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NR 224 QUIZ 3 LATEST EXAM
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NR 224 QUIZ 3 LATEST EXAM
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NR 224 QUIZ 3 LATEST EXAMfactors affecting oxygenation - ANSWER: a. Decreased oxygen-carrying capacity
b. Hypovolemia
c. Decreased inspired oxygen concentration
d. Increased metabolic rate
e. Ineffective gas exchange (lungs)
f. Ineffective pump (heart)
Conditions Affecting chest wall movement - ANSWER: Pregnancy
Obesity
Musculoskeletal abnormalities
Trauma
Neuromuscular diseases
Central nervous system alterations
Influences of chronic lung disease
hypoventilation - ANSWER: Occurs when alveolar ventilation is inadequate to meet
the oxygen demand of the body or eliminate sufficient carbon dioxide
Hyperventilation - ANSWER: A state of ventilation in which the lungs remove
carbon dioxide faster than it is produced by cellular metabolism
Hypoxia - ANSWER: Low oxygen saturation of the body, not enough oxygen in the
blood. A state of ventilation in which the lungs remove carbon dioxide faster than
it is produced by cellular metabolism
Early signs of hypoxia - ANSWER: Restlessness, elevated BP, tachypnea,
tachycardia, pallor, pale mucous membranes
Late signs of hypoxia - ANSWER: Cyanosis, decreased LOC, behavior changes,
confusion, stupor, bradypnea, bradycardia, low BP, cardiac dysrhythmias
Alterations in Cardiac Functioning - ANSWER: disturbances in conduction, altered
cardiac output, impaired valvular function, myocardial ischemia
Left sided heart failure - ANSWER: 1. Pnea, SOB
2. Crackles
3. Oliguria
4. Frothy Sputum
5. Displaced Apical Pulse (Hypertrophy)
Pulmonary edema
right sided heart failure - ANSWER: 1. Jungular Vein Distention
2. Ascending Dependent Edema
3. Weight Gain
, 4. Hepatomegaly (Liver Enlargement)
Angina - ANSWER: Pain in the heart region caused by lack of oxygen. Partial
obstruction
Myocardial infaction - ANSWER: Heart attack. Complete obstruction
occurs when blood flow decreases or stops to a part of the heart, causing damage
to the heart muscle.The most common symptom is chest pain or discomfort which
may travel into the shoulder, arm, back, neck or jaw
Factors influencing oxygenation - ANSWER: - Developmental
- Lifestyle
- Environmental
Lifestyle factors affecting oxygenation - ANSWER: .Nutrition
•Hydration
•Exercise
•Smoking
•Substance abuse
•Stress
Nursing care plan ineffective airway clearance - ANSWER: a. Position patient head
elevated 30-45 degrees
b. Ambulate in room or hall 2x/day or T&R Q2H
c. Patient to cough or deep breath Q hour
d. Teach patient to take a deep breath, hold for a couple seconds, open mouth,
tighten abd muscle, cough 2-3 times with mouth open
e. Increase fluids to 2500ml for 24 hours, offer fluids patient prefers
Coughing and deep breathing exercises - ANSWER: a. Effective technique for
maintaining patent airway
b. Coughing is deliberate maneuver that is effective when spontaneous coughing is
inadequate (allows patient to remove secretions from upper and lower airways)
c. Deep inhalation (increase lung volume and airway diameter)
d. Deep inhalation (allowing air to pass through partially obstructing mucus plus or
objects)
e. Huff cough (stimulates natural cough reflex)
f. Huff cough (used to help move secretions to larger airways)
g. Quad cough/manually assisted cough technique (pt with no abd muscle control-
Spinal cord injuries)
h. Diaphragmatic breathing (encourages deep breathing to increase air to lower
lungs)
Chest physiotherapy - ANSWER: a. External chest wall manipulation using
percussion, vibration, or high-frequency chest wall compression
b. Used in conjunction with postural drainage
c. Help mobilize pulmonary secretions in select group of patients
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