NCLEX Review- Uworld rationales Thoracentesis Post procedure monitoring.
Assess: - correct answer - Level of alertness
- Lung sounds
- Oxygen Sat
- Resp pattern
- Vital signs
- Check for leakage of fluid, location of puncture site, client tolerance. - Sterile dressing after.
- Check CXR to ensure absence of pneumothorax.
Complication of thoracentesis: - correct answer Pneumothorax, Bleeding (less common)
Signs of pneumothorax - correct answer Include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed). T ension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. NCLEX Review- Uworld rationales Orthostatic vital signs involve: - correct answer Measuring the client's BP and heart rate in
the supine, sitting, and standing positions. Each measurement should be obtained after maintaining each position for 2 minutes. If any position change produces decreased systolic BP ≥20 mm Hg, decreased diastolic BP ≥10 mm Hg, and/or increased pulse ≥20/min from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the health care provide
T o prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions: - correct answer Instruct to lie in a supine position. Instruct to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure.
Apply an air-occlusive dressing (usually gauze with a T egaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line.
Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel. NCLEX Review- Uworld rationales T o reduce the risk of complications and injury during ET suctioning, the nurse should: - correct answer - Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes.
- Suction only while withdrawing the catheter from the airway.
- Use strict sterile technique throughout suctioning
- Limit suctioning to ≤10 seconds on each suction pass
Upper Airway Obstruction: Assessment - correct answer - inability to breathe or speak.
- Cyanosis - Collapse - Death can occur within 4-5 mins
Tracheostomy - correct answer - Cuff is used to prevent aspiration and to facilitate ventilation. - Maintain cuff pressure 20-25 mm Hg - Encourage fluids to facilitate removal of secretions. - Sterile suctioning if necessary. - Frequent oral hygiene
Indications for suctioning tracheostomy - correct answer - Noisy respiration. NCLEX Review- Uworld rationales - Restlessness - Increased pulse - Increased respirations. - Presence of mucus in airway
Nursing Care for patients hospitalized with Acute Epiglottitis, Acute laryngotracheobronchitis - correct answer - Maintain airway (Keep tracheostomy set at bedside)
- Oxygen hood
- Monitor HR and RR for early sign of hypoxia
- Oxygen with humidification.
- IV fluids - Meds: antipyretics, bronchodilators, nebulized epinephrine, steroids - Position infant seat or prop with pillow
Implementation for Myocardial Infarction - correct answer - Thrombolytic therapy w/in 6 hrs,
- Relieve client's and family's anxiety.
- Bed rest- bedside commode for bowel movement. - Semi Fowler position
- Monitor I & O ( 2L fluid intake)
Assess: - correct answer - Level of alertness
- Lung sounds
- Oxygen Sat
- Resp pattern
- Vital signs
- Check for leakage of fluid, location of puncture site, client tolerance. - Sterile dressing after.
- Check CXR to ensure absence of pneumothorax.
Complication of thoracentesis: - correct answer Pneumothorax, Bleeding (less common)
Signs of pneumothorax - correct answer Include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed). T ension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. NCLEX Review- Uworld rationales Orthostatic vital signs involve: - correct answer Measuring the client's BP and heart rate in
the supine, sitting, and standing positions. Each measurement should be obtained after maintaining each position for 2 minutes. If any position change produces decreased systolic BP ≥20 mm Hg, decreased diastolic BP ≥10 mm Hg, and/or increased pulse ≥20/min from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the health care provide
T o prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions: - correct answer Instruct to lie in a supine position. Instruct to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure.
Apply an air-occlusive dressing (usually gauze with a T egaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line.
Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel. NCLEX Review- Uworld rationales T o reduce the risk of complications and injury during ET suctioning, the nurse should: - correct answer - Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes.
- Suction only while withdrawing the catheter from the airway.
- Use strict sterile technique throughout suctioning
- Limit suctioning to ≤10 seconds on each suction pass
Upper Airway Obstruction: Assessment - correct answer - inability to breathe or speak.
- Cyanosis - Collapse - Death can occur within 4-5 mins
Tracheostomy - correct answer - Cuff is used to prevent aspiration and to facilitate ventilation. - Maintain cuff pressure 20-25 mm Hg - Encourage fluids to facilitate removal of secretions. - Sterile suctioning if necessary. - Frequent oral hygiene
Indications for suctioning tracheostomy - correct answer - Noisy respiration. NCLEX Review- Uworld rationales - Restlessness - Increased pulse - Increased respirations. - Presence of mucus in airway
Nursing Care for patients hospitalized with Acute Epiglottitis, Acute laryngotracheobronchitis - correct answer - Maintain airway (Keep tracheostomy set at bedside)
- Oxygen hood
- Monitor HR and RR for early sign of hypoxia
- Oxygen with humidification.
- IV fluids - Meds: antipyretics, bronchodilators, nebulized epinephrine, steroids - Position infant seat or prop with pillow
Implementation for Myocardial Infarction - correct answer - Thrombolytic therapy w/in 6 hrs,
- Relieve client's and family's anxiety.
- Bed rest- bedside commode for bowel movement. - Semi Fowler position
- Monitor I & O ( 2L fluid intake)
