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Nur 195 Test 1: Questions & Correct Answers
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Nur 195 Test 1: Questions & Correct Answers
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Nur 195 Test 1: Questions & Correct AnswersRespiratory: What is the nurse's priority? Right Ans - A Airway: upper respiratory tract natural or artificial airway B Breathing: lower respiratory tract respiration: ventilation, perfusion, diffusion C Circulation: adequate BP and Hemoglobin (Hg)
Morbidly obese Right Ans - increase risk for airway and breathing issues, increased respiratory rate, circulatory issues, etc, DVT- can change into a pulmonary embolism
Head of the bed must be up for Right Ans - respiratory patients and the elderly
If patient is unconscious Right Ans - keep them on their side in case they vomit
Anything below the trachea is Right Ans - sterile
If someone aspirates, what lung will most likely be affected? Right Ans - Right lung
PLEURAL EFFUSION Right Ans - Addtl fluid in the lung (pleural space)
diaphragm Right Ans - the major muscle of respiration located at the base of the thoracic cavity use of accessory muscles Right Ans - Scalenes, intercostal, flaring of nostrils
Surfactant Right Ans - keeps the alveoli open and decreases surface
Atelectasis Right Ans - unable to keep the alveoli open (collapsed alveoli), low grade temp and may have crackles, leads to hospital acquired pneumonia, important to use incentive spirometer
anatomic dead space Right Ans - Nose to bronchioles
What Controls Respiratory Rate and Depth? Right Ans - Chemoreceptors in the Brain, Peripheral receptors -Carotid and Aortic Bodies, Mechanical receptors in the Lungs
Chemoreceptors in the Brain Right Ans - --Chemical changes in H+ ion concentration or pH --Changes in carbon dioxide concentration
Peripheral receptors -Carotid and Aortic Bodies Right Ans - respond to oxygen levels, carbon dioxide and pH
Mechanical receptors in the Lungs Right Ans - Physiologic factors: pulmonary muscle stretching, alveolar wall distortion, irritants and fluid build
up.
Why must COPD patients be conscious of the amt of oxygen that they get? Right Ans - they have higher levels of carbon dioxide
What is a focused respiratory assessment? Right Ans - Subjective Assessments: •Dyspnea: (rated on a scale of 1-10) •Chest pain: pulmonary v.s. cardiac origin Objective assessments: •Cough: describe characteristics •Sputum: quantity, consistency, color Physical Assessments: Inspection, Palpation, Percussion, Auscultation Arterial Blood Gas (ABG) Right Ans - ABG analysis is used to evaluate respiratory function and provides accurate information about oxygenation, ventilation and acid-base balance. The measurements reported are the pH, PaCO2, PaO2, HCO3 and SaO2.
An arterial puncture is done from the radial, brachial or femoral artery or the blood is obtained from an indwelling arterial catheter. Perform the Allen test before using the radial artery. Use a heparinized syringe and immediately place blood sample on ice and send to the lab.
Nursing Implications:
Explain the procedure to the patient. Make no changes with the patient for twenty minutes prior to test. Indicate whether oxygen was in use at the time blood was drawn. Once the needle is removed, firm, direct pressure is applied for 5 minutes to the arterial site, until the site is no longer bleeding.
M.H. 72 y/o female admitted with diagnosis of Pneumonia , shortness of breath, fever, chest pain with coughing, fatigue. Health History: smoker, Influenza PTA, productive cough Diagnostics: CXR - RLL infiltrates, consolidation: Pneumonia Labs: Blood and Sputum cultures pending, WBC: Leukocytosis Proceed with data collection and the Nursing Process: Right Ans - Physical Exam Observe or Monitor: WOB, LOC, RR and depth, SpO2, sputum production Inspect: skin color and temp, nail beds, chest symmetry Palpate: tactile fremitus Auscultate: adventitious sounds (cackles), egophony (voice resonance- say the
letter A, if it sounds like E it signifies pneumonia
pulse oximetry Right Ans - Nursing implications: values less than 90% indicate inadequate oxygenation. assess patient's status and presence of factors that could interfere with accuracy of readings.
Culture and Sensitivity
Gram Stain
Acid-fast smear and culture
Cytology Right Ans - Purpose is to identify pathogenic organisms to aid in diagnosis, selection and evaluation of treatment. Expectoration is the usual method used to collect sputum in a sterile container
after clearing the nose and throat and rinsing the mouth. Instruct patient to cough forcefully with exhalation.
Nursing Implications: An early morning specimen is best. Deliver to the lab immediately to prevent overgrowth of the specimen.
Chest X-Ray
(CXR) Right Ans - Test used to screen, diagnose and evaluate changes in the
chest.
Most common views are PA and lateral which requires patient transport to Radiology. Nursing Implications:
The nurse should ensure that the patient has removed jewelry, dentures, all external metallic objects, and wires
Nursing Implications:
The nurse should ensure that the patient has removed jewelry, dentures, all external metallic objects, and wires
Computed tomography
(CT) Right Ans - This test is performed for diagnosis of lesions difficult to assess by conventional x-ray studies. Images produced provide a cross-
sectional view of the chest.
Test is done with or without contrast. Contrast media is iodine-based.
Patient may require sedation in order to be able to tolerate the test.
Nursing Implications:
Screen the patient for shellfish or iodine allergies.
Evaluate hydration and renal function.
Determine weight is within limits.
Provides a more detailed diagnostic image and is used for diagnosis of lesions difficult to assess by CT scan.
Contrast media is not iodine-based.
Magnetic Resonance Imaging
(MRI) Right Ans - Nursing Implications:
Carefully screen the patient for any internal (implants) or external metal which may restrict patient from having the test.
Ventilation-Perfusion Scan
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