HACC Nursing 241 Exam Questions/Answer Grade A+
Thorancentesis - aspiration of pleural fluid or air from the pleural space:
◦Patient preparation for stinging sensation and feeling of pressure
◦Correct position
◦Motionless patient
◦Follow-up assessment for complications
Diagnostic Assessment - Laboratory assessment
◦RBC
◦ABG
◦Sputum
Imaging assessment
◦x-rays
◦CT
Other noninvasive diagnostic assessments
◦Pulse oximetry
◦Capnometryand capnography
◦PFTs
◦Exercise testing
Diagnostic Testing - Blood tests
Sputum tests (1st thing in morning)
Radiographic examinations including standard chest x-rays, digital chest radiography,
CT
Ventilation and perfusion scanning
Pulse oximetry
Lung Biopsy - Follow-up care:
◦Assess vital signs and breath sounds at least every 4 hrfor 24 hr.
◦Assess for respiratory distress.
◦Report reduced or absent breath sounds immediately.
◦Monitor for hemoptysis. (blood in sputum)
QSEN: NCLEX Review - Safe Effective Care
◦Safety (check respiratory status every 15 minutes after for 2 hours post endoscopy)
Health Promotion and Maintenance
◦Teach older patients effect of aging
Psychosocial Integrity
◦Allow ptto express feelings
Physiological Integrity
◦Assess the airway and breathing issues
Normal lung sounds - bronchial, bronchovesicular, vesicular
COPD risk factors= - · CIGARETTE SMOKING #1
· Passive smoking
,· Recurrent respiratory infections
· Occupational exposure
· Air pollution
· Genetic-abnormalities
· Asthma - COPD is 12X greater
· AAT deficiency - causes COPD to develop at fairly young age
COPD COMPLICATIONS- - hypoxemia & acidosisoccur because pt with COPD has
reduced gas exchange, leading to decreased oxygenation and increased carbon dioxide
levels. = reduced cellular function
respiratory infection,risk increasesdue to increased mucus and poor gas exchange.
cardiac failure (cor pulmonale) R. sided HF caused by pulmonary disease
dysrhythmias,
respiratory failure.
Cor pulmonale Chart 30-9 KEY FEATURES pg. 574
COPD - chronic obstructive pulmonary disease
Cor pulmonale key features -
Health promotion and maintenance COPD: - · Incidence & severity would be greatly
reduced by smoking cessation.
· Urge adults to quit smoking. Chart 27-2 tips to provide
· Teach pt's to avoid exposure to other inhalation irritants
COPD seen more often in OLDER MEN
Occurs in families with AAT deficiency
Many COPD pts sleep in a semi sitting position
Sits in FORWARD BENDING POSTURE W/ ARMS HELD FORWARD known as
orthopenic or tripod position
WHEEZES usually present, crackles aren't
Reduced breath sounds especially w/ emphysema
Priority problems for patients with COPD: - 1. Decreased gas exchange due to alveolar-
capillary membrane changes, reduced air way size, ventilator muscle fatigue, excessive
mucus production, airway obstruction, diaphragm flattening, fatigue, decreased energy
2. WEIGHT LOSS due to dyspnea, excessive secretions, anorexia, and fatigue
3. ANXIETY due to a change in health status, and situational crisis
4. DECREASED INDURANCE due to fatigue dyspnea, and imbalance between oxygen
supply and demand
5. POTENTIAL FOR PNEOMNIA or other RESPIRATORY INFECTIONS due to
presence of thick secretions and the immunosuppressive effects of some drugs
COPD Expected outcomes- - *Expected to attain & maintain gas exchange at baseline
level, indicators include:*
1. Maintain SpO2 of at least 88%
,2. Remains free of cyanosis
3. Maintains cognitive orientation
4. Coughs & clears secretions effectively
5. Maintains RR & rhythm appropriate to their activity level
Non-surgical management: Nursing management for COPD patients focuses on - ·
airway maintenance
· monitoring breathing techniques
· positioning
· effective coughing - * teach pts to cough on arising in the morning* cough before
meals and at bedtime
· oxygen therapy
· exercise conditioning
· suctioning
· hydration
· use of vibratory positive-pressure device
o *BEFORE ANY INTERVENTION ASSESS* the breathing rate, rhythm, depth, and use
of accessory muscles
o **AIRWAY MAINTENANCE** is the MOST IMPORTANT FORCUS OF
INTERVENTIONS to improve gas exchange
Chronic Bronchitis- - an inflammation of the bronchi and bronchioles caused by
exposure to irritants, especially cigarette smoke. Irritant triggers inflammation,
vasodilation, mucosal edema, congestion, and bronchospasm.
Bronchitisaffects only the *AIRWAYS* not the alveoli.
