Study Guide!!!!

Question 1

SATA The Nurse is performing pre-operational care to a client scheduled for a thoracentesis, what is the nurse required to perform before the procedure?

1. Educate the client on the procedure
2. Obtain written consent
3. Provide local anesthetic 30 minutes before
4. Obtain tray and equipment and keep it clean
5. Position yourself behind PT
6. Allow PT to rest in side-lying, sitting, or bending over the side table position

Answer 1

Answer: 2, 6 (543)

1. Obtain written consent
2. Reinforce or verify PT understands procedure (LPNs do not educate)
3. Have PT void
4. Give an analgesic before the procedure
5. Gather tray and equipment and keep it Sterile!
6. Place PT in sitting, side-lying if they can’t sit, or bending over the bedside table
7. Give local anesthetic before needle insertion

Question 2

SATA The Nurse is assisting a post-operational client after a thoracentesis what should the nurse anticipate?

1. To apply barrier cream around dressing after needle insertion
2. Assess breath sounds and vitals
3. PT should remain on bed rest for at least 30 minutes
4. Label and send the specimen to the lab

Answer 2

Answer: 2,4 (543)

Explanation

1. Petroleum Jelly is put on dressing to prevent leakage of air in the wound site
2. Assess vitals, breath sounds, and wound site as ordered
3. PT is on bed rest for 1 hr after the procedure
4. Label and send the specimen to the lab as ordered

Question 3

After a thoracentesis what procedure is ordered to ensure the PT was not given Pneumothorax?

1. CT scan of lungs
2. ECG of heart
3. X-ray of lungs
4. Electrogram of lungs

Answer 3

Answer: 3

HCP may order an X-ray as described on page 543

Question 4

A client is diagnosed with Pnuemonothorax what procedure should the nurse anticipate?

1. Water Seal Bottle
2. Thoracentesis
3. Chest Wall Oscillation Vest
4. Nebulized Mist Treatment

Answer 4

Answer: 1

The device allows air to escape while the client exhales, it’s also a type of chest drainage system which involves (chest tubes). page 544

Question 5

The HCP is to remove blood from the chest, in what region should the nurse recognize for this chest tubes placement?

1. Upper Anterior Chest, in 2nd-4th intercostal space
2. Upper Lateral Chest Line, in 2nd-3rd intercostal space
3. Lower Medial Chest Region
4. Lower Lateral Chest, in 8th or 9th intercostal space

Answer 5

Answer: 4

page 544

Question 6

SATA The dressing around a PT’s chest tube has become soiled which of these is the nurse allowed to perform?

1. Inform RN
2. Inform HCP
3. Change dressing as ordered
4. Inform specially nurse
5. Collect sterile equipment to perform the procedure
6. Check clamps before performing the procedure

Answer 6

Answer: 1, 2, 4

page 544

Question 7

Why do we (NEVER) clamp a chest tube for more than a few seconds?

Answer 7

Answer: Because the tension created by the clamps within the chest wall can cause air to build up in the pleural space Pnuemonothorax can result.

Question 8

What type of low flow oxygen device, must the PT breath through their nose and receive oxygen at a flow rate of 1-6 L/min?

1. Simple face mask
2. Venturi mask
3. Nasal Cannula
4. Partial rebreather

Answer 8

Answer: 3 (page) 540

Also, COPD PTs cannot have oxygen greater than 2 Liters per minute. (page) 541

Question 9

What kind of low-flow oxygen device may benefit a PT with COPD?

1. Venturi mask
2. Incentive Spirometer
3. Partial rebreather
4. Nasal cannula with reservoir
5. Nebulized mist treatment

Answer 9

Answer 4 (page) 540

Explanation: Oxygen is saved in the reservoir when the patient exhales and is released back to the PT when they inhale. This gives the PT more oxygen than the regular nasal cannula.

Question 10

SATA Which of these are a type of low-flow oxygen delivery mask?

1. Simple face mask
2. Partial rebreather
3. Nonrebreather masks
4. Venturi mask
5. Nasal cannula

Answer 10

Answer: 1, 2, 3 (page) 540-541

Simple face mask- 5-10 L/min oxygen concentrates from 40%-60%.

