NSG-321 Exam 2 Questions and Correct
Answers
Have a good understanding of hypoxia and clinical manifestations. What would you see
in the patient? (479t) ✅-Hypoxia: Inadequate oxygenation. Due to obstruction.
-CNS: (EARLY) Unexplained apprehension, unexplained restlessness or irritability,
unexplained confusion or lethargy, (LATE) unexplained confusion or lethargy,
combativeness, coma.
-Respiratory: (EARLY) Tachypnea, dyspnea on exertion, (LATE) dyspnea at rest, use of
accessory muscles, retraction of intercostal spaces on inspiration, pause for breath
between sentences, words.
-Cardiovascular: (EARLY) Tachycardia, mild hypertension, dysrhythmias, (LATE)
dysrythmias, hypotension, cyanosis, cool/clammy skin.
-Other: (EARLY and LATE) Diaphoresis, decreased urine output, unexplained fatigue.
If you are a patient with chronic hypoxemia combined with polycythemia vera, what will
your skin look like? Blood capacity for carrying O2 is decreased. ✅-Blue and
red/flushed skin.
-Know colors to be able to detect it when you see it.
-Breathing capacity? Accessory muscle use, pursed lip, barrel chest.
-What kind of posture? Tripod.
Goals of patient with COPD? Manage s/s of the disease and being able to maintain
function ✅-Goals: (596)
1. Prevention of disease progression
2. Ability to perform ADLs and improved exercise tolerance
3. Relief from symptoms
4. No complications related to COPD
5. Knowledge and ability to implement a long-term treatment regimen
6. Overall improved quality of life
-Signs and Symptoms: Clinical manifestations typically develop slowly, but COPD
should be considered in all patients over age 40 with 10 or more pack years of cigarette
smoking. A diagnosis of COPD should be considered in any patient who has symptoms
of cough, sputum production, or dyspnea and/or a history of exposure to risk factors for
the disease. (585)
Epistaxis and nursing interventions ✅1. Keep the patient quiet
2. Place the patient in a sitting position, leaning slightly forward with head tilted forward
3. Apply direct pressure by pinching the entire soft lower portion of the nose against the
nasal septum for 10 to 15 minutes. If bleeding does not stop within 10 to 15 minutes,
seek medical assistance.
-Nasal packing may impair respiratory status, especially in older adults. Closely monitor
RR, HR and rhythm, Sp02 using pulse oximetry, and level of consciousness, and
observe for signs of aspiration.
, -Teach the patient about home care before discharge. Instruct the patient to avoid
vigorous nose blowing, engaging in strenuous activity, lifting, and straining for 4-6
weeks. Teach the patient to use saline nasal spray and/or a humidifier, to sneeze with
the mouth open, and to avoid the use of aspirin-containing products or NSAIDS. (499)
Silver nitrate or backing for medical intervention.
Good understanding of impaired gas exchange in pneumonia. What kind of
interventions would nurse take to correct it? Impaired gas exchange high priority in
pneumonia. Think about O2 sats, interventions, and what could correct this. ✅-
Impaired gas exchange related to fluid and exudate accumulation at the capillary-
alveolar membrane.
-Abnormal ABGs with a decrease or normal Pa02, decrease in PaC02, and increase in
pH initially, and later a decrease in Pa02, increase in Pa02, and decrease in pH. (table
28-7)
-Interventions: Monitor physical assessment parameters, provide treatment and monitor
the patient's response to treatment. Along with physical assessment (including pulse
oximetry monitoring, prompt collection of specimens and initiation of antibiotics are
critical. Oxygen therapy, hydration, nutritional support, breathing exercises, early
ambulation, and therapeutic positioning are part of nursing management. Collaboration
with respiratory therapy for postural drainage and chest percussion is important. (528)
Elevate bed, turn 2 hours, ambulate
Note EARLY signs of hypoxia ✅-CNS: (EARLY) Unexplained apprehension,
unexplained restlessness or irritability, unexplained confusion or lethargy
-Respiratory: (EARLY) Tachypnea, dyspnea on exertion
-Cardiovascular: (EARLY) Tachycardia, mild hypertension, dysrhythmias
-Other: (EARLY and LATE) Diaphoresis, decreased urine output, unexplained fatigue.
