MCN 374 EXAM 2 ACTUAL EXAM 100 QUESTIONS AND CORRECT ANSWERS|ALREADY GRADED A+
Upper respiratory tract - (answer) Oropharynx
Pharynx
Larynx
Lower respiratory tract - (answer) Trachea
Bronchi
Bronchioles
Alveoli
Trachea - (answer) Passage for air to the lungs (trunk)
Bronchus - (answer) Branches off the trachea (primary bronchi)
Bronchi - (answer) Smaller subdivisions of bronchus (smaller branches)
Bronchioles - (answer) Even smaller subdivisions of the bronchi (even smaller branches)
Alveoli - (answer) Gas exchange units (leaves)
Pediatric Airway - (answer) Shorter trachea
Angle of the right bronchus at bifurcation is more acute
Bifurcation of trachea is at T3
Infant's airway diameter is 4mm (1mm swelling reduces to 2mm)
Distance between structures is shorter allowing organisms to rapidly move down
Epiglottis is underdeveloped
Chest A:P diameter 1:1
At age 6, chest diameter is 1:2
Less alveolar surface area = reduced area for gas exchange
,MCN 374 EXAM 2 ACTUAL EXAM 100 QUESTIONS AND CORRECT ANSWERS|ALREADY GRADED A+
Age of Incidence of Respiratory Infection - (answer) <3m - maternal antibodies
3-6m - infection rate increases
Toddler/preschool - high rate of viral infections
>5yrs - increase in pneumonia and strep infections
Respiratory Assessment: Parts - (answer) Inspection
Color
Vital signs
Respiratory rate, depth, and ease
Oxygen saturation
Auscultation
Chest retractions
Respiratory distress
Symptoms of hypoxia
Inspection - (answer) What does the patient look like at first glance? Calm? Anxious? Alert? Asleep?
Position of comfort?
Color - (answer) Observe color of skin, nail beds, mucous membranes
Cyanosis = inadequate oxygenation
Clubbing of nails = chronic hypoxemia
Does crying or coughing worsen or improve color?
Respiratory rate, depth, and ease - (answer) Infant 30-55
Toddler 20-40
Preschool 20-30
School age 12-22
,MCN 374 EXAM 2 ACTUAL EXAM 100 QUESTIONS AND CORRECT ANSWERS|ALREADY GRADED A+
Adolescent 12-20
Oxygen saturation - (answer) Mild hypoxemia 91-94%
Is patient on O2? How much? Delivery system?
Auscultation - (answer) What do you hear? Adventitious sounds? Diminished sounds? Absent sounds?
Bilateral? Anterior? Posterior?
Observe work of breathing (stridor, labored breathing, retractions, head bobbing, nasal flaring, weak cry
or strong, equal chest rise and fall, cough?)
Chest retractions - (answer) Suggest an obstruction to inspiration
Degree and level of retractions emend on the extent and level of obstruction
S/S of Respiratory distress - (answer) Can lead to respiratory failure
S/S include grunting, severe retractions, nasal flaring, diminished or absent breath sounds, apnea,
gasping respirations, tachycardia, bradycardia, decreased oxygen saturation)
Early signs of hypoxia - (answer) Tachypnea
Tachycardia
Restlessness
Pallor
Increased systolic BP
Use of accessory muscles
Late signs of hypoxia - (answer) Bradypnea
Bradycardia
Confusion/stupor
Cyanosis
Hypotension
, MCN 374 EXAM 2 ACTUAL EXAM 100 QUESTIONS AND CORRECT ANSWERS|ALREADY GRADED A+
Dysrhythmias
Nursing Diagnoses for Respiratory Distress - (answer) Ineffective breathing pattern
Risk for volume deficit
Fear (child)
Ineffective airway clearance
Impaired gas exchange
Ineffective therapeutic regime management
Nursing Care for Oxygenation Alteration - (answer) Maintain patent airway
Allow for a position of comfort
Assess respiratory status q1-4hrs
Maintain oxygenation
Assess continuous pulse oximetry
Assess hydration status - maintain I/Os
Assess IV access site
Cardiorespiratory monitoring
Oxygen Delivery Systems - (answer) Non-rebreather in emergency situations
Don't use non-rebreather long-term as patient may develop high levels of carbon dioxide
Nasal cannula with humidified air over 4L
Foreign Body Aspiration - (answer) Most common in 1-3yr olds
Can cause respiratory distress
Symptoms depend on location
Usually items get stuck in *right bronchus*
