MEDSURG RESPIRATORY EXAM QUESTIONS WITH COMPLETE ANSWERS
Nursing diagnoses of pulmonary TB -Answer-Ineffective airway clearance
Ineffective breathing pattern
Anxiety
Impaired gas exchange
Imbalanced nutrition—because the drugs are harsh (nausea, vomiting, diarrhea)
Activity intolerance
Noncompliance****
Because they are so harsh, the patient often wants to stop taking them
Non-compliance -Answer-What is the biggest issue with management of pulmonary TB?
Nursing management of pulmonary TB -Answer-Major role is teaching about meds & compliance
Patent airway (encourage to keep well hydrated because of systemic effects of antibiotic)
Encourage activity
Nutritional plan to prevent malnourishment
Infection control-proper PPE
Community follow-up
DOT—directly observed therapy
Directly-observed therapy is healthcare workers observe patients as they take their medicine. -Answer-What is DOT?
Medications**
Adequate fluids
Monitor temp
Smoking & balanced diet
Prevent infection
Recognition of recurrence symptoms
Follow-up care for at least 1 year during active treatment -Answer-Client teaching with pulmonary TB should include:
Pulmonary embolism -Answer-An occlusion of a portion of the pulmonary artery or one of its branches by a thrombus. Most develop from thrombi (blood clot), but could be from tumour, air, fat, bone marrow, hole in amniotic sac, etc.
Associated with trauma, surgery, pregnancy, heart failure, age older than 50, hyper coagulable states, and prolonged immobility
True, can be lethal depending on size—could die within an hour -Answer-True or false, pulmonary embolism is a medical emergency
Causes of pulmonary embolism -Answer-DVT
Fracture of large bones
Other sources:
Heart failure
Age 50
Obesity (fat emboli)
Amniotic fluid
Air & other foreign substances
Tumors
1. Stasis of blood (or turbulence)
2. Vessel wall injury
3. Hypercoagulability -Answer-Triad of virchow includes:
Stasis of blood (or turbulence) -Answer-alteration in blood flow, generally occurs when blood flow is reduced; gives it reason to pool and clot
Vessel wall injury -Answer-endothelial lining of vessel is damaged/injury
Hypercoagulability -Answer-increased clotting potential of patient's blood
Immobility -Answer-_____ increases the risk for all of these factors
*You should always look at your patients risk factors especially in regard to the triad of Virchow.
Risk factors of PE -Answer-Prolonged immobility (venous stasis)
Hypercoagulability
Endothelial damage
Age
Family history
Recent surgery
Medical conditions
Lifestyle
Manifestations of PE -Answer-Dependent upon size and location of thrombus:
Dyspnea (most common symptom) **
Tachypnea (most common sign) **
Pleuritic chest pain **—this is very sudden
Anxiety (sense of doom)/apprehension **
Diaphoresis
Cough; hemoptysis
Low grade fever
Tachycardia, crackles, S3 &S4
↓O2 sats/ increase respirations
Syncope
Dyspnea, tachypnea, pleuritic chest pain, and anxiety (sense of doom), apprehension -Answer-The four most important manifestations to note if patient is experiencing these symptoms of PE are:
Dyspnea -Answer-The most common symptom of PE is:
Tachypnea -Answer-The most common sign of PE is:
Pleuritic chest pain -Answer-A very sudden manifestation of PE is:
Diagnostic tests of PE -Answer-CXR, CT D-Dimer, ABGs, PT/PTT/INR, ventilation perfusion (VQ) scan, and pulmonary angiography
CT -Answer-Shows 3D slices of the chest
D-Dimer -Answer-blood test, is a product of fibrin lyses (breakdown). Measures the breakdown of the products of the actual blood clot. Not definitive.
ABGs of PE -Answer-typically they are in respiratory alkalosis; PO2 and PACO2 levels are low
Respiratory alkalosis (PO2 and PACO2 levels are low) (pH is high) -Answer-PE patients are typically in:
PT/PTT/INR -Answer-these are to assume a baseline level for anticoagulation treatment.
If patient has a PE they will get a loading dose of heparin right away, and then on an warfarin infusion.
Ventilation perfusion (VQ) scan -Answer-lung scan where radioactive agent is injected into patient and studies the airflow into the lungs. Also helps visualize pulmonary vasculature (blood flow)
Pulmonary angiography -Answer-inject dye into vena cava and look to see if there is a blockage in the pulmonary blockage, and locate exactly where it is. This is the best method, but is very invasive and risky.
Management of PE -Answer-Stabilizing the cardiopulmonary system
Patient may be intubated, IV fluids, bronchodilators, steroids, etc.
