure what has been completed before a transthoracic needle aspiration (TTNA) or video-assisted thoracic surgery (VATS) is performed?
Patient has signed a consent form
If a patient has a pneumothorax what type of lung sounds will be heard upon auscultation?
- Nothing
- Absent lung sounds
Describe a thoracentesis.
Insertion of large bore needle into chest wall to aspirate intrapleural fluid
What is the primary nursing responsibility during a thoracentesis?
Ensure position is maintained
The nurse should assess for what condition following a thoracentesis if the patients oxygen saturation is less than 90%?
Pneumothorax
How much fluid is typically removed during a thoracentesis?
1000 mL to 1200 mL
What conditions may occur if too much fluid is removed or if the fluid is removed too quickly during a thoracentesis?
- Hypertension
- Hypoxemia
- Pulmonary edema
Describe the patients oxygen saturation following a thoracentesis.
Improve to >90%
What is the most common complication of a thoracentesis?
Pneumothorax
How will the nurse position a patient fixing to undergo a thoracentesis?
Sitting up on side of bed leaning forward on bedside table with pillows
A pulmonary function test is used to determine what?
- Diagnose pulmonary disease
- Monitor disease progression
- Assess response to bronchodilators
What is the nurses responsibility in relation to a pulmonary function test?
Educate patient on how to perform the test
Describe how to perform a pulmonary function test.
- Mouthpiece in place
- Take a deep breath
- Exhale as hard, as fast, and for as long as possible
The six minute walking test is commonly performed on patients with type of disease?
Heart disease
The nurse can best determine adequate arterial oxygenation of the blood by assessing
A. Heart rate
B. Hemoglobin level
C. Arterial oxygen partial pressure (PaO2)
D. Arterial carbon dioxide partial pressure
C
A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that ABG can measure? (SATA) A. Acid-base balance B. Oxygenation status C. Acidity of the blood D. Bicarbonate (HCO3) E. Compliance and resistance
A, B, C, D
To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for?
A. Dyspnea and hypotension
B. Apprehension and restlessness
C. Cyanosis and cool, clammy skin
D. Increased urine output and diaphoresis
B
Which respiratory assessment finding does the nurse interpret as abnormal?
A. Inspiratory chest expansion of 1 inch
B. Symmetric chest expansion and contraction
C. Resonance (to percussion) over the lung bases
D. Bronchial breath sounds in the lower lung fields
D
The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? A. Thoracentesis B. Bronchoscopy C. Pulmonary angiography D. Sputum culture and sensitivity
A
When assessing subjective data related to the respiratory health of a patient with emphysema, the nurse should ask about what?
- Dyspnea during rest or exercise
- Ability to sleep through the entire night
- Prescription and OTC medication
What diagnostic study is the least invasive?
Chest x-ray
List the nursing management for a patient who has had a CT scan with contrast?
- Hydration
- Monitor kidney function
- Assess for shellfish allergy
A spiral CT assess’s for what condition?
Pulmonary embolism
What is necessary to perform a spiral CT?
- Contrast
- 20 gauge IV
What type of medication is used during a V/Q scan?
Nuclear medication
The nurse should do what to maintain their own health and safety when administering a nuclear medication?
- Be aware of pregnancy
- Wear PPE
- Carefully dispose of patient urine
Describe the process of a V/Q scan.
Nuclear medication is injected into a vein that spreads to help visualize the lungs
List the nursing management for a patient undergoing an MRI?
- Ensure no metal is present
- Assess for contrast allergies
- Monitor renal function
What medication must be held if the patient has received contrast dye? How long is this medication held?
- Metformin
- 24 to 48 hours
List the three mechanisms for acid-base regulation.
- Buffer system
- Respiratory system
- Renal system
Describe the action of the buffer system.
Changes stronger acids into weaker acids or binds them so they neutralize
What systems must be adequately working in order for the buffer system to work properly?
- Respiratory system
- Renal system
Which acid-base regulation mechanism has the fastest and most immediate reaction?
