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Basic Nursing Skills (LVN) > Unit 5 & 6 Review (Exam 4) > Flashcards

Unit 5 & 6 Review (Exam 4) Flashcards

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1
Q

What is Inspiration?

A

Breathing in (diaphragm contracts).

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2
Q

What is expiration?

A

Breathing out (diaphragm relaxes).

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3
Q

What is Ventilation?

A

The movement of air in and out of the lungs.

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4
Q

Where does External Respiration occur?

A

At the most distal point in the airway between the alveolar and capillary membranes.

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5
Q

Where does Internal Respiration occur?

A

At the cellular level by means of hemoglobin and body cells.

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6
Q

What must we assess for Oxygenation?

A
  • Physical Assessment
  • Arterial Blood Gases
  • Pulse Oximetry
  • Hypoxemia
  • Hypoxia
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7
Q

What are ABG’s?

A

Arterial Blood Gases

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8
Q

What is Hypoxemia?

A

Insufficient oxygen within arterial blood.

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9
Q

What is Hypoxia?

A

Inadequate oxygen at the cellular level.

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10
Q

Normal pH

A

7.35-7.45

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11
Q

PaO2

A

Partial pressure of oxygen dissolved in plasma; 80-100 mmHg.

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12
Q

PaCO2

A

Partial pressure of carbon dioxide dissolved in plasma; 35-45 mmHg.

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13
Q

SaO2

A

Percentage of hemoglobin saturated with oxygen; 95%-100%.

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14
Q

HCO

A

Bicarbonate level; 22-26 mEq

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15
Q

What is Acidosis?

A

Low acidity level of 7.35

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16
Q

What is Alkalosis?

A

High acidity level of 7.45

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17
Q

What does R.O.M.E. represent?

A

Acid Base Mnemonic

R - Respiratory
O - Opposite
M - Metabolic
E - Equal

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18
Q

What is Pulse Oximetry?

A

Noninvasive, transcutaneous method of measuring oxygen saturation of blood.

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19
Q

What are ways to promote oxygenation in terms of positioning?

A
  • High Fowler’s
  • Tripod
  • Orthopneic
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20
Q

What are ways to promote oxygenation in terms of Breathing Techniques?

A
  • Deep Breathing
  • Pursed-Lip Breathing
  • Diaphragmatic Breathing
  • Nasal Strips
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21
Q

What is Oxygen Therapy?

A

Administering more oxygen than is present in the atmosphere.

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22
Q

What does Oxygen Therapy require?

A
  • Oxygen
  • Flowmeter
  • Humidifier
  • Delivery devices
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23
Q

Types of Oxygen Sources

A
  • Wall Outlet
  • Portable Tanks
  • Liquid Oxygen Unit
  • Oxygen Concentrator
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24
Q

What is the purpose of a Flowmeter?

A

To regulate the amount of oxygen delivered through a gauge.

25
Q

How is Oxygen Delivery measured?

A

Liters per minute (L/min)

26
Q

FIO2

A

Fraction of Inspired Oxygen

27
Q

What are some Oxygen Delivery Devices?

A
  • Nasal Cannula
  • Masks
  • Face Tent
  • Tracheostomy Collar
  • T-Piece
28
Q

What are the signs and symptoms of Oxygen Toxicity?

A
  • Nonproductive Cough
  • Substernal Chest Pain
  • Nasal Stiffness
  • Nausea and Vomiting
  • Fatigue
  • Headache
  • Sore Throat
  • Hypoventilation
29
Q

What are some Oxygen Hazards?

A
  • Fire

- Oxygen Toxicity

30
Q

Positive Airway Pressure

A
  • Relieve impaired oxygen levels caused by sleep apnea

- Relaxed muscles in the soft palate and tongue cause mild airway obstruction resulting in dyspnea or apnea.

31
Q

What does OSA represent?

A

Obstructive Sleep Apnea

32
Q

What does the Three Chamber System consist of?

A

One Chamber - Collects blood/acts as a exit route for pleural air

Two Chamber -

33
Q

What is Intubation?

A

Placement of a tube into a body.

34
Q

What is Orogastric Intubation?

A

Insertion of a tube through the mouth into the stomach.