Anticoagulant therapy
Fibrinolytic therapy
Pulmonary embolectomy
Vena cava filter
Pharmacological therapy of PE -Answer-Anticoagulants, thrombolytics (clot dissolver) are:
Anticoagulants -Answer-They would have blood work done to see PT (prothrombin time), PTT (partial thrombotic time) and INR (international normalized ratio)
Heparin
Warfarin
Heparin -Answer-decrease clotting of blood and decrease chances of another clot forming
Antidote is protein
Warfarin -Answer-Once INR is at a level of 2 or 3, warfarin can be introduced.
Once they maintain 2-3 for 3-5 days, it can then be stopped
This has a long half-life, so if patient has a procedure, the drug has to be stopped 5-7 days or else there is a high chance of bleeding
WARFARIN ANTIDOTE IS VITAMIN K—patient shouldn't eat food high in vitamin K because it can reduce
Nursing diagnoses of pulmonary TB -Answer-Ineffective airway clearance
Ineffective breathing pattern
Anxiety
Impaired gas exchange
Imbalanced nutrition—because the drugs are harsh (nausea, vomiting, diarrhea)
Activity intolerance
Noncompliance****
Because they are so harsh, the patient often wants to stop taking them
Non-compliance -Answer-What is the biggest issue with management of pulmonary TB?
Nursing management of pulmonary TB -Answer-Major role is teaching about meds & compliance
Patent airway (encourage to keep well hydrated because of systemic effects of antibiotic)
Encourage activity
Nutritional plan to prevent malnourishment
Infection control-proper PPE
Community follow-up
DOT—directly observed therapy
Directly-observed therapy is healthcare workers observe patients as they take their medicine. -Answer-What is DOT?
Medications**
Adequate fluids
Monitor temp
Smoking & balanced diet
Prevent infection
Recognition of recurrence symptoms
Follow-up care for at least 1 year during active treatment -Answer-Client teaching with pulmonary TB should include:
Pulmonary embolism -Answer-An occlusion of a portion of the pulmonary artery or one of its branches by a thrombus. Most develop from thrombi (blood clot), but could be from tumour, air, fat, bone marrow, hole in amniotic sac, etc.
Associated with trauma, surgery, pregnancy, heart failure, age older than 50, hyper coagulable states, and prolonged immobility
True, can be lethal depending on size—could die within an hour -Answer-True or false, pulmonary embolism is a medical emergency
Causes of pulmonary embolism -Answer-DVT
Fracture of large bones
Other sources:
Heart failure
Age 50
Obesity (fat emboli)
Amniotic fluid
Air & other foreign substances
Tumors
1. Stasis of blood (or turbulence)
2. Vessel wall injury
3. Hypercoagulability -Answer-Triad of virchow includes:
Stasis of blood (or turbulence) -Answer-alteration in blood flow, generally occurs when blood flow is reduced; gives it reason to pool and clot
Vessel wall injury -Answer-endothelial lining of vessel is damaged/injury
Hypercoagulability -Answer-increased clotting potential of patient's blood
Immobility -Answer-_____ increases the risk for all of these factors
*You should always look at your patients risk factors especially in regard to the triad of Virchow.
Risk factors of PE -Answer-Prolonged immobility (venous stasis)
Hypercoagulability
Endothelial damage
Age
Family history
Recent surgery
Medical conditions
Lifestyle
Manifestations of PE -Answer-Dependent upon size and location of thrombus:
Dyspnea (most common symptom) **
Tachypnea (most common sign) **
Pleuritic chest pain **—this is very sudden
Anxiety (sense of doom)/apprehension **
Diaphoresis
Cough; hemoptysis
Low grade fever
Tachycardia, crackles, S3 &S4
↓O2 sats/ increase respirations
Syncope
Dyspnea, tachypnea, pleuritic chest pain, and anxiety (sense of doom), apprehension -Answer-The four most important manifestations to note if patient is experiencing these symptoms of PE are:
Dyspnea -Answer-The most common symptom of PE is:
Tachypnea -Answer-The most common sign of PE is:
Pleuritic chest pain -Answer-A very sudden manifestation of PE is:
Diagnostic tests of PE -Answer-CXR, CT D-Dimer, ABGs, PT/PTT/INR, ventilation perfusion (VQ) scan, and pulmonary angiography
CT -Answer-Shows 3D slices of the chest
D-Dimer -Answer-blood test, is a product of fibrin lyses (breakdown). Measures the breakdown of the products of the actual blood clot. Not definitive.
ABGs of PE -Answer-typically they are in respiratory alkalosis; PO2 and PACO2 levels are low
Respiratory alkalosis (PO2 and PACO2 levels are low) (pH is high) -Answer-PE patients are typically in:
PT/PTT/INR -Answer-these are to assume a baseline level for anticoagulation treatment.
