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34 Cards in this Set

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Partial assessment of a dyspneic client would not include which of the following?

1) respiratory rate
2) sputrm
3) Chest X-ray
4) breathing pattern
X-Ray
2 L/min of O2 via nasal cannula or simple face mask is given to clients with underlying chronic obstructive lung disease in oder to:

1) reduce the risk of O2 toxicity
2) reduce the risk of carbon dioxide retention
3) increase pH level
4) increase diaphragmatic excursion
Reduce the risk of carbon dioxide retention
Humidification is added to O2 therapy via nasal cannula O2 in order to

1) prevent drying of the nasal mucosa
2) liquefy pulmonary secretions
3) increase the client's cough
4) improve oxygenation
prevent drying of the nasal mucosa
BiPAP difffers from CPAP in that

1) positive pressure is only given during inhalation
2) Positive pressure is only given during exhalation
3) it uses negative pressure during inhalation and exhalation
4) it uses positive pressure during inhalation and exhalation
it uses positive pressure during inhalation and exhalation
the use of noninvasive ventilation (CPAP or BIPAP) has the potential to cause carbon dioxide retention in selected clients. which clients are at greater risk for carbon dioxide retention?

1) Clients with an underlying diagnosis of congestive heart failure
2) clients with an underlying diagnosis of pulmonary fibrosis
3) clients with an underlying diagnosis of chronic obstructive pulmonary disease
4) clients with an underlying diagnosis of pulmonary edema
clients with an underlying diagnosis of chronic obstructive pulmonary disease
Your client is on mechanical ventilation. Suddenly he develops sever respiratory distress, his vital signs change, his O2 saturation suddenly declines, and his tracheal tube is no longer mideline. You suspect a tension pneumothorax. Your immediate actions are to:

1) Begin manual ventilation and obtain vital signs and pulse oximetry as soon as possible
2) Keep the ventilator settings the same and notify physician
3) Notify the physician
4) Suction the client and obtain vital signs
begin manual ventilation and obtain vital signs and pulse oximentry as soon as possible
Your client has a large amount of pulomnary secretions. Over the last hour you note that the secretions are thicker and the volume has increased. During the last 30 min, the pressure alarm on the mechanical ventilator has triggered repeatedly. What actions is appropriate to correct this problem?

1) Manually ventilate the client
2) Change the sensitivity setting on the ventilator.
3) suction the client's airway
4) Call the physician.
suction the client's airway
What is cyanosis
bluish coloration of the skin due to the presence of deoxygenated hemoglobin in blood vessels near the skin surface. It occurs when the oxygen saturation of arterial blood falls below 85%.

The elementary principle behind cyanosis is that deoxygenated hemoglobin produces the bluish discoloration, and also produces vasoconstriction that makes it more evident. Thus oxygen deficiency - hypoxia - leads to blue discoloration of the lips and other mucus membranes.
What is hypercapnia
(from the Greek hyper = "above" and kapnos = "smoke"), also known as CO2 Poisoning, is a condition where there is too much carbon dioxide (CO2) in the blood. Carbon dioxide is a gaseous product of the body's metabolism and is normally expelled through the lungs.
What is hypoxemia
abnormal deficiency in the concentration of oxygen in arterial blood (Mosby's Medical Dictionary). A frequent error is made when the term is used to describe poor tissue diffusion as in hypoxia. It is possible to have a low oxygen content (eg due to anemia) but a high PO2 in arterial blood so incorrect use can lead to confusion.
What is hypoxia
shortage of oxygen in the body, when there is not enough O2 in the body to meet the metabolic demands of the tissues and cells.
The Six Rights of Medication Administration
* Right client
* Right time
* Right medicine.
* Right dose
* Right route
* Right documentation.
Noninvasive ventilation (NIV)
maintains positive airway pressure and improves alveolar ventilation without the need for an artificial airway
continuous positive airway pressure (CPAP)
maintains a set positive airway pressure is a NIV
Bilevel positive airway pressure(BiPAP)
generates a preset positive pressure support, which increases the client's tidal volume and ultimately alveolar ventilation, pressure support ends when the client initiates the expiration phase
when would you use a negative pressure system for O2 delivery
clients with multiple sclerosis and muscular dystrophy
what is pneumothorax
collapsed lung
cascade in a O2 delivery
temperature of the heater in the ventilation, can be a source of infection water in tubing should drain out into back into water source
What are the ONLY reliable indicator of pain
Onset and duration
location
Intensity
quality
pain pattern
relief measures
concomitant symptoms
What is ment by quality of pain
aching
burning
throbbing
pulling
sharp
tingling
What is pallor
pale skin (loss of color)
cyanosis
bluish discoloration
jaundice
yellow, orange discoloration
erythema
red discoloration, inflamation
macule
flat nonpalpable
papule
palpable circumscribed solid elevation
nodule
elevated deeper and firmer (wart)
tumor
soild mass may be deep > 1-2cm
wheal
elevated localized edema (hives, bug bite)
vesicle
circumscribed elevation filled with fluid < .5cm crusty (herpes simples)
Pustule
circumscribed elevation filled with pus (acne)
ulcer
deep loss of skin surface
atrophy
thinning of skin wall with loss of normal skin furrow with skin apperaring shinny and translucent
what is neuropathy
decreased sensation in feet