Buffer system
Which of the three acid-base regulation mechanisms is considered the primary regulator?
Buffer system
The respiratory system will respond within _________ if the buffer system fails to correct the body pH.
Minutes
How long does it take the respiratory system to reach max capacity?
Hours
What anatomical structure within the brain controls the respiratory system and the rate of CO2 excretion?
Medulla
If the CO2 level is elevated within the body, how will the respiratory system respond?
Increase respiratory rate to blow off excess CO2
If the CO2 level is decreased within the body, how will the respiratory system respond?
Decrease respiratory rate to retain CO2
The renal system will respond within _________ ___ _______ if the respiratory system fails to correct the body pH.
Hours to days
Describe the functions of the renal system in relation to acid-base regulation.
- Absorb bicarbonate
- Increase blood pH
- Decrease urine acidity
What is the normal range for pH?
7.35 - 7.45
What is the normal range for PCO2?
35 - 45
What is the normal range for HCO3?
22 - 26
A pH less than 7.35 is referred to as what?
Acidosis
A pH greater than 7.45 is referred to as what?
Alkalosis
A PaCO2 less than 35 is referred to as what?
Alkalosis
A PaCO2 greater than 45 is referred to as what?
Acidosis
An HCO3 less than 22 is referred to as what?
Acidosis
An HCO3 greater than 26 is referred to as what?
Alkalosis
PaCO2 is regulated by the __________ system.
Respiratory
HCO3 is regulated by the _________ system.
Renal
List the three steps in ABG interpretation.
- Determine acidosis or alkalosis of pH
- Determine if its respiratory or metabolic
- Determine if its compensated or uncompensated
If the PaCO2 is within normal range, but the HCO3 is abnormal, the problem is __________.
Metabolic
If the HCO3 is within normal range, but the PaCO2 is abnormal, the problem is __________.
Respiratory
Complete the acid-base balance example:
pH = 7.56
PaCO2 = 28
HCO3 = 22
Respiratory Alkalosis
Complete the acid-base balance example:
pH = 7.56
PaCO2 = 40
HCO3 = 35
Metabolic Alkalosis
If the pH, PaCO2, and HCO3 values are all abnormal, is the problem compensated, partially compensated, or uncompensated?
Partially compensated
If the pH is normal, but the PaCO2 and HCO3 values are abnormal, is the problem compensated, partially compensated, or uncompensated?
Compensated
If the pH is normal or abnormal, and there is a normal PaCO2 or normal HCO3 value present, is the problem compensated, partially compensated, or uncompensated?
Uncompensated
Complete the acid-base balance example:
pH = 7.30
PaCO2 = 50
HCO3 = 49
What is the primary problem? What is the type of compensation?
What is the level of compensation?
- Primary: Respiratory acidosis
- Type: Metabolic alkalosis
- Level: Partial compensation
Complete the acid-base balance example:
pH = 7.50
PaCO2 = 51
HCO3 = 41
What is the primary problem? What is the type of compensation?
What is the level of compensation?
- Primary: Metabolic alkalosis
- Type: Respiratory acidosis
- Level: Partial compensation
Complete the acid-base balance example:
pH = 7.35
PaCO2 = 49
HCO3 = 30
What is the primary problem? What is the type of compensation?
What is the level of compensation?
- Primary: Respiratory acidosis
- Type: Metabolic alkalosis
- Level: Full compensation
Complete the acid-base balance example:
pH = 7.42
PaCO2 = 30
HCO3 = 20
What is the primary problem? What is the type of compensation?
What is the level of compensation?
- Primary: Respiratory alkalosis
- Type: Metabolic acidosis
- Level: Full compensation
Complete the acid-base balance example:
pH = 7.25
PaCO2 = 32
HCO3 = 20
What is the primary problem? What is the type of compensation?
What is the level of compensation?
- Primary: Metabolic acidosis
- Type: Respiratory alkalosis
- Level: Partial compensation
Complete the acid-base balance example:
pH = 7.35
PaCO2 = 42
HCO3 = 25
What is the primary problem? What is the type of compensation?