If patient has a PE they will get a loading dose of heparin right away, and then on an warfarin infusion.
Ventilation perfusion (VQ) scan -Answer-lung scan where radioactive agent is injected into patient and studies the airflow into the lungs. Also helps visualize pulmonary vasculature (blood flow)
Pulmonary angiography -Answer-inject dye into vena cava and look to see if there is a blockage in the pulmonary blockage, and locate exactly where it is. This is the best method, but is very invasive and risky.
Management of PE -Answer-Stabilizing the cardiopulmonary system
Patient may be intubated, IV fluids, bronchodilators, steroids, etc.
Anticoagulant therapy
Fibrinolytic therapy
Pulmonary embolectomy
Vena cava filter
Pharmacological therapy of PE -Answer-Anticoagulants, thrombolytics (clot dissolver) are:
Anticoagulants -Answer-They would have blood work done to see PT (prothrombin time), PTT (partial thrombotic time) and INR (international normalized ratio)
Heparin
Warfarin
Heparin -Answer-decrease clotting of blood and decrease chances of another clot forming
Antidote is protein
Warfarin -Answer-Once INR is at a level of 2 or 3, warfarin can be introduced.
Once they maintain 2-3 for 3-5 days, it can then be stopped
This has a long half-life, so if patient has a procedure, the drug has to be stopped 5-7 days or else there is a high chance of bleeding
WARFARIN ANTIDOTE IS VITAMIN K—patient shouldn't eat food high in vitamin K because it can reduce
Nursing diagnoses of pulmonary TB -Answer-Ineffective airway clearance
Ineffective breathing pattern
Anxiety
Impaired gas exchange
Imbalanced nutrition—because the drugs are harsh (nausea, vomiting, diarrhea)
Activity intolerance
Noncompliance****
Because they are so harsh, the patient often wants to stop taking them
Non-compliance -Answer-What is the biggest issue with management of pulmonary TB?
Nursing management of pulmonary TB -Answer-Major role is teaching about meds & compliance
Patent airway (encourage to keep well hydrated because of systemic effects of antibiotic)
Encourage activity
Nutritional plan to prevent malnourishment
Infection control-proper PPE
Community follow-up
DOT—directly observed therapy
Directly-observed therapy is healthcare workers observe patients as they take their medicine. -Answer-What is DOT?
Medications**
Adequate fluids
Monitor temp
Smoking & balanced diet
Prevent infection
Recognition of recurrence symptoms
Follow-up care for at least 1 year during active treatment -Answer-Client teaching with pulmonary TB should include:
Pulmonary embolism -Answer-An occlusion of a portion of the pulmonary artery or one of its branches by a thrombus. Most develop from thrombi (blood clot), but could be from tumour, air, fat, bone marrow, hole in amniotic sac, etc.
Associated with trauma, surgery, pregnancy, heart failure, age older than 50, hyper coagulable states, and prolonged immobility
True, can be lethal depending on size—could die within an hour -Answer-True or false, pulmonary embolism is a medical emergency
Causes of pulmonary embolism -Answer-DVT
Fracture of large bones
Other sources:
Heart failure
Age 50
Obesity (fat emboli)
Amniotic fluid
Air & other foreign substances
Tumors
1. Stasis of blood (or turbulence)
2. Vessel wall injury
3. Hypercoagulability -Answer-Triad of virchow includes:
Stasis of blood (or turbulence) -Answer-alteration in blood flow, generally occurs when blood flow is reduced; gives it reason to pool and clot
Vessel wall injury -Answer-endothelial lining of vessel is damaged/injury
Hypercoagulability -Answer-increased clotting potential of patient's blood
Immobility -Answer-_____ increases the risk for all of these factors
*You should always look at your patients risk factors especially in regard to the triad of Virchow.
Risk factors of PE -Answer-Prolonged immobility (venous stasis)
Hypercoagulability
Endothelial damage
Age
Family history
Recent surgery
Medical conditions
Lifestyle
Manifestations of PE -Answer-Dependent upon size and location of thrombus:
Dyspnea (most common symptom) **
Tachypnea (most common sign) **
Pleuritic chest pain **—this is very sudden
Anxiety (sense of doom)/apprehension **
Diaphoresis
Cough; hemoptysis
Low grade fever
Tachycardia, crackles, S3 &S4
↓O2 sats/ increase respirations
Syncope
Dyspnea, tachypnea, pleuritic chest pain, and anxiety (sense of doom), apprehension -Answer-The four most important manifestations to note if patient is experiencing these symptoms of PE are:
Dyspnea -Answer-The most common symptom of PE is:
Tachypnea -Answer-The most common sign of PE is:
Pleuritic chest pain -Answer-A very sudden manifestation of PE is:
Diagnostic tests of PE -Answer-CXR, CT D-Dimer, ABGs, PT/PTT/INR, ventilation perfusion (VQ) scan, and pulmonary angiography
CT -Answer-Shows 3D slices of the chest
D-Dimer -Answer-blood test, is a product of fibrin lyses (breakdown). Measures the breakdown of the products of the actual blood clot. Not definitive.
