Nur220 -Exam 1 - Respiratory and Cardiac Complete Questions With Guaranteed Solutions Graded A+

What are the 5 rights of delegation? - correct answers 1. Right task- can it be delegated 2. Right Circumstance- Should it be delegated 3. Right person- can this person do the task 4. Right direction/ communication- is the task being conveyed in a clear manner 5. Right supervision- is the task being followed up on once complete What are the scopes of practice for the below? RN LPN UAP - correct answers RN - Work under APRN/DR must do INITIAL assessment of the patient when coming to/transferring to their unit. Takes phone calls on pt and takes the most unstable pt LPN - can carry on teaching that is ALREADY set up by RN but cannot initiate teaching - can give all meds but NO IV's, cannot take/give any verbal/phone order UAP - can do ADL's delegated by RN or LPN - no meds, can't apply any lotion that came from pharmacy Describe delegation - correct answers Responsibility retained by RN Do NOT delegate: - nursing judgement - nursing process; assessment, planning, implementation - med administration include topicals to UAP Describe prioritization - correct answers ABC's: airway usually but not ALWAYS 1st priority - if airway breathing is NOT an issue in the scenario, then it is not the priority option Maslow's hierarchy - safety first Nursing process: Assess 1st - gather more data, before intervening unless the situation is an emergency then jump right into doing something Least invasive approach 1st that will achieve your outcome What are the Prioritization Principles? - correct answers Systemic before local: "life over limb" Acute vs. chronic actual before potential trends vs transient findings - be concerned with those deteriorating trends VS the occasional change When it comes to patient prioritization, what question should we always ask ourselves? - correct answers What is the worst thing that can happen to my patient today? The nurse evaluates assignments on a medical/surgical unit. The nurse determines that assignments are appropriate if a nursing assistant performs which of the following tasks? 1. Encourages client to practice postop exercises taught by RN 2. Irrigates NG tube of a patient receiving a tube feeding 3. Covers a skin tear with a transparent dressing 4. Determines the effectiveness of the restraints for a client in Buck traction - correct answers 1. Encourages client to practice postop exercises taught by RN *LPN and UAP should not teaching - they can encourage and an LPN can remind the patient of the teaching AFTER the RN has taught it first A nurse is planning client assignments has an RN and LPN on the team. Select the client that the nurse most appropriately assigns to the RN: 1. A client with stable congestive heart failure who has early-stage Alzheimer's disease 2. A client being treated for dehydration who is weak and needs assistance with bathing 3. A client with emphysema who is receiving oxygen at 2 L/minute by nasal cannula and becomes dyspneic on exertion 4. A client who is scheduled for an EKG and CXR - correct answers 3. A client with emphysema who is receiving oxygen at 2L/minute by nasal cannula and becomes dyspneic on exertion Which task is least appropriate to delegate to the nursing assistant? 1. Accompanying a man to his care who is being d/c home 2. Collecting a client's urine specimen 3. Assist post-cardiac cath client required to lie flat to eat lunch 4. Taking frequent oral temps on a client - correct answers 3. Assist post-cardiac cath client required to lie flat to eat lunch You have an RN and LPN on your unit. Which of the following is the most appropriate assignment? 1. RN: unemployed 26 y/o woman newly diagnosed w/ advanced AIDS 2. RN: 65 y/o admitted for chest pain waiting to be d/c home 3. LPN: 41 y/o male 2 days postop from acoustic neuroma resection transferred from ICU today 4. LPN: Provide d/c teaching re: meds and nephrostomy tube care - correct answers 1. RN: unemployed 26 y/o woman newly diagnosed w/ advances AIDS You ask another nurse who did not hear report to check a patient's BP. She measures the BP in the left arm which has an arteriovenous shunt. Which "right" of delegation did you violate? 1. Right task 2. Right person 3. Right circumstance 4. Right communication 5. Right supervision/evaluation - correct answers 4. Right communication A newborn is arriving in the nursery with APGARS of 1 and 4. What is the priority intervention? 