What is the level of compensation?
-Primary: None
-Type: None
-Level: None
Normal!
Complete the acid-base balance example:
pH = 7.52
PaCO2 = 38
HCO3 = 30
What is the primary problem? What is the type of compensation?
What is the level of compensation?
- Primary: Metabolic alkalosis
- Type: None
- Level: Uncompensated
Respiratory acidosis is common in what type of diagnoses?
- COPD
- Respiratory failure
Oversedation, such as taking too many opioids or barbiturates, may result in what type of complication?
Respiratory acidosis
List health conditions related to respiratory acidosis.
- Brain stem trauma
- Immobility
- Respiratory muscle paralysis
- Pulmonary edema
- Emphysema
- Bronchitis
List the signs and symptoms of respiratory acidosis.
- Lethargy
- Dizziness
- Headache
- Blurred vision
- Restlessness
- Hypoventilation with hypoxia
- Hypotension
- Seizure activity
- Ventricular fibrillation
- Extracellular fluid shift in potassium
Is respiratory acidosis a consequence of hypoventilation or hyperventilation?
Hypoventilation
Describe the workload on the lungs during respiratory acidosis.
Lungs are working too hard and not effectively
What is the primary goal when attempting to correct respiratory acidosis?
- Improve respirations
- Increase the release of CO2
List examples of medications used to correct a patients respiratory rate during respiratory acidosis.
- Albuterol
- Ipratropium bromide
List examples of medications used to increase a patients respiratory drive during respiratory acidosis.
-Diamox/acetazolamide
What is the antidote for opioids?
Narcan/naloxone
What is the antidote for benzodiazepines?
Flumazenil
What is considered as a last resort to correct respiratory rate during respiratory acidosis?
- Endotracheal tube
- Ventilation support
What is the main drive for breathing?
CO2
What is the main cause of respiratory alkalosis?
Hypoxemia
List the causes of hypoxemia.
- Hyperventilation
- Pneumonia
- Pulmonary embolism
Respiratory alkalosis is a ________ ________ during pregnancy.
Normal finding
List the signs and symptoms of respiratory alkalosis.
- Tachypnea
- Confusion
- Lightheadedness
- Seizure activity
- Dysrhythmias
- Epigastric pain
- Numbness/tingling of extremities
What types of medications are used in the correction of respiratory alkalosis?
Antidepressants
Should respiratory alkalosis be corrected quickly or slowly?
Slowly
What may happen if the CO2 correction is done too quickly?
Causes metabolic acidosis
The nurse recommends breathing into a paper bag to correct what condition?
Respiratory alkalosis
What is a sign or symptom that a patient on a ventilator is in stress?
- Hyperventilation
- Asynchronous breathing/respirations
- Working against ventilation machine
What is the most important nursing assessment for a patient who is currently on a ventilator?
Assessing CO2 level
What may occur if the settings on a ventilator are incorrect?
- Decreased tidal volume
- Decreased respiratory rate
Metabolic acidosis is almost always accompanied by ___________.
Hyperkalemia
If a patient misses a session of dialysis, they may experience what condition?
Metabolic acidosis
List the causes of metabolic acidosis.
- Diabetic ketoacidosis
- Lactic acidosis
- Diarrhea
- Renal failure
- Shock
- Ileostomy
List the signs and symptoms of metabolic acidosis.
- Rapid shallow breathing
- Confusion
- Fatigue
- Headache
- Lack of appetite
- Increased heart rate
- Fruity breath
- Hyperkalemia
What medication may be given to correct metabolic acidosis if kidney disease or lactic acidosis is the underlying problem?
Sodium bicarbonate
What is the primary goal when correcting metabolic acidosis?
Returning pH back to a value of 7.2 or greater
If a patient is experiencing metabolic acidosis due to diabetic ketoacidosis, what type of treatment is recommended?
- Insulin
- IV hydration
What is the best way to track the response to treatment of metabolic acidosis?
