Respiratory NGN Flashcards
The following flashcards are going to be about respiratory NGN
Which action will the nurse include when doing tracheostomy care? Select all that apply. (3)
- Provide oxygen via nasal cannula during suctioning
- Use sterile technique when cleaning the inner cannula
- Use sterile cotton-tipped swabs to clean the inner cannula
- Don sterile gloves before removing the inner cannula
- Use hydrogen peroxide to clean the skin around the stoma
- Cut a 4x4 gauze pad to utilize as a drain sponge if necessary
- Dry the inside of the inner cannula completely
- Ensure the non-dominant hand remains sterile
Explain why these are correct
Explain why the rest isnt
- use a sterile technique when cleaning the inner cannula
- Don sterile gloves before removing the inner cannula
- Dry the inside of the inner cannula completely
The nurse should always use a sterile technique when cleaning the inner cannula to avoid transmitting microorganisms to the lungs ; which will include sterile gloves
Its important to dry off the inner cannula completely before replacing it per protocol
now the wrongs
- the client may be preoxygneted before removing the inner cannula with high flow oxygen vita tracheal mask - but in this case it isnt needed since the patient has a nasal cannuila in placed
- A brush is used to clean the isnide of the cannula
- hydrogen peroxide is used to clean secretions from the inner cannula, not around the skin because it is irriating
- there is no need to cut the gauze because the small pieces can go inside the cannula and be inhaled
- dominant hand must be sterile at all times, non-dominant is considered to be needed as clean
Which action will the nurse take when caring for a client with a chest tube in place after a thoracotomy? Select all that apply. (4)
- Administer prescribed analgesic medications
- Check around chest tube insertion site for crepitus
- Clamp the chest tube before the client ambulates
- Add fluid to the suction control chamber as needed
- Offer a high-potassium diet
- Check for air bubbling in the water seal chamber
- Use a stripping action to milk the tubing
- report tidaling of water in chamber two
explain why these 4
explain why not the rest
- Administer prescribed analgesic medications
- Check around chest tube insertion site for crepitus
- Add fluid to the suction control chamber as needed
- Check for air bubbling in the water seal chamber
just having a chest tube inside of you is uncomfortable so giving medications to aid with that will help
Creptius found around the chest tube can indicate air leakage and should be monitored
fluid level inside the chamber aids with the negative pressure applied and should be kept at a certain level
the water seal chamber is assessed for bubbling, which indicates that air is exiting the pleural space
the wrongs
- clmaping the tube is only needed if there is damange but otherwise should not occur
- no need for high potassium
- stripping should be avoidding cause it can increase the risk of trauma and bleeding
- tidaling is normal for chamber two with breathing
Which action will the nurse take after noticing bibasilar crackles in a client who had an open cholecystectomy on the previous day? Select all that apply. (5)
- perform frequent breath sounds assessment
- encourage regular turning and coughing
- teach the importance of frequent deep breathing
- reduce the amount of fluid taken by mouth
- ensure a high-potassium diet is provided
- provide a folded blanket to assist with splinting
- ask the healthcare provider to order a chest x-ray
- educate the client on the use of incentive spirometry (IS)
explain the 5 right
explain the rest wrong
- perform frequent breath sounds assessment
- encourage regular turning and coughing
- teach the importance of frequent deep breathing
- provide a folded blanket to assist with splinting
- educate the client on the use of incentive spirometry (IS)
when having crackles, its important to do breath sounds no matter what
turning to cough, and deep breathing can help improve ventilation and resolve atelectasis
after surgery, an incisional marking can cause a patient to be nervous to cough, so telling them to splint the area with a pillow or blanket can help reduce the risk of pain and developing more complications
IS devices are used post-surgically to help with chest expansion
now the no’s
- it would need to be an increase in fluids to help thin out secretions
- potassium will not do anything here
- chest x-ray is not needed for atelectasis
Which finding would the nurse expect when taking the health history and assessing a client with active pulmonary tuberculosis? select all that apply (4)
- fever
- dry cough
- night sweats
- frothy sputum
- engorged neck veins
- blood-tinged sputum
- anorexia
- hyperexcitability
explain why yes for the 4
explain why no for the rest
- fever
- night sweats
- blood-tinged sputum
- anorexia
fever is usually present since its an infection and usually in the late afternoon
night sweats ( diaphoresis at night ) is a classical sign
hemoptysis is a result from the trauma to mucous membranes from TB
anorexia is common since patients lose their appeitite
now the wrongs
- its a productive cough, not a dry one
- frothy sputum is a sign of PE
- engorged neck veins is a sign of right sided heart failure
- they are going to be fatigued and tired, not excitied
Which assessment finding in a client with a left pneumothorax who has a chest tube in place requires the nurse to take immediate action? select all that apply. (5)
- tracheal deviation from midline
- oxygen saturation of less than 90%
- drainage system found below the chest
- tubing is coiled on bed
- visible eyelets on chest tube
- bubbling noted upon exhalation
- disconnection of chest tube from system
- sudden dyspnea onset
explain why yes
explain why no
- tracheal deviation from midline
- oxygen saturation of less than 90%
- visible eyelets on chest tube
- disconnection of chest tube from system
- sudden dyspnea onset
the nurse should immediately notify the surgeron or intitiate a rapid response of they noticed a tracehal deviation from the midline
oxygen being lower than 90 means they cant breathe
visible eylets means the chest tube is coming out and will be exposed to the nonsterile world
disconnection from the system causes the nurse to place the end of the tube in sterile water and should notify the doctor to place it back in
sudden dyspnea again they cant breathe and having issue with the system
now the wrongs
- drainage should be below the chest
- tubing can be colied ever so slightly
- bubbling is normal during exhalation, sneezing, coughing, or position changes
we are skipping question 6 and moving on to question 7 since question 6 is basically asking what are signs of declining to that respected patient.