ABGs of PE -Answer-typically they are in respiratory alkalosis; PO2 and PACO2 levels are low
Respiratory alkalosis (PO2 and PACO2 levels are low) (pH is high) -Answer-PE patients are typically in:
PT/PTT/INR -Answer-these are to assume a baseline level for anticoagulation treatment.
If patient has a PE they will get a loading dose of heparin right away, and then on an warfarin infusion.
Ventilation perfusion (VQ) scan -Answer-lung scan where radioactive agent is injected into patient and studies the airflow into the lungs. Also helps visualize pulmonary vasculature (blood flow)
Pulmonary angiography -Answer-inject dye into vena cava and look to see if there is a blockage in the pulmonary blockage, and locate exactly where it is. This is the best method, but is very invasive and risky.
Management of PE -Answer-Stabilizing the cardiopulmonary system
Patient may be intubated, IV fluids, bronchodilators, steroids, etc.
Anticoagulant therapy
Fibrinolytic therapy
Pulmonary embolectomy
Vena cava filter
Pharmacological therapy of PE -Answer-Anticoagulants, thrombolytics (clot dissolver) are:
Anticoagulants -Answer-They would have blood work done to see PT (prothrombin time), PTT (partial thrombotic time) and INR (international normalized ratio)
Heparin
Warfarin
Heparin -Answer-decrease clotting of blood and decrease chances of another clot forming
Antidote is protein
Content preview
MEDSURG RESPIRATORY EXAM
QUESTIONS WITH COMPLETE
ANSWERS
Nursing diagnoses of pulmonary TB -Answer-Ineffective airway clearance
Ineffective breathing pattern
Anxiety
Impaired gas exchange
Imbalanced nutrition—because the drugs are harsh (nausea, vomiting, diarrhea)
Activity intolerance
Noncompliance****
Because they are so harsh, the patient often wants to stop taking them
Non-compliance -Answer-What is the biggest issue with management of pulmonary TB?
Nursing management of pulmonary TB -Answer-Major role is teaching about meds &
compliance
Patent airway (encourage to keep well hydrated because of systemic effects of
antibiotic)
Encourage activity
Nutritional plan to prevent malnourishment
Infection control-proper PPE
Community follow-up
DOT—directly observed therapy
Directly-observed therapy is healthcare workers observe patients as they take their
medicine. -Answer-What is DOT?
Medications**
Adequate fluids
Monitor temp
Smoking & balanced diet
Prevent infection
Recognition of recurrence symptoms
Follow-up care for at least 1 year during active treatment -Answer-Client teaching with
pulmonary TB should include:
Pulmonary embolism -Answer-An occlusion of a portion of the pulmonary artery or one
of its branches by a thrombus. Most develop from thrombi (blood clot), but could be
from tumour, air, fat, bone marrow, hole in amniotic sac, etc.
, Associated with trauma, surgery, pregnancy, heart failure, age older than 50, hyper
coagulable states, and prolonged immobility
True, can be lethal depending on size—could die within an hour -Answer-True or false,
pulmonary embolism is a medical emergency
Causes of pulmonary embolism -Answer-DVT
Fracture of large bones
Other sources:
Heart failure
Age > 50
Obesity (fat emboli)
Amniotic fluid
Air & other foreign substances
Tumors
1. Stasis of blood (or turbulence)
2. Vessel wall injury
3. Hypercoagulability -Answer-Triad of virchow includes:
Stasis of blood (or turbulence) -Answer-alteration in blood flow, generally occurs when
blood flow is reduced; gives it reason to pool and clot
Vessel wall injury -Answer-endothelial lining of vessel is damaged/injury
Hypercoagulability -Answer-increased clotting potential of patient's blood
Immobility -Answer-_____ increases the risk for all of these factors
*You should always look at your patients risk factors especially in regard to the triad of
Virchow.
Risk factors of PE -Answer-Prolonged immobility (venous stasis)
Hypercoagulability
Endothelial damage
Age
Family history
Recent surgery
Medical conditions
Lifestyle
Manifestations of PE -Answer-Dependent upon size and location of thrombus:
Dyspnea (most common symptom) **
Tachypnea (most common sign) **
Pleuritic chest pain **—this is very sudden
Anxiety (sense of doom)/apprehension **
Diaphoresis