Chest x-ray
Bronchoscope to remove object
Upper respiratory tract - (answer) Oropharynx
Pharynx
Larynx
Lower respiratory tract - (answer) Trachea
Bronchi
Bronchioles
Alveoli
Trachea - (answer) Passage for air to the lungs (trunk)
Bronchus - (answer) Branches off the trachea (primary bronchi)
Bronchi - (answer) Smaller subdivisions of bronchus (smaller branches)
Bronchioles - (answer) Even smaller subdivisions of the bronchi (even smaller branches)
Alveoli - (answer) Gas exchange units (leaves)
Pediatric Airway - (answer) Shorter trachea
Angle of the right bronchus at bifurcation is more acute
Bifurcation of trachea is at T3
Infant's airway diameter is 4mm (1mm swelling reduces to 2mm)
Distance between structures is shorter allowing organisms to rapidly move down
Epiglottis is underdeveloped
Chest A:P diameter 1:1
At age 6, chest diameter is 1:2
Less alveolar surface area = reduced area for gas exchange
,MCN 374 EXAM 2 ACTUAL EXAM 100 QUESTIONS AND CORRECT ANSWERS|ALREADY GRADED A+
Age of Incidence of Respiratory Infection - (answer) <3m - maternal antibodies
3-6m - infection rate increases
Toddler/preschool - high rate of viral infections
>5yrs - increase in pneumonia and strep infections
Respiratory Assessment: Parts - (answer) Inspection
Color
Vital signs
Respiratory rate, depth, and ease
Oxygen saturation
Auscultation
Chest retractions
Respiratory distress
Symptoms of hypoxia
Inspection - (answer) What does the patient look like at first glance? Calm? Anxious? Alert? Asleep?
Position of comfort?
Color - (answer) Observe color of skin, nail beds, mucous membranes
Cyanosis = inadequate oxygenation
Clubbing of nails = chronic hypoxemia
Does crying or coughing worsen or improve color?
Respiratory rate, depth, and ease - (answer) Infant 30-55
Toddler 20-40
Preschool 20-30
School age 12-22
,MCN 374 EXAM 2 ACTUAL EXAM 100 QUESTIONS AND CORRECT ANSWERS|ALREADY GRADED A+
Adolescent 12-20
Oxygen saturation - (answer) Mild hypoxemia 91-94%
Is patient on O2? How much? Delivery system?
Auscultation - (answer) What do you hear? Adventitious sounds? Diminished sounds? Absent sounds?
Bilateral? Anterior? Posterior?
Observe work of breathing (stridor, labored breathing, retractions, head bobbing, nasal flaring, weak cry
or strong, equal chest rise and fall, cough?)
Chest retractions - (answer) Suggest an obstruction to inspiration
Degree and level of retractions emend on the extent and level of obstruction
S/S of Respiratory distress - (answer) Can lead to respiratory failure
S/S include grunting, severe retractions, nasal flaring, diminished or absent breath sounds, apnea,
gasping respirations, tachycardia, bradycardia, decreased oxygen saturation)
Early signs of hypoxia - (answer) Tachypnea
Tachycardia
Restlessness
Pallor
Increased systolic BP
Use of accessory muscles
Late signs of hypoxia - (answer) Bradypnea
Bradycardia
Confusion/stupor
Cyanosis
Hypotension
, MCN 374 EXAM 2 ACTUAL EXAM 100 QUESTIONS AND CORRECT ANSWERS|ALREADY GRADED A+
Dysrhythmias
Nursing Diagnoses for Respiratory Distress - (answer) Ineffective breathing pattern
Risk for volume deficit
Fear (child)
Ineffective airway clearance
Impaired gas exchange
Ineffective therapeutic regime management
Nursing Care for Oxygenation Alteration - (answer) Maintain patent airway
Allow for a position of comfort
Assess respiratory status q1-4hrs
Maintain oxygenation
Assess continuous pulse oximetry
Assess hydration status - maintain I/Os
Assess IV access site
Cardiorespiratory monitoring
Oxygen Delivery Systems - (answer) Non-rebreather in emergency situations
Don't use non-rebreather long-term as patient may develop high levels of carbon dioxide
Nasal cannula with humidified air over 4L
Foreign Body Aspiration - (answer) Most common in 1-3yr olds
Can cause respiratory distress
Symptoms depend on location
Usually items get stuck in *right bronchus*
Chest x-ray
Bronchoscope to remove object
