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67 Cards in this Set
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- Back
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Nurse is assessing a client who has emphysema. The nurse should report which of the following assessment findings?
1. digital clubbing 2.Elevated Temp. 3. Barrel Chest 4. Diminished Breath sound |
1.digital clubbing-normal findings 2.Elevated temp-higher risk for pneumonia and rest. infections 3. barrel chest -normal findings 4. diminished breath sounds-normal findings |
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Pt taking albuterol what side effect should the nurse watch for?
1.Hyperkalemia 2.Dyspnea 3.Tachycardia 4.Candidasis |
1.hyperkalemia-Not a side effect of this med 2.Dyspnea- you would give the med to treat this 3.Tachy- common side effect of the drug 4.Candidiasis(thrush)- side effect of inhaled glucocorticoids(beclomethasone) |
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RN caring for PT following Chest Tube insertion. RN should plan to have which item in the room?
1.Extra drainage System 2.Suture set 3. container of Sterile water 4.Nonadherent pads |
1.Extra drainage- not needed 2.Suture set- not needed until removal 3. Sterile Water- should have in case tube becomes disconnected b/c place open tube in water to prevent pnuemothroax. 4. Nonadherent pads- not needed |
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RN assessing PT with Chest tube. Which finding needs intervention?
1. fluctuation of drainage in the tubing with inspiration. 2. Continous bubbling in the water seal chamber 3. Drainage of 75ml in 1st hr 4. Several blood clots in tubing |
1. fluctuation with inspiration- expected(normal) 2. continuous bubbling in water seal- AIR LEAK 3. Drainage of 75ml in 1st hr- only concerned if over 100ml in 1hr 4. clots in tubing- expected (normal finding) |
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PT underwent bronchoscopy with conscious sedation. What is the priority assessment?
1. Gag reflex 2. Pain Level 3. Dehydration 4. Redness at IV site |
1. Gag reflex- Greatest risk is ASPIRATION due to depressed gag reflex. 2. Pain level- needed but not priority ABC 3. dehydration- needed since NPO but not priority 4.Phlebitis- Needed due to med through IV but again not priority. |
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RN is to perform NG Suctioning on PT. Which should the nurse need to clairfy before performing.
1. Closed head injury and lethargic 2.Fractured femur and reporting sever pain 3. Ruptured appendix and temp of 102.2 4. Emphysema PT with RR of 36 |
1. Head injury- No suctioning b/c it will increase ICP 2. Femur- does not matter 3. Temp/appendix- does not matter 4. Emphysema- does not matter |
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PT in acute respiratory failure who is on mechanical ventilation what assessment would the nurse check to see effectiveness of the mechanical ventilation? 1. BP 2. Cap refill 3. ABG 4. HR |
1.BP- should monitor for circulatory system but not for respiratory. 2. Cap refill- should monitor for circ. system but not resp. 3. ABG- ABC's ABG's determine O2 saturation and acid- base balance. 4. HR- should monitor for circ. system but not resp. |
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PT suffering from Acute respiratory distress syndrome. What would indicate a decline in status?
1.Increase RR 2.Increase in O2 sat 3.Decrease in CO2 retention 4.Decrease in intercostal retractions |
1. High RR- increased work load harder breathing de to not meeting oxygen requirements. 2.O2 Sat- would be a sign of improvement 3.decreased CO2 retention- would be a sign of improved gas exchange 4.decreased retractions- would be a sign of improving gas exchange |
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PT 1 hr post-op thoracentesis which is the priority assessment?
1. Pallor 2.Insertion site pain 3.Tracheal deviation to unaffected side 4.Temp 37.3 |
1. Pallor- can indicate blood loss but not priority 2.pain at site- can lead to shallow respirations but not priority 3.Traceal deviation- ABC's can indicate a tension pneumothorax (emergency) 4. temp- can indicate infection but not priority. |
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RN giving instruction on using a Montelukast to treat chronic asthma which statement indicates understanding by the client? 1. will take with each meal 2.will take during attacks 3.will take up to 3 times a day when I wheeze 4. will take every evening, even if asymptomatic |
1. with meals- this med should only be given once/day 2. asthma attacks- this med is used for maintenance therapy. 3. when I wheeze- this med should be on a schedule 4. every evening- This med is used as prophylaxis for asthma exacerbation and should be taken on a daily basis in the evening as part of a maintenance therapy. |
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PT has bacterial pneumonia the RN should expect which finding?
1.Decreased fremitus 2. O2 sat of 95% RA 3.. Temp 101.8 4.Bradypnea
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1.Fremitus- should be increased with bacterial pneumonia 2.O2 sat 95%- The O2 sat should be lower with bacterial pnuemonia 3. Temp- Common finding indicating infection 4. Bradypnea- should be tachypnea with B. Pneumonia |
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COPD PT what finding should the nurse report abnormal?
1. O2 sat 89% 2.Prodcutive cough with green sputum 3. Clubbing of fingers 4. Pursed lip breathing with exertion |
1. O2 sat 89%-COPD causes normally low O2 as a result of disease 2. sputum- should be reported indicates infection 3. clubbing- expected with COPD as result of long term hypoxic state. 4. pursed lips- should be encouraged to improve O2 with exercise |
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Tuberculosis PT sent home on Rifampin what should the nurse include in discharge teaching?
1. Tinnitus 2.improved PPD in 4 months 3.Urine/secretions will be orange 4.Take the medication with meals. |
1.Tinnitus- not a side effect of this drug 2. PPD test- should be positive forever even when disease is gone. 3. Urine- Common side effect of this drug 4. med with meals- should be taken on a empty stomach once a day |
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what is the device that will provide a high oxygen via a low-flow system for a respiratory distress PT?
1. NC 2. Non rebreather 3. Simple face mask 4. Partial rebreather mask |
1.NC- has a limit up to 6l per minute so not right choice 2. Nonrebreather- delivers the highest amount of O2 90% FIO2 due to the reservoir bag 3.simpleface mask- can deliver 40-60% FIO2 but not the highest. 4. Partial- delivers 60-75% FIO2 not the highest. |
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ER nurse gets a chest trauma PT and she know the following is indicative of a tension pneumothorax?
1.Collapsed neck veins on affected side 2.collapsed neck veins on unaffected side 3. tracheal deviation on affected side 4. tracheal deviation on unaffected side. |
1. collapsed on affected side- will not present on affected side 2. collapsed on unaffected side- should not have if tension pnuemothroax 3. trachea affected side- will not deviate to the affected side 4.trachea unaffected side- will happen due to air filling chest cavity causing lung to collapse forcing the trachea to deviate to unaffected side |
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Post-op PT develops sever chest pain that worsens with inspiration. PT is anxious and tachypneic. What should the nurse do first? 1. supplemental O2 2. Increase Fluids 3. Administer Pain meds 4. Initiate Heparin therapy. |
1. O2- ABC's greatest risk is hypoxemia 2. increase fluids- Should to increase CO but not priority. 3. Pain meds- should do to decrease discomfort but not priority. 4. heparin- should to prevent further development of emboli but not priority. |
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PT has asthma which medication should be given in an acute asthma attack?
1. Cromolyn sodium 2. Prednisone 3. Fluticasone and salmeterol 4. Albuterol |
1.Cromolyn sodium- anti inflammatory but used as maintenance 2. prednisone- should be given after the attack to promote anti inflammatory effects. 3. salmeterol/fluticasone- long acting so should be used as maintenance. 4. Albuterol- short/fast acting B2 agonist acts quickly so should be given to produce bronchodilation during an attack |
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COPD PT would need which of the following?
1. Scheduled respiratory treatments following meals. 2. Sit in a char for 2-hr periods 3 times a day. 3. Provide diet high in calories and protein. 4. Combine activités to allow for longer rest periods between activities. |
1. treatments following meals- should be done before meals. 2. 2-hr in chair- should provide short periods of activity throughout the day 3. diet high in Cal/Pro- COPD Pts should have high protein high calories low carbs. 4.long rest periods- should have activities short in duration with adequate rest periods to prevent fatigue |
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TB Pt just arrived to the unit what isolation precautions should be implemented?
1. Airborne 2. Neutropenic 3. Contact 4. Droplet |
1. Airborne- Yes TB is respiratory infection that is spread through air. 2. Neutropenic- should be used for PT's who need to be protected from others 3. Contact- should only be used for infections that are transmitted through direct contact. 4. droplet- should be used for infection that travel by droplet such as flu |
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PT on mechanical ventilation has low pressure alarm sound off the RN knows that the cause is?
1. Excess secretions 2. Kinks in tubing 3. Artificial airway cuff leak 4. Biting on tube |
1. excess secretions- will sound of high pressure alarm 2. kinks in tubing- will sound high pressure alarm due to obstruction. 3. cuff leak- interferes with O2 and will cause a low pressure alarm. 4. biting- will ring off as high pressure alarm. |
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PT has a pulmonary embolism what intervention is priority?
1. Provide a quiet enviorment 2. Encourage IS every 1-2 hrs 3. Initiate cont. cardiac monitoring 4. Start heparin via IV |
1. quiet environment- should do this but not urgent. 2. IS 1-2hrs- should encourage but not urgent 3. Cardiac monitoring- should due to risk of dysrhythmias but not urgent. 4. Heparin via IV- ABC's should stabilize circulation to the lungs by giving heparin to prevent further clot formation |
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PT with lung cancer the nurse should expect?
1. Blood tinged sputum 2. decreased tactile fremitus 3. resonance with percussion 4. Peripheral edema |
1.Bloody sputum- expected finding secondary to tumor. 2. decreased tactile remits- should be increased due to tumor tissue replacing airspace. 3.resonance with percussion- should be dull/flat sounding due to tumor mass. 4. Edema- is abnormal for lung cancer |
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PT 4hr post op total laryngectomy as a result laryngeal cancer what is the priority?
1. Bleeding at the surgical site. 2.O2 sat 3.Urinary retention 4.LOC |
1. Bleeding-Hemorrhage is concern but not priority 2. O2 sat- ABC's due to risk for hypoxia due to airway obstruction an a decreased O2 sat is indicative of obstructed airway 3. Urine- common complication but not priority 4.LOC- concern duw to anesthesia but nor priority |
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what is the best position for an Emphysema PT to promote effective breathing? 1. Lateral position with pillow over chest to support arms. 2.High fowlers with arms supported on the overbed table. 3.semi fowlers with pillows supporting both arms 4. supine position with HOB at 15 degrees
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1. lateral position- side lying makes breathing difficult. 2. High fowlers over bed table- this allows for greater chest expansion 3. semi fowlers- does not allow the PT lean forward which promotes chest expansion. 4. supine- this allows pressure on the thoracic cavity which compromised chest expansion |
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Which ABG is considered respiratory acidosis? 1. pH- 7.5 PO2- 95mmHg PaCO2-25mmHg HCO3-22mEq/L
2. pH-7.5 PO2- 87mmHg PaCO2-35mmHg HCO3-30mEq/L
3. pH-7.3 PO2 90mmHg PaCO2-35mmHG HCO3-20mEq/L
4. pH-7.3 PO2-80mmHG PaCO2-55mmHg HCO3 22mEq/L
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1. pH- 7.5 PO2- 95mmHg PaCO2-25mmHg HCO3-22mEq/L-respiratory alkalosis(H ph & L PaCO2)
2. pH-7.5 PO2- 87mmHg PaCO2-35mmHg HCO3-30mEq/L-metabolic alkalosis (H pH & H PaCO2)
3. pH-7.3 PO2 90mmHg PaCO2-35mmHG HCO3-20mEq/L-metabolic acidosis(L pH & L PaCO2)
4. pH-7.3 PO2-80mmHG PaCO2-55mmHg HCO3 22mEq/L- Respiratory acidosis(L pH & H PaCO2) |
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Respiratory failure will present as what with ABG's?