· Thick excess mucus = chronic cough
· Increased # of mucus glands
· Bronchial walls thicken(INFLAMMATION)=impair flow blocking airways
· Increased mucus allows for breeding ground for organisms leading to chronic infection
· Impairs AIRFLOW & GAS EXCHANGE=PAO2 decreases (hypoxemia), PACO2
increases = ****RESPIRATORY ACIDOSIS***
Emphysema- - remember PINK PUFFER / BARRELLED CHEST
· 2 major changes = LOSS OF LUNG ELASTICITY & HYPERINFLATION of the lung
· Retain more CO2
INCREASED RR
Proteases damage alveoli and small airways by breaking down elastin
· resulting in destroyed alveoli and others flabby with less area for GAS EXCHANGE
· Uses accessary muscles in neck, chest wall, and abdomen to inhale and exhale
· Increase need for O2= patient having *"AIR HUNGER" * sensation
· Increased air trapped in lungs
· ABG may not show problems until advanced disease
· Leads to chronic respiratory acidosis
Late stage=low PAO2
, Lung Cancer Warning signs table 30-5 - · Hoarseness
· Change in respiratory pattern
· Persistent couch or change in cough
· Blood streaked sputum
· Rust colored or purulent sputum
· Frank hemoptysis
· Chest pain or chest tightness
· Shoulder, arm, or chest wall pain
· Recurring episodes of pleural effusion, pneumonia, or bronchitis
· Dyspnea
· Fever associated with 1 or 2 other signs
· Wheezing
· Weight loss
· Clubbing of the fingers
Lung cancer Diagnosing - is made by examination of cancer cells
· -early morning sputum may identify tumor cells; however cancer cells may not be
present
· -if pleural effusion present then thoracentesis is performed
· -Most commonly lung lesions are 1stidentified on chest X-RAY
· -CT scans are then used to identify the lesions more clearly and guide biopsy
procedures
· -Thoracoscopy allows direct view of lung entering the chest wall through a small
incision
· -mediastinoscopy done to see if spread to mediastinal lymph nodes done through
small chest incision
· -Other tests: needle biopsy of lymph nodes
· Direct surgical biopsy
· Thoracentesis with pleural biopsy
· MRI w/ radionuclide scans of liver, spleen, brain & bone to help determine metastatic
tumors
· PFTs & ABG's to determine overall respiratory status
· PET becoming most thorough way to determine metastases
A nurse obtains the health history of a client who is recently diagnosed with lung cancer
and identifies that the client has a 60-pack-year smoking history. Which action is most
important for the nurse to take when interviewing this client?
a. Tell the client that he needs to quit smoking to stop further cancer development.
b. Encourage the client to be completely honest about both tobacco and marijuana use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
Thorancentesis - aspiration of pleural fluid or air from the pleural space:
◦Patient preparation for stinging sensation and feeling of pressure
◦Correct position
◦Motionless patient
◦Follow-up assessment for complications
Diagnostic Assessment - Laboratory assessment
◦RBC
◦ABG
◦Sputum
Imaging assessment
◦x-rays
◦CT
Other noninvasive diagnostic assessments
◦Pulse oximetry
◦Capnometryand capnography
◦PFTs
◦Exercise testing
Diagnostic Testing - Blood tests
Sputum tests (1st thing in morning)
Radiographic examinations including standard chest x-rays, digital chest radiography,
CT
Ventilation and perfusion scanning
Pulse oximetry
Lung Biopsy - Follow-up care:
◦Assess vital signs and breath sounds at least every 4 hrfor 24 hr.
◦Assess for respiratory distress.
◦Report reduced or absent breath sounds immediately.
◦Monitor for hemoptysis. (blood in sputum)
QSEN: NCLEX Review - Safe Effective Care
◦Safety (check respiratory status every 15 minutes after for 2 hours post endoscopy)
Health Promotion and Maintenance
◦Teach older patients effect of aging
Psychosocial Integrity
◦Allow ptto express feelings
Physiological Integrity
◦Assess the airway and breathing issues
Normal lung sounds - bronchial, bronchovesicular, vesicular
COPD risk factors= - · CIGARETTE SMOKING #1
· Passive smoking
,· Recurrent respiratory infections
· Occupational exposure
· Air pollution
· Genetic-abnormalities
· Asthma - COPD is 12X greater
· AAT deficiency - causes COPD to develop at fairly young age
COPD COMPLICATIONS- - hypoxemia & acidosisoccur because pt with COPD has
reduced gas exchange, leading to decreased oxygenation and increased carbon dioxide
levels. = reduced cellular function
respiratory infection,risk increasesdue to increased mucus and poor gas exchange.
cardiac failure (cor pulmonale) R. sided HF caused by pulmonary disease
dysrhythmias,
respiratory failure.
Cor pulmonale Chart 30-9 KEY FEATURES pg. 574
COPD - chronic obstructive pulmonary disease
Cor pulmonale key features -
Health promotion and maintenance COPD: - · Incidence & severity would be greatly
reduced by smoking cessation.
