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Nur 195 Test 1 | Questions And Answers Latest {} A+ Graded | 100% Verified
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Nur 195 Test 1 | Questions And Answers Latest {} A+ Graded | 100% Verified
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Nur 195 Test 1 | Questions And Answers Latest {2024- 2025} A+ Graded |100% Verified
Respiratory: What is the nurse's priority? - A
Airway:
upper
respiratory tract
natural or artificial airway
B
Breathing:
lower
respiratory tract
respiration: ventilation, perfusion, diffusion
C
Circulation: adequate BP and Hemoglobin (Hg)
Morbidly obese - increase risk for airway and breathing issues, increased respiratory rate, circulatory
issues, etc, DVT- can change into a pulmonary embolism
Head of the bed must be up for - respiratory patients and the elderly
If patient is unconscious - keep them on their side in case they vomit
Anything below the trachea is - sterile
If someone aspirates, what lung will most likely be affected? - Right lung
,PLEURAL EFFUSION - Addtl fluid in the lung (pleural space)
diaphragm - the major muscle of respiration located at the base of the thoracic cavity
use of accessory muscles - Scalenes, intercostal, flaring of nostrils
Surfactant - keeps the alveoli open and decreases surface
Atelectasis - unable to keep the alveoli open (collapsed alveoli), low grade temp and may have crackles,
leads to hospital acquired pneumonia, important to use incentive spirometer
anatomic dead space - Nose to bronchioles
What Controls Respiratory Rate and Depth? - Chemoreceptors in the Brain, Peripheral receptors -
Carotid and Aortic Bodies, Mechanical receptors in the Lungs
Chemoreceptors in the Brain - --Chemical changes in H+ ion concentration or pH
--Changes in carbon dioxide concentration
Peripheral receptors -Carotid and Aortic Bodies - respond to oxygen levels, carbon dioxide and pH
Mechanical receptors in the Lungs - Physiologic factors: pulmonary muscle stretching, alveolar wall
distortion, irritants and fluid build up.
Why must COPD patients be conscious of the amt of oxygen that they get? - they have higher levels of
carbon dioxide
What is a focused respiratory assessment? - Subjective Assessments:
•Dyspnea: (rated on a scale of 1-10)
•Chest pain: pulmonary v.s. cardiac origin
,Objective assessments:
•Cough: describe characteristics
•Sputum: quantity, consistency, color
Physical Assessments:
Inspection, Palpation, Percussion, Auscultation
Arterial Blood Gas (ABG) - ABG analysis is used to evaluate respiratory function and provides accurate
information about oxygenation, ventilation and acid-base balance. The measurements reported are the
pH, PaCO2, PaO2, HCO3 and SaO2.
An arterial puncture is done from the radial, brachial or femoral artery or the blood is obtained from an
indwelling arterial catheter. Perform the Allen test before using the radial artery. Use a heparinized
syringe and immediately place blood sample on ice and send to the lab.
Nursing Implications:
Explain the procedure to the patient. Make no changes with the patient for twenty minutes prior to test.
Indicate whether oxygen was in use at the time blood was drawn. Once the needle is removed, firm,
direct pressure is applied for 5 minutes to the arterial site, until the site is no longer bleeding.
M.H. 72 y/o female admitted with diagnosis of Pneumonia , shortness of breath, fever, chest pain with
coughing, fatigue.
Health History: smoker, Influenza PTA, productive cough
Diagnostics: CXR - RLL infiltrates, consolidation: Pneumonia
Labs: Blood and Sputum cultures pending, WBC: Leukocytosis
Proceed with data collection and the Nursing Process: - Physical Exam
Observe or Monitor: WOB, LOC, RR and depth, SpO2, sputum production
Inspect: skin color and temp, nail beds, chest symmetry
Palpate: tactile fremitus
Auscultate: adventitious sounds (cackles), egophony (voice resonance- say the letter A, if it sounds like E
it signifies pneumonia
, pulse oximetry - Nursing implications: values less than 90% indicate inadequate oxygenation. assess
patient's status and presence of factors that could interfere with accuracy of readings.
Culture and Sensitivity
Gram Stain
Acid-fast smear and culture
Cytology - Purpose is to identify pathogenic organisms to aid in diagnosis, selection and evaluation of
treatment.
Expectoration is the usual method used to collect sputum in a sterile container after clearing the nose
and throat and rinsing the mouth. Instruct patient to cough forcefully with exhalation.
Nursing Implications: An early morning specimen is best. Deliver to the lab immediately to prevent
overgrowth of the specimen.
Chest X-Ray
(CXR) - Test used to screen, diagnose and evaluate changes in the chest.
Most common views are PA and lateral which requires patient transport to Radiology. Nursing
Implications:
The nurse should ensure that the patient has removed jewelry, dentures, all external metallic objects,
and wires
Nursing Implications:
The nurse should ensure that the patient has removed jewelry, dentures, all external metallic objects,
and wires
Computed tomography
(CT) - This test is performed for diagnosis of lesions difficult to assess by conventional x-ray studies.
Images produced provide a cross-sectional view of the chest.
Test is done with or without contrast. Contrast media is iodine-based.
Patient may require sedation in order to be able to tolerate the test.
Nursing Implications:
Screen the patient for shellfish or iodine allergies.
Evaluate hydration and renal function.
Determine weight is within limits.
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