A 42-year-old male client presents to the health clinic for a Mantoux test. For each parameter to assess, click to specify the questions the nurse should ask the client.
Respiratory (1)
- do you have a persistent productive cough?
- do you have any wheezing after contact with dust or pollen?
Integumentary (1)
- do you sweat at night?
- doy ou have a rash with itching?
Nutrition (1)
- have you had unplanned weight loss?
- how many eggs do you eat a day?
Living arrangements (2)
- where do you live?
- do you live by yourself?
Travel (1)
- have you traveled to a foreign country?
- have you water-skied on a lake recently?
explain why those are correct and the other isnt
Respiratory
- do you have a persistent productive cough?
you want to ask this because they will have a productive cough if they have TB ; the other question isnt applicaible cause we arent talking about dust or pollen
Integumentary
- do you sweat a night?
you want to ask about the sweating at night as its common for TB patients to have, the rash while itching isnt applicable and when people itch themselves, they can develop a rash if its too hard
Nutrition
- do you have unplanned weight loss
yes because TB patients will loss appeitite and lose weight
and the other question is just why.
Living arrnagement?
- where do you live
- do you live by yourself
depending on the area youre in the world, tb can be more prevelant, and if you live in a croweded community you can catch it there too
Travel
- have you traveled to a foreign country
again, depending on where you go its more prevlant and the water skied thing is weird
Question 8 on the NGN is basic knowledge that i want to remember
how long does it take for a manutox (skin tb) test to be read?
what is a positive sign for a normal person?
what is a postitive sign for immunecompresied person?
a positive test is an area of what?
a positive reaction indicates what?
48-72 hours
10mm
5mm
induration(hardness)
exposure to tuberculosis
Question 9 is talking about what are we trying to prevent with a client who has a diagnoses of TB
- spread of infection
- drug-resistant infection
- impaired airway clearance
Why those 3
and why not these 3 below
- neurovascular compromise
- cerebrovascular accident
- myocardial infarction
Tb is an infection and we should avoid spreading it by airborne precautions in the hospital and being indoors when discharged home.
drug resistant because TB is very hard to kill we should ensure patient is compliant with taking the medications
impaired airway clearance, cause tb affects the lungs, producing sputum and choking can happen.
now the no’s
- neurovascular is associated with muscles and bones, not TB
- stroke is from brain ischemia, not TB
- heart attack is decreased blood flow to the heart, not tb
question 10
which physician orders would the nurse anticipate being prescribed? select all that apply (4)
- nothing by mouth (NPO)
- rifampin 600mg po daily
- chest x-ray
- sputum culture
- isoniazid 300mg po daily
- rifabutin 150mg po bid
- abdominal computed tomography
- packed red blood cell infusion x2
- serum lipase in am
why those 4
why not the rest
- rifampin 600mg po daily
- chest x-ray
- sputum culture
- isoniazid 300mg po daily
rifampin and isoniazid are first line treatments for TB.
since the client is positive, chest x-ray can confirm it even more
sputum culture is the best method of seeing if it is positive or not
now the no’s
- we want to encourage fluids to aid with secreations and prevent dehydrations. client needs nutrition to heal
- rifabutin is used to great HIV
- CT scan isn’t used for the lungs
- packed red blood cellsisnt needed, cause it treats anemia and hemorrhage, not tb.
- serum lipase helps diagnose pancreatitis not TB
