NUR 215 Exam 3 2025

upper airway - Correct Ans- - not sterile - nasal passage, mouth, and pharynx - infections: common cold, pharyngitis, influenza, rhinosinusitis lower airway - Correct Ans- - sterile - trachea, bronchi, bronchioles - gas exchange - infections: RSV, acute bronchitis, TB, pneumonia ventilation - Correct Ans -moving air in and out - adequate ventilation necessary for O2 to blood - body - tissue respiration - Correct Ans-gase exchange in lungs - external: CO2 - O2 (in lungs) - internal: O2 - CO2 (in tissue) (capillary - tissue gas exchange) factors affecting ventilation - Correct Ans- - respiratory rate and depth - hyper/hypoventilation - lung compliance, elasticity - airway resistance factors affecting pulmonary function - Correct Ans- - developmental state - environment (stress. allergies, air quality) - lifestyle (substances, exercise, occupation) - smoking and 2nd hand - CNS depressants (meds) alterations to gas exchange - Correct Ans-alveoli cant recoil (trapped air) - COPD - emphysema pulmonary assessment - Correct Ans-- physical: inspect, palpate, percuss, auscultate - respiratory distress: gather symptoms (quick exam: adequacy of breathing, circulating, oxygenation) - healthy person: risk of respiratory disease - extensive questions and physical exam eupnea - Correct Ans-normal breathing 12-20 BPM bradypnea - Correct Ans-less than 12 BPM tachypnea - Correct Ans-more than 20 BPM apnea - Correct Ans-period of no breathing dyspnea - Correct Ans-SOB, labored breathing hyperventilation - Correct Ans-- increased rate and depth - blows off CO2 - decrease level in blood - anxiety, fear, extreme exertion kussmauls - Correct Ans-- hyperventilation with metabolic acidosis - fruity acetone breath boits - Correct Ans-- irregular periods of inspiration and expiration, followed by apnea - trauma or affected CNS cheyne-stokes - Correct Ans-- end of life - periods of apnea with periods of inspiration and expiration early symptoms of hypoxia - Correct Ans-R - restless A - anxiety T - tachypnea/tachycardia late symptoms of hypoxia - Correct Ans-B - bradycardia E - extreme restlessness D - dyspnea (severe) pediatric symptoms of hypoxia - Correct Ans-F- feeding difficulty I - inspiratory stridor N - nares flared E - expiratory grunting S - sternal retractions diagnostic testing - Correct Ans-- ABG's blood test: tests levels of CO2 and O2 (most accurate) - chest x-ray - sputum culture - pulse ox - peak expiratory flow rate (PEFR) = asthma interventions for optimal oxygenation - Correct Ans-- pt position - pulmonary hygiene - promote respiratory function - smoking cessation - aspiration precautions patient position - Correct Ans-elevate HOB, turn, cough, deep breathe, mobility, lean forward on bedside table pulmonary hygiene - Correct Ans-- chest physiotherapy (CPT): postural drainage, chest percussion, check vibration - hydration - TCDB (turn, cough, deep breath) - humidifier promote respiratory function - Correct Ans-- prevent nosocomial pneumonia - immunizations/prevent URI's - incentive spirometry O2 delivery systems - Correct Ans-- nasal cannula - simple face mask - non-rebreather mask - partial rebreather mask - venturi mask - face tent - tracheostomy collar nasal cannula - Correct Ans-- 24-44% - 1-6L - pros: safe, simple, eat, walk, talk - cons: skin break down (ears, nose), dislodged tubing simple face mask - Correct Ans-- 40-60% - 6-12L - pros: humidified O2, comfortable - cons: aspiration risk, no claustrophobic patients, humidity buildup = skin break down non-rebreather mask - Correct Ans-- 80-95% - 10-15L - has a reservoir bag (no CO2 re-entry): must be 2/3 full, may rebreathe large amounts of CO2 if empty - highest, non-invasive, O2 concentration partial rebreather mask - Correct Ans-- 60-75% (varies upon pt. breath pattern) - 6-11L - bag must be 1/3-1/2 full on inspiration = decreased CO2 buildup - no-valve: pt. rebreathes up to 1/3 of exhaled air with room air - NC during meals - bag can twist and kink venturi mask - Correct Ans-- 24-50% - 4-12L (different adaptors allow for different flow rates) - most precise O2 concentration with humidity added - best for chronic lung disease (COPD) face tent - Correct Ans-- percentage FiO2 unknown - 10L - fits loosely around face and neck - face trauma, surgery, claustrophobic pts tracheostomy collar - Correct Ans-- 24-100% - at least 10L - small mask covering the trachea artificial airways - Correct Ans-- orotracheal - nasotracheal - endotracheal tube - tracheostomy tube suction patency oxygen toxicity - Correct Ans-lung damage from breathing too much supplemental O2 - signs/symptoms: cough, chest pain, dizziness, blurred vision, nausea, fatigue, restless, dyspnea - risk: high concentration of O2 for long period of time (50% for 24-48 hrs) nursing interventions for O2 toxicity - Correct Ans-- lowest level of O2 to maintain SpO2 - monitor ABG's - decrease FiO2 as SpO2 improves home oxygen use - Correct Ans-- O2 in use sign - 10ft away from heat source - well ventilated - no wool clothing - backup system if needed - clutter free area