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Respiratory acidosis
Low pH High CO2 Low O2sat Low partial pressure(PaO2) |
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ABG Normals? |
pH- 7.35-7.45
PaO2- 80 -100mmHg
PaCO2- 35 - 45mmHg
HCO3(bi-carb)- 22-26mEq/L
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Assiting with thoracentesis the RN will assist with? (Select all that apply) 1. Wear goggles and mask 2.Cleanse the area with antiseptic 3.Instruct client to take deep breaths during insertion. 4.Position PT laterally on affected side 5.Apply pressure to site after needle is withdrawn
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1. Wear goggles and mask- correct will reduce exposure 2.Cleanse the area with antiseptic -Correct decrease risk for infection 3.Instruct client to take deep breaths during insertion-Incorrect PT should remain as still as possible to reduce risk of puncture to pleura/lung. 4.Position PT laterally on affected side-Incorrect should be sitting position leaned over bedside table or laterally on unaffected side 5.Apply pressure to site after needle is withdrawn- Correct reduces risk of bleeding at site. |
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PT requires endotracheal suctioning what should the nurse do? 1. use clean technique 2. use rotating motion to remove catheter 3. Suction the oropharyngeal cavity prior to suctioning endotracheal tube. 4. Suction clients endotracheal tube Q2 |
1. use clean technique - Should be Sterile 2. use rotating motion to remove catheter-Correct will reduce the risk of tissue damage 3. Suction the oropharyngeal cavity prior to suctioning endotracheal tube- will cross contaminate 4. Suction clients endotracheal tube Q2- routine suctioning can result in hypoxia/tissue damage/ bleeding/bronchospasms |
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RN caring for PT with acute respiratory failure the RN expects the following finding? 1. Arterial pH 7.5 2.PaCO2 25mmhg 3. SaO2 92% 4. PaO2 58 mmHg |
1. Arterial pH 7.5- should be low with resp. failure 2.PaCO2 25mmhg- should increase with resp. failure 3. SaO2 92%- should decrease 4. PaO2 58 mmHg- Correct lower partial pressure of O2 will be expected |
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which PT is at highest risk for pulmonary embolism? 1. 12hr post op hip arthoplasty 2. 8hr post op appendectomy 3. 2hr post op external fixation of radius 4. 4hr post op laparoscopic cholecystecomy |
1. 12hr post op hip arthoplasty- greatest risk due to impaired mobility 2. 8hr post op appendectomy- low risk 3. 2hr post op external fixation of radius- low risk 4. 4hr post op laparoscopic cholecystecomy- low risk |
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you are the RN doing discharge instructions for tracheostomy you know the PT needs further teaching when? 1. I will inspect the stoma for signs of infection 2. I will clean with half strength peroxide and NS rinse 3. I can remove the old ties when the new ones are placed. 4. I will apply suction while inserting the catheter |
1. I will inspect the stoma for signs of infection- should do this 2. I will clean with half strength peroxide and NS rinse-should do this 3. I can remove the old ties when the new ones are placed.- good way to prevent decannulation 4. I will apply suction while inserting the catheter- Only apply suction when withdrawing the catheter to prevent tracheal tissue damage. |
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Which of the following PT's have an increased risk for developing pneumonia? SELECT ALL 1.PT with dysphagia 2.PT with aids 3.PT who was vaccinated for flu and pneumonia 6 mn ago. 4. PT who is post op and has had anesthesia 5. PT with head injury and on a vent 6. PT with myasthenia gravis. |
1.PT with dysphagia- due to risk for aspiration 2.PT with aids- due to being immunocompromised 3.PT who was vaccinated for flu and pneumonia 6 mn ago.- Least likely 4. PT who is post op and has had anesthesia- least likely 5. PT with head injury and on a vent-Invasive and High risk 6. PT with myasthenia gravis.- Generalized weakness diff. removing secretions=increasing risk |
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Pt comes is confused reporting chills and chest pain that worsens upon inspiration which is priority for the RN? 1. obtain VS and O2 Sat 2. Obtain sputum culture 3. Obtain complete history 4.provide pneumococcal vaccine |
1. obtain VS and O2 Sat- highest priority 2. Obtain sputum culture-good but not priority 3. Obtain complete history-good but not priority 4.provide pneumococcal vaccine-good but not priority |
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Pt has pneumonia VS are 100F,30RR,130/76BP,100HR,91%O2 using a scale from 1-4 label with 1 being the highest priority. ___administer antibiotics ___administer O2 ___perform sputum culture ___administer antipyretic med for comfort |
1.administer O2- ABC's 2.perform sputum culture- should be done before meds given to get accurate specimen 3.administer antibiotics- treat the problem accordingly to sputum culture 4.administer antipyretic med for comfort- lowest priority |
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Rn is taking care of PT who has Sinusitis which of the following techniques should the nurse use to identify clinical manifestations of the disorder? 1. percussion of posterior lobes of lungs 2. auscultation of the trachea 3. insepection of the conjunctiva 4. palpation of the orbital areas |
1. percussion of posterior lobes of lungs- good for pneumonia 2. auscultation of the trachea- good for bronchitis 3. insepection of the conjunctiva- good for anemia 4. palpation of the orbital areas- if tender the RN knows this is a manifestation of sinusitis |
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RN teaching about influenza which statement needs clarification? 1. i should wash my hands after i blow my nose to prevent spreading. 2. I need to avoid drinking fluids if i develop symptoms 3. I need a flu shot every year b/c of different strains. 4. I should sneeze into my elbow rather than my hands. |
1. i should wash my hands after i blow my nose to prevent spreading. 2. I need to avoid drinking fluids if i develop symptoms 3. I need a flu shot every year b/c of different strains. 4. I should sneeze into my elbow rather than my hands. |
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Identify 3 risk factors for Rhinitis? |
Lack of immunization recent exposure exposure to plant pollen, other allergen triggers tobacco smoke drug use inactivity/immobility foreign body presence |
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Rn caring for a client who is scheduled for a thoracentesis. prior to procedure which if the following actions should the nurse take? 1. position client in an upright position, leaning over the bedside table. 2. explain the procedure 3. Obtain ABG's 4. Administer benzocaine spray to PT |
1. position client in an upright position, leaning over the bedside table.- opens the pleural space better 2. explain the procedure - NOT RN job 3. Obtain ABG's- Not indicated 4. Administer benzocaine spray to PT- Used with bronchoscopy not thoracentesis |
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Rn caring for PT in respiratory distress. RN recognizes these can cause a low pulse ox reading? SELECT ALL 1. nail polish 2. Inadequate peripheral circulation 3. Hyperthermia 4.Increased Hgb level 5. Edema
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1. nail polish 2. Inadequate peripheral circulation 3. Hyperthermia- would be hypothermia 4.Increased Hgb level- would be decreased 5. Edema |
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Rn is assessing PT following a bronchoscopy. what should the RN report? 1. blood tinged sputum 2. Dry, non productive cough 3. Sore Throat 4. Bronchospasms |
1. blood tinged sputum- expected 2. Dry, non productive cough- expected 3. Sore Throat- expected 4. Bronchospasms- could indicate difficulty maintaining AIRWAY ABC's |
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RN is caring PT who is scheduled for a Thoracentesis. what supplies should the RN have in the room? 1. Oxygen equip. 2. IS 3. Pulse Ox. 4. Sterile dressing 5. Suture removal set |
1. Oxygen equip. 2. IS- used following the surgery 3. Pulse Ox. 4. Sterile dressing- 5. Suture removal set- used following the surgery |
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RN caring for PT following a thoracentesis what clinical manifestations should the RN recognize as risks for complications? 1. Dsypnea 2. Localized bloody drainage 3. Fever 4. Hypotension 5. Pain at Puncture site |
1. Dsypnea-indicate pneumothorax/ reaccumulation of fluid 2. Localized bloody drainage-expected 3. Fever-indicate infection 4. Hypotension- indicate intrathoracic bleeding 5. Pain at Puncture site-expected |
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Rn preparing for PT following Chest tube placement which of the following should the RN have in the room? 1.Oxygen 2. sterile water 3. enclosed hemostat clamps 4.indwelling catheter 5. occlusive dressing |
1.Oxygen 2. sterile water-recreate water seal 3. enclosed hemostat clamps- used to check for air leaks 4.indwelling catheter - not indicated 5. occlusive dressing-allows air movement and reduces the risk of tension pneumothorax |
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RN is taking care of PT with chest tube and drainage system in place. RN observed the tube has been disconnected. What should come first? 1. place tube in sterile water 2. apply sterile gauze to insertion site 3. place tape around insertion site 4 assess respiratory status |
1. place tube in sterile water-good but not priority 2. apply sterile gauze to insertion site-this allows air to escape and reduce the risk of tension pneumothorax 3. place tape around insertion site- good but not priority 4 assess respiratory status -good but not priority |