1. Prepare for insertion of IV w/ D5W 2. Connect resuscitation bag to O2 3. Turn on apnea and cardiac monitors 4. Set radiant warmer control to 97.5F - correct answers 2. Connect resuscitation bag to O2 (ABC's, airway breathing and circulation) A client with cancer is receiving morphine sulfate 10mg subcutaneously every 3 to 4 hours for pain. Select the priority action that the nurse includes when preparing the plan of care for the client 1. Monitor urine output 2. Encourage fluid intake 3. Monitor stools 4. Encourage cough and deep-breathe - correct answers 4. Encourage cough and deep-breathe (due to morphine causing resp. depression - breathing is more important option) The patient showing s/s of a hypoglycemic reaction. Put the following in order of priority: 1. Give the patient 4oz of OJ 2. Obtain a blood glucose level 3. Document 4. Determine the cause of the reaction - correct answers 2,1,4,3 (assess, intervene, analyze, document) You have just taken report on these 4 clients. Place in order of your assessment priority. 1. Pulmonary wedge resection 1 day ago w/ closed chest tube drainage system 2. Ulcerative colitis, scheduled for d/c 3. Admitted overnight w/ severe exacerbation of asthma 4. Scheduled for KUB (kidney, ureter, bladder xray) to locate kidney stone - correct answers 3,1,4,2 (airway, asthma, first then chest tube, then pain (kidney stone), then d/c The mother of a 10-year-old boy with Type 1 Diabetes calls the clinic nurse to discuss the child's blood glucose results. The child is regulated with combination of NPH and regular insulin before breakfast and supper. The past 2 mornings, his blood sugar readings were 220 and 210 mg/dL. What should the nurse advise the mother to do? 1. Give the NPH insulin later in the evening 2. Continue with the medication regime 3. Check the blood sugar during the night 4. Serve a bedtime snack earlier in the evening - correct answers 3. Check the blood sugar during the night Check the BS during the night (DR's order is to give the insulin before meals, can't go against that - need to check the BS during the night, when the NPH is at it's peak (6-8hrs after the shot) to see if the dose is high enough - BS can be normal or low at NPH peak so you wouldn't increase the NPH due to risk of hypoglycemia but if the BS is high at the peak then the DR will increase the NPH A 19 y/o patient presents with acute asthma, RR44, respiratory distress. What is your priority with this patient? 1. Apply cardiac monitor 2. Conduct a full respiratory assessment 3. Provide emotional support 4. Administer bronchodilator via nebulizer - correct answers 4. Administer bronchodilator via nebulizer Define ventilation - correct answers movement of O2 and CO2 in and out of the alveoli (movement of air in/out of the lungs) What kind of patient does ventilation affect? - correct answers Those who has asthma and COPD. Patients that are obese can develop narrowed airways Musculoskeletal problems - brain injury or spinal cord injury, muscles in diaphragm aren't working or as strong as they need to be so one can't inhale/exhale Define diffusion - correct answers Where O2 and CO2 are exchanged - takes place at alveoli level What kind of patient does diffusion affect? - correct answers Patients who have: COPD Emphysema (alveoli stretch and remain stretched and traps CO2, retain CO2, too much CO2 doesn't allow O2 to be exchanged efficiently - Patients with fluid in their lungs or pneumonia effects the alveoli wall space to exchange gases and causes problems Define perfusion - correct answers passage of O2 and CO2 which occurs at a cellular level - if the heart isn't pumping strong enough oxygenated blood perfused or transported to the tissues is affected and not getting to tissues or cells What kind of patient does perfusion affect? - correct answers Patients with acute respiratory illnesses Rate, depth and rhythm of ventilation are controlled by? - correct answers Medulla and pons What is respiration stimulated by? - correct answers Elevated CO2 in the blood *when CO2 gets too high the body is stimulated to breathing more deeply and rapidly to get rid of CO2 When is the only time respiration is NOT stimulated by elevated CO2 in the blood? - correct answers If the patient has COPD If a patient has COPD, when is their body stimulated to breathe? - correct answers Their bodies are stimulated to breathe when oxygen gets too low - results in hypoxia *don't crank the oxygen up too high What questions should you be asking the patient who presents with respiratory complaints? - correct answers - last xray/tuberculosis screenings - family hx, smoking hx, hx of asthma? - SOB with activity? Does it alleviate when resting? - Med list - Any allergies? What is performed/assessed when it comes to a focused respiratory assessment? - correct answers Inspection: Head, neck, fingers, chest - muscles, nasal flaring, asymmetric chest movements, open-mouth breathing, gasping RR: tachypnea, bradypnea, do all vital signs Is chest expanding and contracting equally? What does it mean when chest expansion and contraction aren't equal? - correct answers That means that one lung isn't getting any air What are the normal values for the below ABG's: pH pCO2 HCO3 PO2 - correct answers pH = 7.35-7.45 pCO2 = 35-45 HCO3 = 22-26 PO2 = 80-100 A PCO2 reading that is between 35-45 means what? - correct answers You don't have a respiratory