NUR 265- Respiratory Review UPDATED ACTUAL Questions and CORRECT
Answers
- Start passive and active ROM exercises for extremities of immobilized and post-op
pt's
- Ambulate pt ASAP post-op
- Use pneumatic compression devices after surgery as prescribed
- Evaluate pt for criteria indicating need for anticoagulant therapy
- Give prescribed prophylactic low-dose anticoagulant or antiplatelet drugs after
specific surgical procedures as soon as surgical bleeding risk has subsided
- Teach pt's to avoid the use of tight garters, girdles, and constricting clothing
- Prevent pressure under the popliteal space (e.g., do not place a pillow under the
PE Prevention
knee; instead use an alternating pressure mattress)
- Perform a comprehensive assessment of peripheral circulation every 8 hrs
- Elevate the affected limb 20 degrees or more above the level of the heart to
improve venous return, as appropriate
- Change pt position every 2 hrs or ambulate as tolerated
- Refrain from massaging leg muscles
- Instruct pt's to not cross their legs
- Teach the pt and family about precautions
- Encourage smoking cessation
What pre-surgical intervention can be Preoperative placement of a retrievable inferior vena cava (IVC) filter, that is
done for adults who have an ongoing risk removed when the pt is fully ambulatory post-op
for VTE and PE to reduce the risk post-op?
, - Sudden onset of dyspnea
- Sharp, stabbing chest pain
- Apprehension, restlessness
- Feeling of impending doom
- Cough
- Hemoptysis
- Diaphoresis
Classic S/S of PE - Increased RR
- Crackles
- Pleural friction rub
- Tachycardia
- S3 or S4 heart sound
- Fever, low grade
- Petechiae over chest and axillae (usually only associated w/FES)
- Decreased arterial oxygen saturation (Sa02)
What is the first ABG of a PE? Respiratory Alkalosis d/t compensatory mechanism of tachypnea (hyperventilation)
What ABG's of a PE follows Respiratory - Respiratory Acidosis occurs as deoxygenated blood enters the left atrium
Alkalosis? - Later on: Metabolic Acidosis occurs d/t tissue hypoxia
When a patient has sudden onset of - Call rapid
dyspnea and chest pain: What do you do? - Apply 02, reassure pt, and raise HOB
Antidote for Heparin Protamine sulfate
Antidote for Warfarin Vitamin K
Antidote for Fibrinolytic Therapy Clotting factors, FFP, and Aminocaproic acid
- Look for oozing around puncture sites (e.g., IV catheter)
- Bruised gums
- Petechiae
How do you assess for bleeding for a - Purpura
patient on anticoagulation? - Look at stools, urine, drainage, vomitus for gross blood, test for occult blood
- Ensure abdomen doesn't look distended or firm
- Rigid abdomen is always the priority pt! (concerned about bleeding in abdominal
cavity, or bowel obstruction)
What ABG's indicate Acute Respiratory - Pa02 <60, or;
Failure (ARF)? - Respiratory acidosis w/ 02 sat <90%
What is the number one hallmark of Dyspnea
respiratory failure (RF)?
What is the priority intervention for a pt 02 therapy- if ineffective, mechanical ventilation may be needed
with acute hypoxemia?
What is the best thing you can do for your Aspiration precautions (sit pt up- esp. if on tube feedings!)
patient to prevent ARDS?
This often occurs after an ALI in pt's who have no pulmonary disease as a result of
Who is at risk for ARDS? their other conditions such as:
- sepsis, burns, pancreatitis, trauma and transfusion
Initial phase:
ARDS- Exudative Phase - extra fluid collecting
- early interventions: focus on supporting pt and providing 02
Answers
- Start passive and active ROM exercises for extremities of immobilized and post-op
pt's
- Ambulate pt ASAP post-op
- Use pneumatic compression devices after surgery as prescribed
- Evaluate pt for criteria indicating need for anticoagulant therapy
- Give prescribed prophylactic low-dose anticoagulant or antiplatelet drugs after
specific surgical procedures as soon as surgical bleeding risk has subsided
- Teach pt's to avoid the use of tight garters, girdles, and constricting clothing
- Prevent pressure under the popliteal space (e.g., do not place a pillow under the
PE Prevention
knee; instead use an alternating pressure mattress)
- Perform a comprehensive assessment of peripheral circulation every 8 hrs
- Elevate the affected limb 20 degrees or more above the level of the heart to
improve venous return, as appropriate
- Change pt position every 2 hrs or ambulate as tolerated
- Refrain from massaging leg muscles
- Instruct pt's to not cross their legs
- Teach the pt and family about precautions
- Encourage smoking cessation
What pre-surgical intervention can be Preoperative placement of a retrievable inferior vena cava (IVC) filter, that is
done for adults who have an ongoing risk removed when the pt is fully ambulatory post-op
for VTE and PE to reduce the risk post-op?
, - Sudden onset of dyspnea
- Sharp, stabbing chest pain
- Apprehension, restlessness
- Feeling of impending doom
- Cough
- Hemoptysis
- Diaphoresis
Classic S/S of PE - Increased RR
- Crackles
- Pleural friction rub
- Tachycardia
- S3 or S4 heart sound
- Fever, low grade
- Petechiae over chest and axillae (usually only associated w/FES)
- Decreased arterial oxygen saturation (Sa02)
What is the first ABG of a PE? Respiratory Alkalosis d/t compensatory mechanism of tachypnea (hyperventilation)
What ABG's of a PE follows Respiratory - Respiratory Acidosis occurs as deoxygenated blood enters the left atrium
Alkalosis? - Later on: Metabolic Acidosis occurs d/t tissue hypoxia
When a patient has sudden onset of - Call rapid
dyspnea and chest pain: What do you do? - Apply 02, reassure pt, and raise HOB
Antidote for Heparin Protamine sulfate
Antidote for Warfarin Vitamin K
Antidote for Fibrinolytic Therapy Clotting factors, FFP, and Aminocaproic acid
- Look for oozing around puncture sites (e.g., IV catheter)
- Bruised gums
- Petechiae
How do you assess for bleeding for a - Purpura
patient on anticoagulation? - Look at stools, urine, drainage, vomitus for gross blood, test for occult blood
- Ensure abdomen doesn't look distended or firm
- Rigid abdomen is always the priority pt! (concerned about bleeding in abdominal
cavity, or bowel obstruction)
What ABG's indicate Acute Respiratory - Pa02 <60, or;
Failure (ARF)? - Respiratory acidosis w/ 02 sat <90%
What is the number one hallmark of Dyspnea
respiratory failure (RF)?
What is the priority intervention for a pt 02 therapy- if ineffective, mechanical ventilation may be needed
with acute hypoxemia?
What is the best thing you can do for your Aspiration precautions (sit pt up- esp. if on tube feedings!)
patient to prevent ARDS?
This often occurs after an ALI in pt's who have no pulmonary disease as a result of
Who is at risk for ARDS? their other conditions such as:
- sepsis, burns, pancreatitis, trauma and transfusion
Initial phase:
ARDS- Exudative Phase - extra fluid collecting
- early interventions: focus on supporting pt and providing 02
