STUDY GUIDE WITH VERIFIED SOLUTIONS
◉ MDI nursing actions. Answer: shake inhaler 5-6 times, 2-4 cm
away, hold breath for 10 secs.
◉ MDI complications. Answer: Clean spacer after each use. gargle
with warm water after admin. fungal infections w/ corticosteriod
use
◉ CPT nursing actions. Answer: schedule treatments 1 hr before
meals or 2hr after meals, bedtime. admin med prior. note color,
amount, character of secretions. provide basin/tissue. stop if feeling
faint o/ dizzy
◉ Early signs of hypoxemia. Answer: tachypnea, tachycardia,
restlessness, eleveated bp, pallor of skin/membranes. Signs of
respiratory distress
◉ late signs of hypoxemia. Answer: confusion and stupor, cyanosis,
bradypnea, bradycardia hypotension, cardiac dysrhytmias
,◉ oxygen therapy nursing actions. Answer: do not allow oxygen to
blow directly in face of infants. monitor temp for hypothermia.
decrease environmental stimuli, promote rest, d/c gradually
◉ oxygen hood. Answer: 4-5 L/min. ensure upper body doesn rup
◉ oxygen tent. Answer: older than 2-3 months. use plastic/ vinyl
toys. cluster care to avoid letting out oxygen
◉ oxygen toxicity. Answer: may result from high concentrations. S/S
substernal pain, nasal stuffiness, n & v, headache, fatigue, sore
throat, hypoventilations.
◉ suctioning. Answer: pre- vitals signs, hyperoxygenate, high o/
fowlers. suction pressure-110 (child) 95( infants). allow 30-60 sec
recovery times. advance till resistance is met. suction attempt 5-10
secs long, 2-3x. hyperoxygenate after.
◉ suctioning complications. Answer: decreasing sats or cyanosis
◉ artificial airways nursing actions. Answer: children under 8yrs
must use uncuffed endotracheal tube. Assess stoma site/vital signs.
provide humidifications to thin secretions and decrease mucous
pluggings. oral care q2hr. provide trach care q8hr. reposition q2hr.
accidental decannulation in 1st 72 hrs after sugery is emergency.
, ◉ tonsillitis. Answer: hx of otitis media, hearing difficulties, sore
throat w/ swallowing. lab tests throat culture for group a strept.
preop cbc to assess anemia/infections
◉ tonsil nursing actions. Answer: elevate head, asses for bleeding
(clearing the throat, restlessness, bright red emesis, tachycardia/
pallor, frqt swallowing). Vitals/airways/ difficulty breathing.
Comfort- ice collar/ keep throat moist/ pain meds. Diet- clear
liquids/fluids after gag reflex returns. soft bland foods. No coughing/
throat clearing/ nose blowing/ no pointed object. Maybe blood
tinged mucous or clots in vomit.
◉ tonsil client education. Answer: full recovery w/n ten days to 2
wks. limit strenous activity and physical play/ swimming for 2 wks.
◉ Risk factors for respiratory illness. Answer: seasonal, anatomy-
short/narrow airway, short respiratory tract, smaller surface areas,
short eustachian tubes. decreased resistance
◉ nasopharyngitis- common cold. Answer: rhinorrhea, cough, dry
throat, fever ,decrasesed appetite, irriability, nasal inflammation. self
limiting virus 7-10 days