NUR390 Exam 2 Questions with Verified Answers.
Nursing Care: Trach: Intervention for thick secretions - Correct Answer If the patient can
not independently clear secretions, sterile suction is needed (80-120mm Hg)
-Humidified air to keep secretions thin and ↓ mucous plugs
-Encourage coughing
-Auscultate lungs to verify suction
hyper oxygenate the patient with a new trach and suction if they cannot clear secretions.
Nursing Evaluation: Pneumonia: S/S of effective treatment - Correct Answer -Clear lung
sounds all lobes
-Normal breathing pattern
-No s/s of hypoxia
-WNL WBC, chest xray
-No complications r/t pneumonia
Pneumonia: Which order should the RN implement first? - Correct Answer Orders for
pneumonia in order
-IV fluids - 0.9% sodium chloride for hydration.
-Antipyretics for fever.
-Analgesics for pain.
-NSAIDs for pain and fever.
-Antibiotics to treat the infection - based on sputum culture results.
Thoracentesis: Patient preparation - Correct Answer - Patient upright, leaning over a bed
or table with feet supported.
(If the patient is unable to sit, the patient may be placed in a side-lying position on the edge
of the bed on the unaffected side)
- Skin is cleansed and lidocaine is injected SQ.
- Tell pt not to cough
,- Chest xray or u/s used to determine puncture site
- SIGNED CONSENT
- Post position: good side down for hour or so
Assessment: -A pneumothorax from needle laceration of the visceral pleura is more likely
to occur if an effusion is completely drained so: Monitor the patient's vital signs, oxygen
saturation, and
Pneumonia: Treatment Priorities - Correct Answer ABCDs
- Assess Lungs, heart, LOC
- Prompt specimen collection and abx tx
- upright position (Prevent aspiration).
- Resposition q 2hr to promote lung expansion
- Early ambulation
Resp and skin assessment
Incentive spirometry
*Pneumococcal vaccine
Pneumonia: Anticipated Orders - Correct Answer - IV fluids - 0.9% sodium chloride for
hydration
- O2 therapy
- Nutrition therapy
- Breathing exercises, encouraging coughing
- Other Rx: Antipyretics, Analgesics, NSAIDS, cough suppressants, mucolytics,
corticosteroids
Pneumonia: Nursing Diagnosis/Priority Problem - Correct Answer Acute bacterial or viral
infection of lung tissue.
Priority problems are:
1. Ineffective airway clearance: Abnormal or absent breath sounds, inability to cough
, 2. Impaired gas exchange : Abnormal ABGs, hypoxic v/s and labs
Both can be caused by Atelectasis, ↑ secretions, pleural effusion, pneumothorax
TB Medications: Potential Complication - Correct Answer Isoniazid: Liver tox, v/d
Rifampin: Turns bodily fluids orange (normal), non-viral hepatitis, liver tox,
thrombocytopenia, Upset stomach, heartburn, nausea
Ethambutol: ocular toxicity (Ethan is blind)
Prevention of aspiration pneumonia - Correct Answer Suctioning, teach patient how to
cough and spit out saliva
(occurs when food, secretions, liquids, or other material enter lungs and cause
inflammation and a chemical pneumonitis)
-For patients with decreased LOC: avoid oral feeding and oral drugs and elevate head of
bed >30
-Patients with dysphagia- diets with specialized textures that reduce aspiration risk
-Speech pathologist train for strategies to reduce risk (chin tuck, etc)
-Good oral hygiene
Patient prioritization following change of shift report - Correct Answer In order:
ABC
Sx site (dressings, drains)
Genitourinary (I&Os)
GI (n/v)
Pain
Pt safety (fall risk, position)
1. Life-threatening conditions
2. Potentially life-threatening conditions
3. Activities Essential to Safety
Nursing Care: Trach: Intervention for thick secretions - Correct Answer If the patient can
not independently clear secretions, sterile suction is needed (80-120mm Hg)
-Humidified air to keep secretions thin and ↓ mucous plugs
-Encourage coughing
-Auscultate lungs to verify suction
hyper oxygenate the patient with a new trach and suction if they cannot clear secretions.
Nursing Evaluation: Pneumonia: S/S of effective treatment - Correct Answer -Clear lung
sounds all lobes
-Normal breathing pattern
-No s/s of hypoxia
-WNL WBC, chest xray
-No complications r/t pneumonia
Pneumonia: Which order should the RN implement first? - Correct Answer Orders for
pneumonia in order
-IV fluids - 0.9% sodium chloride for hydration.
-Antipyretics for fever.
-Analgesics for pain.
-NSAIDs for pain and fever.
-Antibiotics to treat the infection - based on sputum culture results.
Thoracentesis: Patient preparation - Correct Answer - Patient upright, leaning over a bed
or table with feet supported.
(If the patient is unable to sit, the patient may be placed in a side-lying position on the edge
of the bed on the unaffected side)
- Skin is cleansed and lidocaine is injected SQ.
- Tell pt not to cough
,- Chest xray or u/s used to determine puncture site
- SIGNED CONSENT
- Post position: good side down for hour or so
Assessment: -A pneumothorax from needle laceration of the visceral pleura is more likely
to occur if an effusion is completely drained so: Monitor the patient's vital signs, oxygen
saturation, and
Pneumonia: Treatment Priorities - Correct Answer ABCDs
- Assess Lungs, heart, LOC
- Prompt specimen collection and abx tx
- upright position (Prevent aspiration).
- Resposition q 2hr to promote lung expansion
- Early ambulation
Resp and skin assessment
Incentive spirometry
*Pneumococcal vaccine
Pneumonia: Anticipated Orders - Correct Answer - IV fluids - 0.9% sodium chloride for
hydration
- O2 therapy
- Nutrition therapy
- Breathing exercises, encouraging coughing
- Other Rx: Antipyretics, Analgesics, NSAIDS, cough suppressants, mucolytics,
corticosteroids
Pneumonia: Nursing Diagnosis/Priority Problem - Correct Answer Acute bacterial or viral
infection of lung tissue.
Priority problems are:
1. Ineffective airway clearance: Abnormal or absent breath sounds, inability to cough
, 2. Impaired gas exchange : Abnormal ABGs, hypoxic v/s and labs
Both can be caused by Atelectasis, ↑ secretions, pleural effusion, pneumothorax
TB Medications: Potential Complication - Correct Answer Isoniazid: Liver tox, v/d
Rifampin: Turns bodily fluids orange (normal), non-viral hepatitis, liver tox,
thrombocytopenia, Upset stomach, heartburn, nausea
Ethambutol: ocular toxicity (Ethan is blind)
Prevention of aspiration pneumonia - Correct Answer Suctioning, teach patient how to
cough and spit out saliva
(occurs when food, secretions, liquids, or other material enter lungs and cause
inflammation and a chemical pneumonitis)
-For patients with decreased LOC: avoid oral feeding and oral drugs and elevate head of
bed >30
-Patients with dysphagia- diets with specialized textures that reduce aspiration risk
-Speech pathologist train for strategies to reduce risk (chin tuck, etc)
-Good oral hygiene
Patient prioritization following change of shift report - Correct Answer In order:
ABC
Sx site (dressings, drains)
Genitourinary (I&Os)
GI (n/v)
Pain
Pt safety (fall risk, position)
1. Life-threatening conditions
2. Potentially life-threatening conditions
3. Activities Essential to Safety