problem, this means you most likely have a metabolic issue CO2 dissolved in water equals? - correct answers Acid *too much CO2 makes you acidic What does respiratory acidosis mean? Alkalosis? - correct answers Acidosis = Retaining too much CO2 Alkalosis = blowing off too much CO2 What does metabolic acidosis mean? Alkalosis? - correct answers Acidosis = the 3 D's (diabetes, diarrhea, dialysis) Alkalosis = copious vomiting/NGT drainage A nurse is monitoring a group of clients for acid-base imbalance. Which clients are at highest risk for metabolic acidosis? Select all that apply 1. Renal failure client 2. Asthma client 3. Pneumonia client 4. Diabetic with mellitus client 5. Patient with copious vomiting 6. Patient with copious diarrhea - correct answers 1,4,6 (the 3 D's) What is acute respiratory failure (ARF)? - correct answers Altered gas exchange on room air - pt is unable to adequately absorb oxygen or excrete carbon dioxide - issue with ventilation (air in/out) - issue with perfusion/diffusion and issue w/ exchange of gas at alveolar level How does acute respiratory failure differ from chronic respiratory failure? - correct answers Chronic respiratory failure has absence of acute sx due to compensation (pH is above 7.35 so it's compensated) What is the treatment for Acute respiratory failure? - correct answers - find the underlying cause - mechanical ventilation - assess LOC (perfusion, pt will get confused if not enough O2) Why would a patient be put on mechanical ventilation? - correct answers Due to patients not being able to ventilate properly or adequately in order to maintain adequate oxygenation, so they are put on mechanical ventilation Define alveolar hypoventilation - correct answers Problems with moving air into and out of the lungs - mechanical abnormality of lungs/chest wall - What do patients with alveolar hypoventilation experience? - correct answers Issues with ventilation due to obesity, chest wall deformities, neuromuscular, CNS depression, COPD and asthma - all of which cause the airway to be narrowed What are some diffusion abnormalities that occur when it comes to alveolar hypoventilation? - correct answers Air can get in okay but it's not diffusing gases - air movement (ventilation) normal but decreased lung perfusion across alveolar/capillary membrane What is the pathophysiology of ARDs? - correct answers - systemic inflammatory response syndrome (SIRS) causing... - release of inflammatory mediators causing... - damage to alveolar-capillary membrane causing... - increased capillary permeability leading to... - pulmonary edema (noncardiogenic) - microatelectasis - decreased surfactant (damage to type II cells) *all lead to severely impaired gas exchange What is the purpose of surfactant? - correct answers To lower tension and prevent alveolar collapse, surfactant prevents the alveoli from sticking together What causes pulmonary edema when it comes to ARDS? - correct answers Capillary membrane damage that causes fluids to leak therefore causing pulmonary edema What does ARDS stand for? - correct answers acute respiratory distress syndrome What are some common causes of ARDS? - correct answers Septic patients - causes capillary permeability and fluid leaks into the lungs Massive trauma - multiple traumas and body has serge response Hypovolemia - due to loss of so much blood Pancreatitis - common cause for sepsis that leads to ARDS What are symptoms of ARDS? - correct answers - dyspnea and tachypnea - hyperventilation with normal breath sounds - respiratory alkalosis - V/Q ratio 1 (ventilation is decreased) -- should be 1 - increased HR and temp (due to infection) - HEMO = high (means fluid overload and heart issue) -- should be low to normal - xray - show fluid accumulation that progress to "white out" or ground-glass appearance (cloudy/white) What is the treatment for ARDS? - correct answers Endotracheal intubation and ventilation with PEEP When is PEEP setting used on a patient? - correct answers When they can't breathe on their own, very critical, severely deprived of oxygen What does PEEP stand for? - correct answers Positive End Expiatory Pressure How does the PEEP setting work? - correct answers When on the ventilator, it is pushing air into the lungs during inspiration and then it stops pushing air into the lungs and pt exhales naturally -- pushes air into the lungs during inspiratory phase and pt exhales on their own. But because this specific pt has a decrease in surfactant and their alveoli are collapsing at the end of exhalation, we put them on PEEP which gives them a little burst of air at the end of expiration, while the pt is still exhaling before the next inhalation is delivered to them, they get a pump pf air from the ventilator that opens their alveoli before they collapse and stick together (due to decreased surfactant) True or False: Due to PEEP, alveoli look like grapes, instead of squished grapes - correct answers True What other meds can be given to treat ARDS? - correct answers - corticosteroids - antibiotics - surfactant into lungs via endotracheal tube - IV fluids (watch for dehydration) - Nutrition wise -- tube feeding What is HEMO? - correct answers How much blood is in both R and L atrium and superior vena cava What is a pulmonary embolism (PE)? - correct answers A blood clot becomes lodged in the pulmonary artery and blocks blood flow to the lungs, brain or heart What is Virchow's triad? - correct answers risk factors for DVT that includes 3 main mechanisms that favor the development of venous thrombi What are the 3 main mechanisms in Virchow's triad? - correct answers 1) Venous stasis 2) Altered coagulability of blood 3) Damage to vessel walls What is venous stasis? - correct answers reduction of blood flow ex.) heart disease, immobility, obesity, pregnancy, surgery greater than 45 mins What are examples of where altered coagulability of blood can occur as a result? - correct answers anemias, trauma/surgery, malignancy, oral contraceptives, systemic infection What are examples of how damage to vessel walls can occur? - correct answers Trauma, infection, hx of DVT or major surgery, diabetics (uncontrolled sugar levels) What is the EkoSonic Endovascular system intended for? - correct answers For the controlled and selective infusion of physician-specified fluids including thrombolytics, into the peripheral vasculature or the pulmonary arteries What does the Ekosonic Endovascular system penetrate? - correct answers Penetrates thrombus, in difficult to reach places, such as behind valves What are perks to using the Ekosonic Endovascular System? - correct answers - Uses 50-70% less lytic drug - no thrombus fracture or breakage which reduces the risk of distal embolism - exposes thrombus to greater drug uptake - captures drug within thrombus - no damage to valves or the vascular wall - no hemolysis, does not fracture RBC's so no additional compromise to renal function occurs - Higher vessel patency therefore removes thrombus more completely - shortest physician lab time What is the leading cause of cancer deaths for men and women? - correct answers Chest tumors True or False: Smoking 1 pack of cigarettes per day increases the risk of lung cancer vs. a non-smoker by 20 times - correct answers True What are exposure risk factors for chest tumors? - correct answers Radon, asbestos, industrial pollutants and environmental pollutants What are genetic factors that increase chances of chest tumors? - correct answers Mutations in the genes that regulate cell division What are the 2 types of lung cancer? - correct answers Non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) What are the three types of non-small cell lung cancer? - correct answers - squamous cell - adenocarcinoma - large cell What can one develop when they have small cell lung cancer? - correct answers Paraneoplastic syndromes What is paraneoplastic syndrome? - correct answers When SCLC secrete hormones such as ACTH (Cushings), ADH, FSH, parathyroid and insulin How is the staging of lung cancer? - correct answers TNM: (tumor, nodes, metastases - size of tumors - lymph node involvement - presence or absence of metastatsis What does a nurse need to assess first when it comes to a patient with possible lung cancer? - correct answers Assess if there is a change in cough's frequency or severity - as most of these patients have a smokers cough already What are the s/s of lung cancer? - correct answers Cough, dyspnea, pneumonia, pleural effusion, chest pain, hoarseness What are diagnostic tests that are used to diagnose lung cancer? - correct answers Sputum for cytology, thoracentesis for pleural effusion, CT, bronchoscopy, medistinoscopy, needle or direct biopsy What are 3 treatment options for lung cancer? - correct answers Surgery - segmentectomy, wedge resection, lobectomy (removal of lung) or video assisted thorascopic surgery (tumor separated and removed) Radiation - teach soft foods, assess for xerostomia, late complication is narrowing of esophagus Chemo - rx of choice esp. for SCLC, for NSCLC often not a cure but for palliation What are s/s of Mediastinal tumors? - correct answers Results of pressure against intrathoracic organs - respiratory, cardiac such as Constrictive Pericarditis, palpitations, cyanosis, SVC syndrome What are the diagnostics/treatment for Mediastinal tumors? - correct answers DX: CT, CXR, MRI, PET Treatment: surgical removal if possible, radiation, chemo Describe blunt trauma and its causes - correct answers Rapid acceleration/deceleration caused by motor vehicle accidents, falls What can blunt trauma lead to? - correct answers Hypoxemia, airway disruption or damage, hypovolemia, massive fluid/blood loss, cardiac failure ie. tamponade contusion Describe penetrating trauma - correct answers Foreign object - ie. bullet, knife classed as low or high