Serial ABGs
Metabolic alkalosis is always ___________ to an underlying condition.
Secondary
List the causes of metabolic alkalosis.
- Vomiting
- NG suctioning
- Diuretic therapy
- Hypokalemia
- Excess bicarb intake
Excess bicarb intake is often a result of what?
- Treatment of metabolic acidosis
- Excess intake of antacids
Diuretic therapy excessively __________ the acid within the body causing metabolic alkalosis.
Decreases
List the signs and symptoms of metabolic alkalosis.
- Irritability
- Lethargy
- Confusion
- Headache
- Hypoventilation with compensation
- Tachycardia
- N/V/D
- Hypokalemia
Metabolic alkalosis is accompanied by ___________.
Hypokalemia
If a patient is in metabolic alkalosis with a respiratory rate of 10 breaths per minute and their O2 saturation declines to 88%, what is the priority nursing intervention?
Apply oxygen
What diuretics are given to decrease bicarb?
- Acetazolamide
- Spironolactone
Describe the IV fluid treatment for a patient with metabolic alkalosis.
NS ran at 50 mL to 100 mL greater than the patients urine output
During metabolic alkalosis, a patients respiratory rate will _________.
Decrease
What type of precautions or monitoring devices should the nurse implement for a patient in metabolic alkalosis?
- Seizure precautions
- Cardiac monitor
What is the most common type of facial fracture?
Nasal fracture
Trauma or force to the face that causes clear leakage from the nose should be what?
Test leakage to see if it is cerebrospinal fluid
How is cerebrospinal fluid identified?
- High glucose count
- Presence of halo
List the complications of a nasal fracture.
- Airway obstruction
- Epistaxis
- Meningeal tears
- Cerebrospinal fluid leakage
List the classifications of a nasal fracture.
- Simple
- Complex
A simple nasal fracture is either __________ or ___________.
- Unilateral
- Bilateral
There is little to no ___________ in a simple nasal fracture.
Displacement
If a patient has a complex nasal fracture, the nurse knows they should also be assessed for what?
- Cervical spinal injury
- Orbital cavity fracture
- Mandibular joint fracture
What is the biggest complication of a nasal fracture?
Airway obstruction
What are the priority nursing interventions for a patient with a nasal fracture?
- Maintain airway
- Sit patient upright
- Assess bleeding
- Assess edema
- Assess ability to breath out of both nares
The nurse educates a patient to apply ice to their nasal fracture. The nurse instructs the patient to apply ice for what length of time?
10 to 20 minutes
What types of medication should not be given to a patient with a nasal fracture for at least 48 hours following the injury? Why?
- Aspirin
- NSAIDS
-These medications interfere with clotting
Why should a patient with a nasal fracture be educated to avoid alcohol and hot showers?
To decrease the swelling
What type of surgical procedure is performed to correct a deviated septum?
Septoplasty
Describe a rhinoplasty.
Total reconstruction of the nose
The nurse should educate a patient scheduled for a rhinoplasty to stop taking aspirin or NSAIDS ______ _____ prior to the surgery.
Five days
List the nursing management for a post-operational rhinoplasty patient.
- Maintain airway
- Pain management
- Bleeding
- Swelling
- Infection
A patient arrives at the ED with a severe epistaxis. What question is important for the nurse to asking while gathering the patients health history?
Are you currently taking or have you recently quit taking any antiplatelets or anticoagulants?
A patient should seek medical assistance if a nose bleed lasts longer than ______ _________.
15 minutes
_________ nose bleeds require medical assistance.
Posterior
What is the treatment for an epistaxis?
First aid measures
List the causes of an epistaxis.
- Trauma
- Hypertension
- Low humidity
- Upper respiratory infection
- Allergies
- Nasal sprays
Describe the method used to control and stop a nose bleed.
- Tilt head forward
- Apply pressure
- Squeeze soft part of nose
What type of medication is used to cauterize bleeding vessels during an epistaxis?
Silver nitrate
What method is used for severe bleeding during epistaxis episode? What does this method often require?
- Thermal cauterization
- Local or general anesthesia
If a patient has nasal packing in place and an O2 saturation of 88%, what is priority nursing intervention?
- Apply oxygen!
- Do not remove nasal packing
What is the number one risk factor for developing laryngeal cancer?
Tobacco use
______ of head and neck cancers are caused by tobacco.
85%
People over the age of _____ are at an increased risk for developing laryngeal cancer.
50
What is a predisposing risk factor for developing laryngeal cancer younger than age 50?
HPV
List the signs and symptoms of laryngeal cancer.
- Hoarse voice
- Pain
- Lump/swelling
- Long lasting cough
- Sore throat/earache
- Difficulty breathing in severe cases
What is used to diagnose laryngeal cancer?
Biopsy
A small tumor is graded as a _____.
T1
If a tumor overrides into other tissues, it is graded as a ______.
T4
If there is no node involvement, it is classified as an _____.
N0
If a tumor has spread to more than one node, it is classified as an ____.
N3
M0 is indicative of what?
No metastasis
M1 is indicative of what?
Metastasis is present
A slow growing tumor is graded as a ___.
Grade 1
A rapid growing tumor is graded as a ____.
Grade 3
List the treatment options for laryngeal cancer.
- Surgery
- Chemotherapy
- Radiation
Describe a partial laryngectomy.
- Remove part of larynx
- Vocal cords intact
- Able to speak
- Hoarse voice
- Tracheotomy needed for post-op phase
Describe a total laryngectomy.
- Larynx is removed
- Lymph nodes removed
- Permanent tracheotomy
What type of intervention should be implemented into a patients plan of care if the patient is experiencing hopelessness and powerlessness related to laryngeal cancer or placement of tracheostomy tube?
Involve the patient in their plan of care
List examples of how to involve patient in their plan of care.
Teach patient how to clean their own devices
What portion of a tracheostomy allows the patient to speak?
Fenestration
Humidity aids in what for a patient with a tracheostomy?
Decrease and thin secretions
Humidified air within the collar of the tracheostomy should remain at what temperature?
93.2 to 96.8 degrees
Before cleaning a tracheostomy, the nurse should ensure what?
Tracheotomy does not need to be suctioned
The nurse knows to assess for what before and after providing tracheostomy care?
Oxygen!
What type of dressing is required for a tracheostomy?
Sterile precut dressings
A patient is moved to the medical-surgical floor after having a tracheostomy inserted. Who is responsible for assessing the new trach?
The RN
A patient on the medical-surgical floor has had a tracheostomy for about a month. Who is able to perform care for the established trach?
UAP
The nurse knows that cotton-filled gauze may never be used on a tracheotomy due to what?
Patient may aspirate on cotton or gauze fibers
Tracheostomy care is a _______ procedure.
Sterile
How many seconds should the nurse suction a tracheostomy for at one time?
15 - 30 seconds
Care of a tracheostomy should be scheduled at least ____________ after meals. Why?
- 3 hours
- Decrease risk of vomiting or aspirating
When suctioning a tracheostomy, the suction catheter should be advanced no further than the what?
Carina trachea
A patient is seen in the clinic for a nosebleed, which is controlled by placement of anterior nasal packing. During discharge teaching, the nurse teaches the patient what?
Avoid vigorous nose blowing and strenuous activity
The best method for determining the risk for aspiration in a patient with a tracheotomy is to what?
Consult a speech therapist for swallowing assessment
Which nursing action would be of highest priority when suctioning a patient with a tracheostomy?
Assessing the patients oxygen saturation before, during, and after suctioning
When planning health care teaching to prevent or detect early head and neck cancer, which people would be the priority to target? (SATA)
A. 65-year-old man who has used chewing tobacco most of his life
B. 45-year-old rancher who uses snuff to stay awake while driving his herds of cable
C. 21-year-old college student who drinks beer on weekends with his fraternity brothers
D. 78-year-old woman who has been drinking liquor since her husband died 15 years ago
E. 22-year-old woman who has been diagnosed with HPV of the cervix
A, B, D, E
While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply? (SATA)
A. Notify HCP at once
B. Place patient in semi-Fowlers position
C. Use a bag-valve-mask and begin rescue breathing
D. Instill 10 mL NS into the tracheostomy tube to loosen secretions
E. Continue patient assessment, including O2 saturation, respiratory rate and breath sounds
B, E
Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy for cancer would include? (SATA)
A. Encouraging regular exercise such as swimming
B. Washing around the stoma daily with moist washcloth
C. Encouraging participation in postlaryngectomy support group
D. Provide pictures and hands on instruction for tracheostomy care
E. Teaching how to hold breath and trying to gag to promote swallowing reflex
B, C, D
List the different types of pneumonia.
- Community acquired pneumonia
- Hospital acquired pneumonia
- Aspiration pneumonia
Hospital acquired pneumonia can occur within ___ ________ of hospital admission.
48 hours
What nursing intervention is used to prevent pneumonia development?
Patient repositioning
What position is maintained during eating and drinking to avoid aspiration?
High-Fowlers
Ventilation acquired pneumonia occurs within ___________ after ventilation.
48 hours or more
In order to be classified as community acquired pneumonia, a patient should not have been in a hospital facility in ___ _______ of acquiring the condition.
14 days
List the signs and symptoms of pneumonia.
- Cough
- Fever
- Chills
- Dyspnea
- Tachypnea
- Pleuritic chest pain
What sign or symptom is common and sometimes the only indicator of pneumonia in the geriatric population?
Altered mental status
What signs and symptoms are commonly associated with pneumococcal pneumonia?
- Loose thin secretions
- Increased tactile fremitus
What type of diagnostic test is necessary to diagnose pneumonia?
Chest x-ray
What should be collected prior to starting antibiotic therapy in a patient with pneumonia?
Culture
If a sputum sample cannot be obtained for a culture, the nurse knows to do what regarding antibiotic therapy?
- Do not delay therapy!
- Administer broad spectrum antibiotic
List the treatment options for pneumonia.
- Antibiotics
- Oxygen
- Analgesics
- Antipyretics
- Rest
The nurse educates a patient with pneumonia to expect improvement in symptoms within how many days?
3 to 5 days
What type of pneumonia is self-limiting and cannot be treated with antibiotics?
Viral pneumonia
If viral pneumonia is caused by influenza, what type of medication is given?
Antiviral
Why should the nurse educate a patient with pneumonia on maintaining semi-Fowlers or high-Fowlers position instead of lying flat on the back?
- Laying flat decreases lung expansion
- Laying flat decreases ventilation
- Decreased ventilation causes build-up of secretions
A pneumonia patient should receive a follow-up chest x-ray within what time frame?
6 to 8 weeks
Why is it important to assess pain in a patient with pneumonia?
Patient may not effectively cough due to pain
Besides the lungs, tuberculosis may affect what other organs?
- Bones
- Kidneys
- Brain
List the risk factors for developing tuberculosis?
- Homeless
- Residents of LTC facilities
- Prisoners
- Poor access to healthcare
- Immunosuppressed
Describe primary tuberculosis.
- Bacteria inhaled
- Causes inflammatory response
- Infection does not progress to disease
Describe latent tuberculosis.
- Not active
- Asymptomatic but will become reactive at some point
- Cannot be transmitted by these carriers
Describe reactivated tuberculosis. What are the causes of reactivated tuberculosis?
- Occurs 2+ years after initial infection
- Caused by immunosuppression, diabetes, stress, pregnancy
What is the name of the gram positive bacteria that causes tuberculosis?
Mycobacterium tuberculosis
List pulmonary signs and symptoms of tuberculosis.
- Dry to wet cough
- Fatigue
- Malaise
- Anorexia
- Fever
- Dyspnea
List renal signs and symptoms of tuberculosis.
- Dysuria
- Hematuria
List bone/joint signs and symptoms of tuberculosis.
Severe pain
How long can it take symptoms of tuberculosis to occur after initial exposure to the disease?
