NR 341/ NR341 COMPLEX ADULT HEALTH EXAM 1 LATEST REAL EXAM
QUESTIONS AND CORRECT ANSWERS|A+ GRADE
1. Simple Airway Adjuncts: maintain or open the airway; used to assist w/ manual
ventilation using a BVM and can assist with suctioning #$%^&*(
OPA- stops tongue from obstructing the epiglottis; used in unconscious pts; do not use
pt has gag-reflex; can lead to broken teeth
NPA- used in conscious pt w/ gag-reflex; contraindicated in suspected facial trauma
2. Non-invasive ventilation: mask devices that provide ventilatory support using air
pressure to prevent alveolar collapse and require O2 in acute respiratory failure
when a client remains hypoxic despite optimal medical management. w/ out using an
artificial airway
; also use for obstructive sleep apnea
CPAP- continuous positive airway pressure and O2 (if needed) w/ inhalation and
expiration
BiPAP- administration of 2 levels of airway pressure, one during inspiration and anoth
during expiration (w/ O2 if needed)
not recommended for facial trauma; pt must be able to remove in case of vomiting to
prevent aspiration
3. Artificial airways: provide secure airway to maintain ventilation during emer-
gency or during surgery; allow for external control
Laryngeal mask airway (LMA)- tube designed to cover supraglottic area to open airwa
for short term use; common when endotracheal intubation can not be com- pleted; *ri
of aspiration, do not use if mouth does not open normally or upper airway obstruction
ETT- temporary airway support; longer term (days to weeks); inserted into trachea
through mouth or nose
Tracheostomy- surgical opening below the larynx; used to overcome airway obstruc- tio
or facilitate mechanical ventilation
4. Mechanical Ventilation: provides controlled invasive ventilation using positive or
negative pressure and O2 to facilitate inspiration and expiration in pts who cannot
breath independently
Ventilator- pt cannot maintain effective gas exchange (respiratory failure, pneumo- nia
exacerbation of COPD, ALS)
*risk for ventilator-associated pneumonia (VAP)
5. Methods for Communicating w/ a client on a ventilator: physical communica- tion:
touch, eye contact, nod head
visual communication: pictures,
verbal communication: notebook, speak loud and clear
, 6. Pneumothorax: air in pleural cavity putting pressure on outside of lung causing it
to collapse
- caused by laceration or puncture to lung during medical procedures; trauma (rib
fractures, penetrating wounds, blunt trauma, underlying conditions increased risk of
spontaneous pneumo
Risk Factors: smoking, tall and thin, family Hx, chronic lung disease, pregnancy, lung
infection, mechanical ventilation
7. Spontaneous pneumothorax: caused by rupture of small air-filled sacs (blebs) on
the lung surface
8. Iatrogenic Pneumothorax: occurs during a medical procedure
9. Hemothorax: blood in the pleural cavity causing lung collapse
10. chylothorax pneumothorax: accumulation of chyle in the pleural cavity
11. Tension Pneumothorax: a type of pneumothorax in which air that enters the
chest cavity is prevented from escaping; causes compression of unaffected lung;
shifting caused great vessels to compress, decreasing cardiac output and venous
return
medical emergency- needle decompression
12. manifestation of pneumothorax: sudden chest pain SOB
dyspnea, shallow short rapid respirations
hypoxia
absent breath sounds over affected area
13. Nursing considerations of chest tubes: - continuous air bubbling in water
chamber= leak
- tidaling (water fluctuation)- normal finding, indicates intra-thoracic pressure
changes w/ normal respirations
- water seal allows air to leave pleural space during expiration (positive pressure)
and prevents room air from entering the pleural space during inspiration (negative
pressure)
- position pt in High Fowlers
- ensure tubing is free of kinks
- monitor for subcutaneous emphysema
- keep unit below level of chest
- inspect drainage, water seal and suction checked hourly
- sudden loss of tidaling or bubbling can indicate occlusion
- do not milk, strip, or clamp
14. Patient care w/ chest tube: frequent position changes
encourage pt to cough and deep breath, use incentive spirometer, to promoter lung