35
Q

What is Nasogastric Intubation?

A

Insertion of a tube through the nose into the stomach.

36
Q

What is an Ostomy?

A

A surgically created opening.

37
Q

Why are gastric/intestinal tubes necessary?

A
  • Gavage; provide nourishment
  • Administration of medications
  • Diagnostic sampling of secretion
  • Lavage; removal of substances from stomach
  • Decompression; removing gas and liquid from stomach or bowel
  • Temponade (pressure); controlling gastric bleeding
38
Q

True/False: When choosing the type of tube that is needed, it is a must to remember that the larger the number, the larger the diameter.

A

TRUE.

39
Q

What is the purpose of Orogastric Tubes?

A
  • Used emergently to pump stomach contents.

- Tubes such as Ewald is large enough to remove pill fragments and stomach debris.

40
Q

What is the purpose of Nasointestinal Tubes?

A
  • Used for nutrition; Feeding tubes
41
Q

What is the purpose of Transabdominal Tubes?

A
  • Used when tube feeding will be necessary for longer than 1 month.
42
Q

What are the types of of Transabdominal Tubes?

A
  • Used when tube feeding will be necessary for longer than 1 month.
43
Q

What does the preparation of Nasogastric Tubes consist of ?

A
  • Preparing the client; explain procedure, give instructions on how to assist, provide them with some means of control (waving hand to indicate a pause during insertion)
44
Q

Nasogastric Tube Preintubation Assessment

A
  • LOC
  • Weight
  • Bowel Sounds
  • Abdominal Distention
  • Integrity of nasal and oral mucosa
  • Ability to swallow, cough, and gag
  • Nausea and vomiting
  • Pulse oximetry reading
45
Q

Nasogastric Tube Management

A
  • Nasal Inspection
  • Tube measurement (NEX)
  • Tube Placement
  • Checking Placement (aspirating stomach fluid, pH of aspirate
  • Chest x-ray
  • Monitoring external tube length (after x-ray)
46
Q

True/False: You have to have x-ray placement for feeding.

A

TRUE.

47
Q

Gastric Decompression

A

Suction - continuous/intermittent; prescribed by the physician

Patency - Promoting patency, restoring patency, enternal nutrition (must have doctor’s order)

48
Q

Indications for removal of Nasogastric Tube

A
  • Client’s condition improves
  • Tube is hopelessly obstructed
  • Facility standards for maintaining nasal mucosa
  • Trial period for oral intake may occure, if asymptomatic tube is removed.
49
Q

True/False: Transabdominal Tubes are inserted by Physicians.

A

TRUE.

50
Q

Tube-Feeding Schedules

A
  • Bolus feeding
  • Intermittent feedings
  • Cyclic feedings
  • Continuous feedings
51
Q

What is Gastric Residual?

A

It is done to determine whether the client is receiving too much feeding.

52
Q

What are the causes of overfilling the stomach?

A
  • Gastric Reflux
  • Regurgitation
  • Vomiting
  • Aspiration
  • Pneumonia
53
Q

Rule of Thumb

A

The gastric residual should be no more than 100 cc or no more than 20% of the previous hour’s tube-feeding volume.

54
Q

Maintaining Tube Patency

A
  • Flush tubes with 30-60 ml of water immediately before and after administering a feeding or medications; flush every 4 hours if continously fed.
55
Q

How to clear an Obstruction

A
  • Use warm water; back/forth motion;

- May have to remove tube

56
Q

True/False: Adults require 30ml of water per kilogram of weight. Always check for dehydration and fluid overload.

A

TRUE.

57
Q

Pharmacologic Consideration

A
  • Liquid medications are preferred for central administration.
  • Tablets crushed and mixed with water may reduce GI distress from liquid medications.
58
Q

Gerontological Considerations

A
  • Elderly clients usually have diminished efficency of gag reflex
  • They have ethical considerations for refusal to eat; some older adults tend to tolerate small, continuous feedings.
  • Increased risk for fluid and electrolyte disturbances
  • Check blood glucose levels with tube feedings.
  • Monitor for confusion or agitation

Basic Nursing Skills (LVN) (4 decks)

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