2 weeks
Hemoptysis is a _______ and _____ symptom of tuberculosis.
Rare and late
Describe the signs and symptoms of tuberculosis meningitis.
- Headache
- Nausea
- Vomiting
What diagnostic test is used to confirm tuberculosis if the patient has a positive PPD (skin test)?
Chest x-ray
List the side effects of tuberculosis medications such as isoniazid, rifampin, and pyrazinamide.
Reddish-orange discoloration of teeth, sweat, urine, saliva or tears
A patient is fixing to receive the tuberculosis vaccine. What education should the nurse provide?
PPD (skin test) will always be positive after receiving the vaccine
Therapy for tuberculosis should be ______ ________.
Directly observed
How is a pneumothorax diagnosed?
Chest x-ray
Describe a hemothorax.
Collection of blood
Describe a chylothorax.
Collection of lymphatic fluid
If the patient is experiencing a small pneumothorax, what signs and symptoms will they have?
- Tachycardia
- Pain with breathing
What type of signs and symptoms are common with a large pneumothorax?
- Significant respiratory distress
- Air hunger
- Pain with breathing
- Increased respiratory rate
- Low oxygen saturation
List the risk factors for developing a spontaneous pneumothorax.
- Lung disease
- Smoking
- Previous occurrence
- Tall/thin
- Male
- Asthma
- Cystic fibrosis
- COPD
- Pneumonia
Describe a iatrogenic pneumothorax.
Laceration or puncture of lung during medical procedure
When will a iatrogenic pneumothorax occur?
During a thoracentesis
A tension pneumothorax is considered what?
Medical emergency!
What is affected during a tension pneumothorax?
- Cardiac function
- Pulmonary function
Describe a tension pneumothorax.
Air enters pleural space and it cannot escape
List the clinical manifestations associated with a tension pneumothorax.
- Tracheal deviation
- Decreased cardiac output
- Increased respiratory rate
- Severe hypoxemia
List the causes of a tension pneumothorax.
- CPR
- Mechanical ventilation
- Clamped/obstructed chest tube
- Open chest wound
What is the primary intervention for a patient with a hemothorax?
Insertion of chest tube
List the causes of a hemothorax.
Injury to:
- Chest wall
- Diaphragm
- Lungs
- Blood vessels
Which ribs are most prone to fracture?
Ribs 5 - 9
Patients who have a fractured or splinted ribs are at an increased risk for what?
- Puncture of lung
- Puncture of lung covering
- Puncture of organ
List the nursing management for a patient with a fractured rib.
- Baseline pain assessment
- Baseline respiratory assessment
- Have narcan available
What is flail chest?
Fracture of two or more ribs in two or more places
What type of breathing is common in a patient with flail chest?
- Unsynchronized breathing
- Paradoxical breathing
What is the priority concern for a patient with flail chest?
Gas exchange
List the clinical manifestations of flail chest.
- Paradoxical breathing
- Pain to chest wall
- Tachycardia
- Bruising to chest wall
How is placement of a chest tube confirmed?
Chest x-ray
The drainage system for a chest tube must be placed where?
Below entry level
Who determines or sets the suction amount on a chest tube?
HCP
If there is bubbling in the water seal of a chest tube container, the nurse knows this indicates what?
- Air coming from the patient
- Pneumothorax is still present
If blood or fluid is removed too quickly from the patient, the patient is at an increased risk for what?
Hypovolemic shock
Dressing changes for a chest tube must be what?
Sterile
A patient with TB has been admitted to the hospital and is placed on airborne precautions and in an isolation room. What should the nurse teach the patient? (SATA)
A. Expect routine TB testing to evaluate infection
B. No visitors will be allowed while in airborne isolation
C. Adherence to precaution includes coughing into a paper tissue
D. Take all medications for full length of time to prevent multi-drug resistant TB
E. Wear a standard isolation mask if leaving the airborne infection isolation room
C, D, E
The patient should be instructed to do what when a chest tube is being removed?
Hold breath
What type of dressing is used on a chest tube insertion site?
Occlusive dressing
What is the most common cause of atelectasis?
Obstruction due to secretions
List the nursing interventions for a patient with atelectasis.
- Early mobility
- Incentive spirometer
- Turn
- Cough
- Deep breath
Pulmonary embolism may be caused by what other factors besides blood?
- Tumor tissue
- Amniotic fluid
- Air
- Fat
List the sudden signs and symptoms of a pulmonary embolism.
- Dyspnea
- Hypoxemia
- Tachypnea
- Cough
- Chest pain
What diagnostic test is used to diagnose a pulmonary embolism?
Spiral CT
What type of medications or agents are used to dissolve clots?
Fibrinolytic agents such as TPA
What is the antidote for heparin?
Protamine
What is the antidote for warfarin?
Vitamin K
List the contraindications for receiving a lung transplant.
- Cancer within two years
- Positive for hepatitis B, C,
- Positive for HIV
- Smoking
- Poor nutritional status
- Psychological unpreparedness
Rejection of a lung transplant is most common within ___________ following surgery.
5 to 10 days
List the signs and symptoms of organ rejection.
- Low grade fever
- SOB
- Dry cough
- Low oxygen saturation
A patient who had a lung transplant three days ago develops a low grade fever, what is the nurses priority intervention?
Notify the HCP immediately!
How is organ rejection diagnosed?
Biopsy
What type of medication will the patient be placed on if organ rejection is suspected?
High dose corticosteroids for 3 days followed by supplemental oral steroids
The nurse identifies a flail chest in a trauma patient when
A. Multiple rib fractures are determined by x-ray
B. A tracheal deviation to the unaffected side is present
C. Paradoxical chest movement occurs during respiration
D. There is decreased movement of the involved chest wall
C
The nurse notes tidaling of the water level in the water-seal chamber in a patient with closed chest tube drainage. The nurse should
A. Continue to monitor the patient
B. Check all connections for a leak in the system
C. Lower the drainage collector further from the chest
D. Clamp the tubing at a distal point away from the patient
A
When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes
A. Maintaining the patient on bed rest
B. Using intermittent pneumatic compression devices
C. Encouraging the patient to cough and deep breath
D. Teaching the patient how to use an incentive spirometer
B
Which statements describes the management of a patient following a lung transplantation? (SATA)
A. High doses of O2 administered around the clock
B. Using a home spirometer to help monitor lung function
C. Immunosuppressant therapy usually involves a 3-drug regimen
D. Most patients have acute rejection within the first 2 days
E. A lung biopsy is done using trantracheal method if rejection is suspected
B, C, E
If a patient is at an increased risk for aspiration or aspiration pneumonia, how will the nurse position the patient?
Side-lying position
Which patients have the greatest risk for aspiration pneumonia? (SATA)
A. Patient with seizures
B. Patient with head injury
C. Patient who had thoracic surgery
D. Patient who had a myocardial infarction
E. Patient who is receiving NG tube feeding
A, B, E
An appropriate nursing intervention to assist a patient with pneumonia manage thick secretions and fatigue would be to
A. Perform postural drainage every hour
B. Provide analgesics as ordered to promote patient comfort
C. Administer O2 as prescribed to maintain optimal O2 levels
D. Teach the patient how to cough effectively and expectorate secretions
D
A bacteriologic study is performed after a positive PPD. The nurse knows what about a bacteriologic sputum study for TB?
Three consecutive sputum samples should be obtained over three different days
How is tuberculosis transmitted? What type of conditions need to exist to transmit tuberculosis?
- Airborne
- Must be in close proximity for extended period of time
If a patients tracheostomy tube is dislodged, what is the nurses priority intervention?
- Attempt to reinsert the tube
- Maintain the patient airway
Tuberculosis medications such as isoniazid, rifampin, and pyrazinamide are ____________. What laboratory values should be monitored while receiving these medications?
-Hepatotoxic
- ALT, AST, ALP
- Bilirubin