Partial rebreather mask- Uses reservoir to store oxygen Vents along the sides of the mask let room air mix with the oxygen. It can deliver oxygen at concentrations of 50% or greater.

Nonrebreather mask- Has one or both sides closed to limit oxygen mixing with room air. It also has a reservoir but does not allow entry of the exhaled air. delivers oxygen concentrates at 70%-100%.

Question 11

For a partial and nonrebreather mask, what fraction is it unallowed to collapse less than?

Answer 11

2/3 answer 541

Question 12

Which high flow mask delivers exact amounts of oxygen for conditions such as chronic lung disease with carbon dioxide retention?

1. Venturi mask
2. Regular mask
3. Filtering respirator mask
4. Vessistance with measuring tip

Answer 12

Answer: 1 (page) 541

Explanation: The venturi mask uses ports and certain flow rates that are used to give an exact amount of oxygen.

Question 13

What type of high flow device with a tube is used to deliver oxygen to PTs on long-term oxygen therapy?

1. Nebulized mist treatment
2. Thera resistance oxygen tube
3. Inhaler
4. Transtracheal Catheter

Answer 13

Answer: 4 (541)

Explanation: Transtracheal catheters surgically implant a small tube in the neck which is connected to oxygen through a catheter. It does obstruct the nose or mouth, but PT must be taught how to remove and clean it to prevent a mucous obstruction.

Question 14

SATA The nurse is caring for a PT on oxygen therapy who suddenly becomes confused, their oxygen saturation is below an 88 what should the nurse do?

1. Use an incentive spirometer
2. Inform HCP of suspected Encephalopathy
3. Diagnose PT with hypoxia
4. Check tubing for kinks
5. See if PT has taken off tubing
6. Check tubing for disconnection

Answer 14

Answer: 4,5,6 (page) 540

Question 15

What are some common causes of Epistaxis?

1. Corticosteroids
2. Prednisone
3. Trauma
4. Forceful nose blowing
5. Nose picking
6. Tumors
7. Stroke
8. Hemophilia
9. Anticoagulation theraputolology
10. regular aspirin
11. Cocaine
12. Hypertension
13. Polydrug use
14. anticoagulation therapy
15. Chemo

Answer 15

Answers: 3, 4, 5, 6, 8, 10, 11, 12, 14, 15 (page) 556

Question 16

A nurse is caring for a PT who is having a nose bleed what therapeutic measures can the nurse implement?

1. Have PT hold nose and lean back
2. Have PT sit in a chair leaning slightly forward
3. Nurse should place pressure on the nose 5-10 minutes
4. Use heating pads
5. Local application of a vasoconstrictor such as phenylephrine
6. Local application of Neo-synephrine

Answer 16

Answer: 2, 5, 6 (page 556)

PT should sit in a chair and lean forward, if they lean backward they could aspirate or swallow blood, cause nausea and vomiting, and make it difficult to document and know the extent of bleeding.

The nurse should place pressure on the nares and nose

Ice should be used for vasoconstriction

phenylephrine is (Neo-synephrine) a local vasoconstrictor

Question 17

SATA What should the nurse expect to see in a PT with a deviated septum?

1. Chronic stuffy nose
2. Acute stuffy nose
3. headaches
4. Sinus infection
5. Nasal mucosa infection
6. nosebleeds

Answer 17

Answers: 1, 3, 4, 6 (page 558)

Chronic stuffy nose is caused by blocked sinus drainage

Question 18

SATA What medication should the nurse anticipate giving for a PT with a deviated septum?

1. anticoagulants as ordered
2. decongestants as ordered
3. platelet depleters as ordered
4. cortisone sprays as ordered
5. antihistamines as ordered

Answer 18

Answer: 2, 4, 5 (page 558)

These meds reduce inflammation of the already affected nose.

Question 19

What post-opt care should the nurse perform after an nasoseptoplasty?