velocity, external appearance may mask extent of internal damage How are blunt/penetrating traumas assessed? - correct answers By time elapsed, mechanism, level of responsiveness, specific injuries, estimated blood loss, recent drug/ETOH, pre-hospital hx What diagnostics are used for blunt/penetrating traumas? - correct answers CXR, ABGS, clotting, lytes, type/cross, o2 sat; NGT, foley, IV What is Flail Chest? - correct answers When three or more adjacent ribs fractured in more than one location - segment "floats" freely - Paradoxic chest movement - sinks w/ inspiration, bulges w/ exhalation What are treatments for flail chest/rib fractures? - correct answers Pain control, position to support injured area, intubation possible What is the difference between flail chest and tension pneumothorax?** - correct answers Flail chest is fracture of 3 ribs, floating segment and tension pneumothorax is when air is trapped in the pleural space displacing mediastinal structures What is a pulmonary contusion? - correct answers bruising of lung tissue associated with rib fractures and flail chest - often results in ARDS, may require vent support; pain relief is essential What is open pneumothorax also known as? - correct answers Sucking chest wound What is open pneumothorax? - correct answers Opening through chest wall into pleural space; atmospheric air enters pleural space surrounding the lung causing loss of negative pressure and collapse of the lung What is closed pneumothorax? - correct answers When the chest wall is intact; opening/hole in airway or lung causing air to enter the pleural space leading to loss of negative pressure and collapse of the lung What does simple closed pneumothorax allow for? - correct answers The pressures equilibrate so pressure in the pleural space does not build to dangerous levels What is tension pneumothorax? - correct answers A closed pneumothorax where pressure builds up pleural space - no opening to the outside What happens with pressure when it comes to tension pneumothorax? - correct answers In this case the pressures do not equilibrate, air continues to fill the pleural space and has nowhere to go, so it pushes the collapsed lung toward midline resulting in mediastinal shift What might one see with mediastinal shift? - correct answers May see trachea deviating off to the left - this is a MEDICAL EMERGENCY What does a mediastinal shift do? - correct answers This shift compresses the heart and great vessels, preventing contraction and expansion of the heart. What can mediastinal shift lead to? - correct answers Cardiac tamponade or complete cardiac arrest What is cardiac tamponade? - correct answers Compression of the heart caused by fluid collecting in the sac surrounding the heart - this pressure keeps the heart from filling properly. What can cardiac tamponade lead to? - correct answers Dramatic drop in blood pressure that can be fatal. Due to heart not being able to be filled properly due to pressure When it comes to tension pneumothorax, why won't CPR work? - correct answers Because the heart can't expand to accept blood. Immediate release of the pressure is needed Since pressure keeps building up in the pleural space and has nowhere to go what happens? - correct answers The lung keeps collapsing and pressure keeps building up How is a tension pneumothorax relieved? - correct answers Immediate release of pressure is needed via needle thoracostomy, followed by a chest tube True or False: When it comes to a mediastinal shift - the trachea will be visibly deviated AWAY from the affected side as you look at the patient? - correct answers True What are the 2 types of pneumothorax? - correct answers Hemothorax and pleural effusion (thoracentesis) What is a hemothorax? - correct answers blood fluid in the pleural space; usually from chest traumas or chest surgery What is pleural effusion? - correct answers clear or cloudy liquid in the pleural space; can result from lung cancers, renal failure, CHF When it comes to chest tube setup, what should always be by the bed side? - correct answers Kelly clips, Xorofom, abd pads (taped on 3 sides) What is Non-invasive positive pressure ventilation (NIPPV)? - correct answers short term vent support via nasal cannula or face mask used for - acute pulm edema, chronic resp. insuff. or sleep apnea What is a CPAP? - correct answers Continuous positive air pressure keeping alveoli open during inspiration and expiration *air is being pushed into the lungs continuously What is a BiPAP? - correct answers bilevel positive airway pressure - air is being pushed in at different levels; two levels of pressure What is unique about a BiPAP? - correct answers Two levels of pressure. Expiratory pressure is lower than inspiratory for easier exhalation. Can be spontaneous (pt triggers all breaths), timed (machine delivers set number of breaths) or combo (pt triggers plus set number as backup) True or False: