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nclex > respiratory system > Flashcards

respiratory system Flashcards

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1
Q

TB skin test

A

negative: redness without induration
positive: induration > 15 mm in healthy individuals

induration > 10 mm in immunocompromised pts

induration > 5 mm in high risk pts (e.g. HIV, organ transplant pts, pt had recent contact with TB)

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2
Q

positive for TB

A

no symptoms –> chest x-ray

symptoms –> sputum culture

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3
Q

types of TB

A

latent and active

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4
Q

nursing for TB

A

airborne precautions, wear N95 mask

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5
Q

latent TB

A

no symptoms, no sputum culture, not transmissible

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6
Q

active TB

A

symptoms, positive sputum culture, transmissible

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7
Q

flail chest

A

paradoxical respirations: chest moves in and out when breathing, pain, SOB, high HR, increased RR, decreased lung sounds

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8
Q

nursing for flail chest

A

elevate HOB 30-45 degrees, O2, DB&C, prep for possible intubation

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9
Q

nursing for influenza

A

lung sounds, fluids, meds (antipyretics, antivirals)

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10
Q

pneumothorax

A

lung collapse due to air in pleural space

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11
Q

types of pneumothorax

A

open, tension

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12
Q

open pneumothorax

A

opening in chest area

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13
Q

tension pneumothorax

A

injury to chest

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14
Q

S/S of pneumothorax

A

no lung sounds on that area, SOB, pain, increased RR

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15
Q

nursing for pneumothorax

A

chest dressing, O2, elevate HOB 30-45 degrees, prep for chest tube insertion

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16
Q

nursing for asthma

A

airway patent, meds (corticosteroids to open airway)

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17
Q

types ofCOPD

A

emphysema and bronchitis

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18
Q

emphysema

A

damaged alveoli leading to impaired gas exchange

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19
Q

bronchitis

A

airway filled with mucus

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20
Q

s/s of COPD

A

wheezing, crackles heard upon auscultation of lung sounds, barrel chest,, respiratory acidosis

21
Q

nursing for COPD

A

keep SpO2 88-92%, administer meds (bronchodilators), ABG

22
Q

causes of pneumonia

A

bacterial, viral, fungal, aspiration

23
Q

nursing for pneumonia

A

C+S, droplet precautions, O2, LOC, DB&C, elevate HOB 30-45, chest physiotherapy to break up secretions, ensure good fluids, meds (antibiotics)

24
Q

PE

A

blockage in pulmonary artery

25
Q

s/s of pulmonary embolism

A

blood tinged sputum, SOB, high HR, high RR

26
Q

nursing for pulmonary embolism

A

elevate HOB, O2, ABG, meds (anticoagulants)

27
Q

empyema

A

pus in lungs

28
Q

nursing for empyema

A

elevate HOB, O2, DB&C, meds (antibiotics), drainage (e.g. via chest tube)

29
Q

pleural effusion

A

fluid in pleural space that stops lungs from being able to fully expand

30
Q

s/s of pleural effusion

A

SOB, decreased lung sounds in that area when auscultating,

31
Q

nursing for pleural effusion

A

elevate HOB, monitor lung sounds, prep for thoracentesis

32
Q

ventilator alarms

A

high pressure –> increased secretions, tube kinked, pt coughing

low pressure –> tube disconnected, pt stopped breathing

33
Q

types of O2 delivery

A

nasal prongs: 1-6 L/min, can be used long-term

face mask: 5-8 L/min, short-term O2, emergencies

Venturi mask: 4-10L/min, respiratory failure

partial rebreather mask: 6-15 L/min

non-rebreather mask: 60-100%, deteriorating resp status

34
Q

chest tube suction type

A

wet and dry suction

35
Q

suction control chamber

A

wet: suction regulated by height of water
dry: set by dial

36
Q

removal of chest tube

A

Valsalva maneuver and hold breath

37
Q

nursing for chest tube

A

keep system below pt

38
Q

if chest tube dislodged

A

cover with sterile dressing on all sides so air cannot get in

39
Q

drainage

A

colour, amount

40
Q

normal chest tube drainage

A

less than 100 cc/hr

41
Q

water seal chamber

A

water should fluctuate with every inspiration and expiration

42
Q

if no fluctuation in water seal chamber

A

kink, expanded lung

43
Q

how air leak shown?

A

bubbling

if pt has pneumothorax, then intermittent bubbling is okay

44
Q

lung sounds

A 
fine crackles: crackling, popping
coarse crackles: crackling, popping
wheeze: high pitched, musical sound
ronchi: snoring
stridor: life-threatening, obstruction in airway
45
Q

diseases with crackles

A

pneumonia, heart failure, pulmonary

edema

46
Q

diseases with wheezes

A

asthma

47
Q

nursing for wheezing

A

meds (albuterol)

48
Q

diseases with ronchi

A

bronchitis

49
Q

diseases with stridor

A

aspiration of foreign object, anaphylaxis,

epiglottitis

nclex (17 decks)

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