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RN is taking care of PT with chest tube and drainage system in place. which are expected findings? 1. continuous bubbling in the water seal chamber 2. gentle constant bubbling in the suction control chamber 3. rise and fall in the level of water in the water seal chamber with inspiration 4. exposed sutures without dressing 5. drainage system upright at chest level. |
1. continuous bubbling in the water seal chamber-indicative of air leak 2. gentle constant bubbling in the suction control chamber- air is being removed 3. rise and fall in the level of water in the water seal chamber with inspiration- working correctly 4. exposed sutures without dressing- would be an airtight dressing 5. drainage system upright at chest level.- should below the chest |
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Rn providing assistance with removal of chest tube. What should the nurse instruct the PT to do. 1. lie on his left side 2. use the IS 3. cough at regular intervals 4. perform a valsalva maneuver |
1. lie on his left side- depends on location of insertion site 2. use the IS-not indicated 3. cough at regular intervals-breath normally 4. perform a valsalva maneuver-increase intrathoracic pressure and reduces the risk of an air embolism |
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RN planning for care of PT following chest tube placement what should be included in the plan of care? SELECT ALL 1. cough Q2 2. check for continuous bubbling in the suction chamber 3. strip the tube Q4 4. Milk the tubing once per day 5. Obtain chest xray. |
1. cough Q2- promotes oxygenation 2. check for continuous bubbling in the suction chamber- verify that suction is maintained 3. strip the tube Q4- creates neg. pressure causing damage to lungs 4. Milk the tubing once per day- creates neg. pressure causing damage to lungs 5. Obtain chest xray. - verifies placement |
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discharge teaching for PT with COPD and has a prescription for albuterol what indicates an understanding? 1. this med can increase my blood sugar 2. This med can decrease my immune response 3. I can have an increase in my HR while taking this med 4. I can have sores in my mouth while taking this med |
1. this med can increase my blood sugar anti-inflammatory meds cause hyperglycemia 2. This med can decrease my immune response- anti-inflammatory meds cause decrease immune system 3. I can have an increase in my HR while taking this med-bronchodilators can make you tachycardic 4. I can have sores in my mouth while taking this med- anti-inflammatory meds cause mouth sores |
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RN preparing to administer Prednisone to a PT with COPD which of the following should she monitor for? Select all 1. hypokalemia 2.tachycardia 3.fluid retention 4. Nausea 5. report black tarry stools |
1. hypokalemia-adverse effect of med 2.tachycardia- adverse effect of bronchodilator 3.fluid retention-adverse effect of med 4. Nausea-adverse effect of bronchodilator 5. report black tarry stools-adverse effect of med |
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RN instructing PT on the use of the IS which demonstrates an understanding? 1. I will place the adapter on my finger to read my 02 sat 2. I will lie on my back with my knees bent 3. I will rest my hand over my stomach 4. I will take a deep breath and hold it before exhaling. |
1. I will place the adapter on my finger to read my 02 sat 2. I will lie on my back with my knees bent 3. I will rest my hand over my stomach 4. I will take a deep breath and hold it before exhaling. |
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RN discharging PT who has COPD the PT is concerned that he will never be able to leave his house not that he is on cont. O2. What is the RN's best response? 1. There are portable O2 delivery systems 2. When you go out you can remove the oxygen 3. You will not go out as much as you used too 4. Home health services will come to you so no need to get out |
1. There are portable O2 delivery systems 2. When you go out you can remove the oxygen 3. You will not go out as much as you used too 4. Home health services will come to you so no need to get out |
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RN is instructing PT on how to perform pursed lip breathing what should the RN include? 1. take quick breaths upon inhalation 2. place your hand over your stomach 3. take a deep breath on through your nose 4. puff you cheeks upon exhalation |
1. take quick breaths upon inhalation 2. place your hand over your stomach 3. take a deep breath on through your nose- this aids in control 4. puff you cheeks upon exhalation-does not allow optimal exhalation of co2 |
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Which PT's are at risk for a pulmonary embolism? 1. BMI of 30 2. Post menopausal 3. Fractured Femur 4. Marathon runner 5. chronic Afib |
1. BMI of 30-obese increases risk for blood clot 2. Post menopausal-decreased risk 3. Fractured Femur-long bone fx increase risk 4. Marathon runner-decreased risk 5. chronic Afib- turbulent blood flow increases the risk |
