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NR 224 QUIZ 3 LATEST EXAMNR 224 QUIZ 3 LATEST EXAM
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NR 224 QUIZ 3 LATEST EXAM
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NR 224 QUIZ 3 LATEST EXAMWhat are some factors impacting oxygenation? - ANSWER: -Physiological factors
- Developmental factors
- Lifestyle factors
- Environmental factors
What are some physiological factors that impact oxygenation - ANSWER: - anemia
- Hypovolemia
- Fever
- Muscular dystrophy
- Increased metabolic rate
- Chest wall movement
What are two physiological changes that impact chest wall movement? - ANSWER: -
pregnancy
- obesity
What are some alterations to respiratory functions? - ANSWER: - Hypoventilation
- Hyperventilation
- Hypoxia
What is the definition of hypoventilation? - ANSWER: - occurs when alveolar
ventilation is inadequate to meet O2 demands
- occurs when alveolar ventilation is not sufficient enough to eliminate proper CO2
amounts
What is retained during hypoventilation? - ANSWER: - CO2
What does hypoventilation cause? - ANSWER: respiratory acidosis
What is the definition of hyperventilation? - ANSWER: - Lung removes CO2 faster
than it is produced via cellular metabolism
What is hyperventilation caused by? - ANSWER: - severe anxiety
- infection
- drugs
- acid-base imbalance
What are some signs / symptoms of hyperventilation? - ANSWER: - Rapid respiration
- sighing breaths
- numbness / tingling in hands/ feet
- light headedness
- loss of consciousness
,What is the definition of hypoxia? - ANSWER: - inadequate tissue oxygenation at
the cellular level.
What does hypoxia result from? - ANSWER: - deficiency in O2 delivery
- deficiency of O2 utilization at a cellular level
What can cause hypoxia to occur? - ANSWER: - decreased level of hemoglobin &
lowered O2 carrying capacity of blood
- diminished concentration of inspired O2 at higher altitudes
- inability of tissue extraction O2 from the blood (cyanide poisoning)
- decreased diffusion of O2 from the alveoli to the blood (pneumonia)
- poor tissue perfusion w/ oxygenated blood
- impaired ventilation
What sickness / disease can cause hypoxia to occur? - ANSWER: - pneumonia
What physiological changes to the body can cause hypoxia? - ANSWER: - cyanide
poisoning
- shock
- fractured ribs
- Chest trauma
What are some early signs and symptoms hypoxia? - ANSWER: - restlessness
- apprehension
- decreased level of consciousness (LOC)
- Dizziness
- Behavior changes
What are some early vital sign changes with hypoxia? - ANSWER: - Blood pressure
elevated (unless it is caused by shock)
How does shock impact hypoxia related to Blood pressure? - ANSWER: - Does not
increase BP in early signs of blood pressure
What are some late signs and symptoms of hypoxia? - ANSWER: - Cyanosis
- Respiratory rate decreases
What are the two locations you can observe cyanosis in patients with hypoxia? -
ANSWER: - Central cyanosis
- Peripheral cyanosis
Where can you see central cyanosis in clients with hypoxia? - ANSWER: - tongue
- soft palate
- Conjunctiva
Where can you peripheral cyanosis in clients with hypoxia? - ANSWER: - Lower
extremities
, - upper extremities
- nail beds
- earlobes
What is hypoxia a result of ? - ANSWER: - Constriction
- stagnant blood flow
What are some factors impacting oxygenation? - ANSWER: - Amount of dissolved O2
in plasma
- Amount of hemoglobin
- Ability of hemoglobin to bind with O2
What vital signs are observed in the late stages of hypoxia? - ANSWER: - respiratory
rate decreases
What should a nurse assess during a physical examination of the lungs? - ANSWER: -
assess accessory muscle usage
- assess clavicle elevation during respiration
What does one utilize percussion for when assessing the lungs? - ANSWER: - detects
presence of abnormal fluid / air in lungs
What does one utilize auscultation for when assessing the lungs? - ANSWER: - Lung
sounds
- Adventitious breath sounds
What are some aspects a nurse should remember for tracheostomy care? - ANSWER:
- Need a minimum of 2 HC team members
- Use sterile trach care kit
- Use sterile normal saline or water
What should you do first in trach suctioning: Trach or pharyngeal? - ANSWER: - Trach
first
Why should you always perform trach suctioning prior to pharyngeal suctioning? -
ANSWER: - B/c trach suctioning is sterile and pharyngeal suctioning is not sterile
What should you observe for during trach suctioning? - ANSWER: - skin / mucous
membrane color
- General appearance
- LOC
- Adequacy of systemic circulation
- Breathing patterns
- Chest wall movement
What techniques should one utilize when inspection presented abnormalities? -
ANSWER: - palpation
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