expansion
QUESTIONS AND CORRECT ANSWERS|A+ GRADE
1. Simple Airway Adjuncts: maintain or open the airway; used to assist w/ manual
ventilation using a BVM and can assist with suctioning #$%^&*(
OPA- stops tongue from obstructing the epiglottis; used in unconscious pts; do not use
pt has gag-reflex; can lead to broken teeth
NPA- used in conscious pt w/ gag-reflex; contraindicated in suspected facial trauma
2. Non-invasive ventilation: mask devices that provide ventilatory support using air
pressure to prevent alveolar collapse and require O2 in acute respiratory failure
when a client remains hypoxic despite optimal medical management. w/ out using an
artificial airway
; also use for obstructive sleep apnea
CPAP- continuous positive airway pressure and O2 (if needed) w/ inhalation and
expiration
BiPAP- administration of 2 levels of airway pressure, one during inspiration and anoth
during expiration (w/ O2 if needed)
not recommended for facial trauma; pt must be able to remove in case of vomiting to
prevent aspiration
3. Artificial airways: provide secure airway to maintain ventilation during emer-
gency or during surgery; allow for external control
Laryngeal mask airway (LMA)- tube designed to cover supraglottic area to open airwa
for short term use; common when endotracheal intubation can not be com- pleted; *ri
of aspiration, do not use if mouth does not open normally or upper airway obstruction
ETT- temporary airway support; longer term (days to weeks); inserted into trachea
through mouth or nose
Tracheostomy- surgical opening below the larynx; used to overcome airway obstruc- tio
or facilitate mechanical ventilation
4. Mechanical Ventilation: provides controlled invasive ventilation using positive or
negative pressure and O2 to facilitate inspiration and expiration in pts who cannot
breath independently
Ventilator- pt cannot maintain effective gas exchange (respiratory failure, pneumo- nia
exacerbation of COPD, ALS)
*risk for ventilator-associated pneumonia (VAP)
5. Methods for Communicating w/ a client on a ventilator: physical communica- tion:
touch, eye contact, nod head
visual communication: pictures,
verbal communication: notebook, speak loud and clear
, 6. Pneumothorax: air in pleural cavity putting pressure on outside of lung causing it
to collapse
- caused by laceration or puncture to lung during medical procedures; trauma (rib
fractures, penetrating wounds, blunt trauma, underlying conditions increased risk of
spontaneous pneumo
Risk Factors: smoking, tall and thin, family Hx, chronic lung disease, pregnancy, lung
infection, mechanical ventilation
7. Spontaneous pneumothorax: caused by rupture of small air-filled sacs (blebs) on
the lung surface
8. Iatrogenic Pneumothorax: occurs during a medical procedure
9. Hemothorax: blood in the pleural cavity causing lung collapse
10. chylothorax pneumothorax: accumulation of chyle in the pleural cavity
11. Tension Pneumothorax: a type of pneumothorax in which air that enters the
chest cavity is prevented from escaping; causes compression of unaffected lung;
shifting caused great vessels to compress, decreasing cardiac output and venous
return
medical emergency- needle decompression
12. manifestation of pneumothorax: sudden chest pain SOB
dyspnea, shallow short rapid respirations
hypoxia
absent breath sounds over affected area
13. Nursing considerations of chest tubes: - continuous air bubbling in water
chamber= leak
- tidaling (water fluctuation)- normal finding, indicates intra-thoracic pressure
changes w/ normal respirations
- water seal allows air to leave pleural space during expiration (positive pressure)
and prevents room air from entering the pleural space during inspiration (negative
pressure)
- position pt in High Fowlers
- ensure tubing is free of kinks
- monitor for subcutaneous emphysema
- keep unit below level of chest
- inspect drainage, water seal and suction checked hourly
- sudden loss of tidaling or bubbling can indicate occlusion
- do not milk, strip, or clamp
14. Patient care w/ chest tube: frequent position changes
encourage pt to cough and deep breath, use incentive spirometer, to promoter lung
expansion