· Urge adults to quit smoking. Chart 27-2 tips to provide
· Teach pt's to avoid exposure to other inhalation irritants
COPD seen more often in OLDER MEN
Occurs in families with AAT deficiency
Many COPD pts sleep in a semi sitting position
Sits in FORWARD BENDING POSTURE W/ ARMS HELD FORWARD known as
orthopenic or tripod position
WHEEZES usually present, crackles aren't
Reduced breath sounds especially w/ emphysema
Priority problems for patients with COPD: - 1. Decreased gas exchange due to alveolar-
capillary membrane changes, reduced air way size, ventilator muscle fatigue, excessive
mucus production, airway obstruction, diaphragm flattening, fatigue, decreased energy
2. WEIGHT LOSS due to dyspnea, excessive secretions, anorexia, and fatigue
3. ANXIETY due to a change in health status, and situational crisis
4. DECREASED INDURANCE due to fatigue dyspnea, and imbalance between oxygen
supply and demand
5. POTENTIAL FOR PNEOMNIA or other RESPIRATORY INFECTIONS due to
presence of thick secretions and the immunosuppressive effects of some drugs
COPD Expected outcomes- - *Expected to attain & maintain gas exchange at baseline
level, indicators include:*
1. Maintain SpO2 of at least 88%
,2. Remains free of cyanosis
3. Maintains cognitive orientation
4. Coughs & clears secretions effectively
5. Maintains RR & rhythm appropriate to their activity level
Non-surgical management: Nursing management for COPD patients focuses on - ·
airway maintenance
· monitoring breathing techniques
· positioning
· effective coughing - * teach pts to cough on arising in the morning* cough before
meals and at bedtime
· oxygen therapy
· exercise conditioning
· suctioning
· hydration
· use of vibratory positive-pressure device
o *BEFORE ANY INTERVENTION ASSESS* the breathing rate, rhythm, depth, and use
of accessory muscles
o **AIRWAY MAINTENANCE** is the MOST IMPORTANT FORCUS OF
INTERVENTIONS to improve gas exchange
Chronic Bronchitis- - an inflammation of the bronchi and bronchioles caused by
exposure to irritants, especially cigarette smoke. Irritant triggers inflammation,
vasodilation, mucosal edema, congestion, and bronchospasm.
Bronchitisaffects only the *AIRWAYS* not the alveoli.
· Thick excess mucus = chronic cough
· Increased # of mucus glands
· Bronchial walls thicken(INFLAMMATION)=impair flow blocking airways
· Increased mucus allows for breeding ground for organisms leading to chronic infection
· Impairs AIRFLOW & GAS EXCHANGE=PAO2 decreases (hypoxemia), PACO2
increases = ****RESPIRATORY ACIDOSIS***
Emphysema- - remember PINK PUFFER / BARRELLED CHEST
· 2 major changes = LOSS OF LUNG ELASTICITY & HYPERINFLATION of the lung
· Retain more CO2
INCREASED RR
Proteases damage alveoli and small airways by breaking down elastin
· resulting in destroyed alveoli and others flabby with less area for GAS EXCHANGE
· Uses accessary muscles in neck, chest wall, and abdomen to inhale and exhale
· Increase need for O2= patient having *"AIR HUNGER" * sensation
· Increased air trapped in lungs
· ABG may not show problems until advanced disease
· Leads to chronic respiratory acidosis
Late stage=low PAO2
, Lung Cancer Warning signs table 30-5 - · Hoarseness
· Change in respiratory pattern
· Persistent couch or change in cough
· Blood streaked sputum
· Rust colored or purulent sputum
· Frank hemoptysis
· Chest pain or chest tightness
· Shoulder, arm, or chest wall pain
· Recurring episodes of pleural effusion, pneumonia, or bronchitis
· Dyspnea
· Fever associated with 1 or 2 other signs
· Wheezing
· Weight loss
· Clubbing of the fingers
Lung cancer Diagnosing - is made by examination of cancer cells
· -early morning sputum may identify tumor cells; however cancer cells may not be
present
· -if pleural effusion present then thoracentesis is performed
· -Most commonly lung lesions are 1stidentified on chest X-RAY
· -CT scans are then used to identify the lesions more clearly and guide biopsy
procedures
· -Thoracoscopy allows direct view of lung entering the chest wall through a small
incision
· -mediastinoscopy done to see if spread to mediastinal lymph nodes done through
small chest incision
· -Other tests: needle biopsy of lymph nodes
· Direct surgical biopsy
· Thoracentesis with pleural biopsy
· MRI w/ radionuclide scans of liver, spleen, brain & bone to help determine metastatic
tumors
· PFTs & ABG's to determine overall respiratory status
· PET becoming most thorough way to determine metastases
A nurse obtains the health history of a client who is recently diagnosed with lung cancer
and identifies that the client has a 60-pack-year smoking history. Which action is most
important for the nurse to take when interviewing this client?
a. Tell the client that he needs to quit smoking to stop further cancer development.
b. Encourage the client to be completely honest about both tobacco and marijuana use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