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RN caring for PT with a prescription for heparin therapy. Which of the following statements by the PT indicate concern? 1. Im allergic to morphine 2. I take antacids several times a day 3. I had a blood clot in my leg several years ago 4. it hurts to take a deep breath. |
1. Im allergic to morphine-not immediate concern 2. I take antacids several times a day-possibility of bleeding from a peptic ulcer 3. I had a blood clot in my leg several years ago-not immediate concern 4. It hurts to take a deep breath.- not immediate concern |
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PT has a Pulmonary embolism which manifestation would be expected SELECT ALL 1. Bradypnea 2 Pleural friction rib 3.Hypertension 4.Petechiae 5.Tachycardia |
1. Bradypnea-usually tachypnea 2 Pleural friction rib 3.Hypertension-usually Hypotension 4.Petechiae 5.Tachycardia |
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PT is to receive fibrinolytic therapy which is a contraindication of therapy? 1.Hip arthroplasty 2 wks ago 2. Elevated sedimentation rate 3. incident of exercise induced asthma 1 wk ago 4. Elevated PLT count |
1.Hip arthroplasty 2 wks ago-should not have had surgery within the last 3wks=this increase risk of hemorrhage 2. Elevated sedimentation rate 3. incident of exercise induced asthma 1 wk ago 4. Elevated PLT count |
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Pt has a Pneumothorax what should the RN do first? 1. assess PT pain 2. Obtain Large bore Iv needle for decompression 3. Administer lorazepam 4. Prepare for chest tube insertion |
1. assess PT pain- not priority 2. Obtain Large bore Iv needle for decompression- first ABC's 3. Administer lorazepam-not priority 4. Prepare for chest tube insertion- should gather supplies first |
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Discharge instructions for PT's who experienced a pneumothorax which if the following should be teached? 1. Notify provider if you experience weakness 2. you should be able to return to work in 1 week 3. you need to wear a mask when in crowded areas 4. notify provider if you obtain a cough |
1. Notify provider if you experience weakness-expected 2. you should be able to return to work in 1 week-will need longer recovery 3. you need to wear a mask when in crowded areas-only for immunocomprimised 4. notify provider if you obtain a cough- Indicate rest. infection |
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RN assessing a PT with flail chest which clinical findings confirm it? SELECT ALL 1. bradycardia 2.cyanosis 3.hypotension 4.dyspnea 5. paradoxic chest movement. |
1. bradycardia- would be tachycardia 2.cyanosis- 3.hypotension 4.dyspnea 5. paradoxic chest movement. |
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Which of the following PT's are at risk for developing ARDS(acute respiratory distress syndrome)? Select ALL 1. near drowning 2.CABG (coronary artery bypass graft) 3.Hgb of 15.1 4. dysphagia 5.Drug overdose |
1. near drowning- at risk due to trauma to lungs and cerebral edema 2.CABG (coronary artery bypass graft)-at risk due to chest trauma 3.Hgb of 15.1- normal we need to be low to be at risk 4. dysphagia- at risk b/c aspiration risk 5.Drug overdose- risk due to damage to CNS |
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PT is 91% and is having audible wheezes and use of his accessory muscles what medication do you anticipate on giving? 1. antibiotic 2. Beta blocker 3. Antiviral 4 B2 agonist |
1. antibiotic 2. Beta blocker 3. Antiviral 4 B2 agonist- |
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Pt admitted with acute asthma attack what indicates a decrease in respiratory status? 1.O2 sat 95% 2. Wheezing 3. Retraction sternal muscles 4. pink mucous membranes 5. PVC's |
1.O2 sat 95% 2. Wheezing 3. Retraction sternal muscles 4. pink mucous membranes 5. PVC's |
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What risk factor is associated with asthma? 1. Gender 2.Enviormental allergies 3.Alchol Use 4.Race |
1. Gender 2.Enviormental allergies 3.Alchol Use 4.Race |
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what manifestations would you expect with TB? SELECT ALL 1. persistent cough 2. weight gain 3. fatigue 4. night sweats 5. purulent sputum |
1. persistent cough 2. weight gain 3. fatigue 4. night sweats 5. purulent sputum |
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What are early signs of hypoxemia? Select ALL 1. Confusion 2. Pale skin 3. Bradycardia 4. Hypotension 5. Elevated BP |
1. Confusion-late 2. Pale skin 3. Bradycardia-late 4. Hypotension-late 5. Elevated BP |
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which of the following delivers a precise amount of oxygen? 1. nonrebreather 2.venturi mask 3.nasal cannula 4.simple face mask |
1. nonrebreather-appoaximated 2.venturi mask- adapter allows precise amount 3.nasal cannula-appoaximated 4.simple face mask-appoaximated |