1. These PTs do not need to have their vitals done consistently
2. Monitor for frequent swallowing
3. Give aspirin
4. The PT can take this mustache dressing applied after surgery at home
5. Heating pads are recommended
6. Advise PT to avoid alcohol and smoking
7. Advise PT to elevate their head on recliner or pillow
8. Advise them to drink fluid and use humidifiers

Answer 19

Answers: 2, 6, 7, 8 (page 558)

Always do vitals

Frequent swallowing= throat bleeding

PT must see HCP and receive instruction from surgeon policy before removing the dressing

Alcohol=congestion

Smoking=slower healing

Fluids/Humidifier= Keep nose from drying out

Question 20

Super SATA! The nurse enters the room of a PT who has Pharyngitis what should she assess for in this PT?

1. White patches from the strep throat
2. exudate
3. swollen mouth and tongue
4. dysphagia
5. sore throat
6. accessory muscle use
7. headache
8. tremors

Answer 20

Answers: 2, 4, 5, 7 (page 561)

Sore throat most common symptom #1, dysphagia difficulty swallowing (dysphagia) most likely due to a swollen and red throat. Exudate may be present if the infection is bacterial, with the exudate PT may experience chills, fever, general malaise, and headache.

Question 21

What are the risk factors related to oxygen therapy?

1. Respiratory depression
2. Dry cough
3. Chest pain
4. Numbness in extremities
5. Lethargy
6. Nausea
7. PaO2 >100

Answer 21

Answer: All of them!

PT can experience respiratory depression if they have COPD, and our on oxygen therapy with rates over 2 L per minute.

PT can also suffer lung damage when high oxygen levels above 50% are used for more than 24 hours

Question 22

What is a Nebulized Mist Treatment

Answer 22

A treatment that uses a nebulizer to mist medication directly onto the lungs, reducing systemic side effects. RT or specially trained nurse helps PT use the handheld resevior with tubing and mouth piece to breathe in the medication

Question 23

Which of these are acceptable meds to use with a Nebulized Mist Treatment?

1. corticosteroids
2. mucolytics
3. Antihistamine
4. Bronchodilators
5. Albuterol mixed with oxygen and dextrose

Answer 23

Answer: 1, 2, 4

Bronchodilators including Albuterol, Proventil, ProAir, and HFA can be mixed with normal (saline), and sometimes supplemental oxygen.

corticosteroids, mucolytics, and antibiotics may also be given.

Question 24

What does a Metered-Dose Inhaler use to administer medication, that a Dry-Powdered Inhaler does not use?

Answer 24

Answer Propellants page 541

Question 25

Which Inhaler med is it extremely if overused? 1. Bronchodilators 2. Diffusible Myacin Antiobiotics 3. Corticosteroids 4. Adrenergic Bronchodilators

Answer 25

Answer: 4 Adrenergic Bronchodilators cause severe rebound bronchoconstriction and even death (page 542)

Question 26

What is Chest Physiotherapy

Answer 26

Uses vibration, percussion, and postering to move secretions promoting better breathing. This includes PTs with cystic fibrosis, COPD, bronchiestasis, and those on ventilators.

Question 27

What is a High-Frequency Chest Wall Oscillation Device?

Answer 27

An inflatable vest that uses a compressor to vibrate the PT's chest. This helps to loosen secretions as an alternative to Chest Physiotherapy. PT must cough during and after for treatment to be effective.

Question 28

What is a Vibratory Positive Expiratory Pressure Device?

Answer 28

Bouncy ball device, after PT breaths into the mouthpiece a heavy still ball bounces inside the device this sends vibrations to airway loosening secretions, and also opens up the airway promoting better breathing. another alternative to CPT

Question 29

Why do we never plug a Larygenectomy tube?

Answer 29

It can result in PT suffocation (page 547)

Question 30

What may Trigger a High-Pressure Ventilation Alarm? 1. Kinks 2. PT has been suctioned 3. coughing 4. anxiousness 5. PT pulling out tube

Answer 30

Answer: 1, 3, 4 (page 552)

Question 31

Which Ventilator Mask is used for PTs who struggle with the ability to maintain normal ABG's, with disorders such as severe respiratory disease, sleep apnea, or neuromuscular diseases? 1. Therabase 2. Mask ventilator 3. NIPPV

Answer 31

Answer 3 Noninvasive Positive-Pressure Ventilation (page 553)