What is an early sign of ventricular tachycardia? ✅-RESTLESSNESS!!! Low level of
02. Look for it.
Note s/s of long term COPD (584-585) ✅-Depression, anxiety. Feeling "down or blue"
most of the time.
-In late stages of COPD, dyspnea may be present at rest. Effective abdominal breathing
is decreased because of the flattened diaphragm from the overinflated lungs. The
person becomes more of a chest breather, relying on the intercostal and accessory
muscles.
-Wheezing and chest tightness may be present, but may vary by time of the day or from
day to day, especially in patient with more severe disease.
-The person with severe COPD frequently experiences fatigue, weight loss, and
anorexia. Paroxysms of coughing may be so severe the patient faints for fractures a rib.
-The anteroposterior diameter of the chest is increased "barrel chest" from chronic air
trapping. The patient may sit upright with arms supported on a fixed surface such as an
bedside table (tripod position).
-The patient may naturally purse lips on expiration (pursed-lip breathing) and use
accessory muscles, such as those in the neck, to aid with inspiration.
, -Edema in the ankles may be the only clue to right-sided heart involvement.
-Over time, hypoxemia (Pa02 less than 60 mm Hg or 02 saturation less than 88%) may
develop with hypercapnia (PaC02 over 45 mm Hg). The bluish red color of the skin
results from polycythemia and cyanosis.
-Polycythemia develops as a result of increased production of red blood cells as the
body attempts to compensate for chronic hypoxemia.
-Hemoglobin concentrations may reach 20 g/dL (200 g/L) or more.
What kind of care do you give a patient with COPD? What can you do as a nurse?
✅The overall goals of the patient with COPD will have:
(1) Prevention of disease progression
(2) Ability to perform ADLs and improved exercise tolerance
(3) Relief from symptoms
(4) No complications related to COPD
(5) Knowledge and ability to implement a long-term treatment regimen
(6) Overall improved quality of life (596)
-Health Promotion: QUIT SMOKING!!!
-Early diagnosis and treatment of respiratory tract infections and exacerbations of
COPD help prevent progression of the disease.
-Educate families about the genetic nature of the disease.
-Acute interventions for complications such as exacerbations, pneumonia, cor
pulmonale, and acute respiratory failure.
(Tertiary care) What would we be concerned about?
-That they can function! ADLs (brush teeth, walk around, feed themselves). These
individuals often have profound dyspnea upon exertion, nasal cannula, long stream
tubing to their 02 unit, have to navigate around their house. Can they go to the
bathroom? Can they care for themselves in any way? TRY TO IMPROVE THAT
FUNCTION! We can't change the architecture of their lungs, but we can help to improve
the quality of their life.
Know normal for ABG's and what would cause them to be abnormal. For example, know
why you would have a low pH or a high pH or a low PaC02. (304-305) ✅Normal ABGs:
pH: 7.35-7.45
Pa02: 80-100 mm Hg (*decreases with age, varies in relation to sea level)
Sa02: >95% (*decreases with age) (inaccurate if hemoglobin variants are present)
-Inaccurate if motion, low perfusion, anemia, cold extremities, bright fluorescent lights,
intravascular dyes, thick acrylic nails, and dark skin color.
PaC02: 35-45 mm Hg
HC03-: 22-26 mEq/L (mmol/L)
Side effect of morphine is more acidic. CO2 goes up Narcan is anecdote of morphine
Respiratory Acidosis: ✅Hypoventilation leads to the build up of C02, resulting in a
accumulation of carbonic acid in the blood. Carbonic acid dissociates, liberating H+, and
there is a decrease in pH. If C02 is not eliminated from the blood, acidosis results from
the accumulation of carbonic acid.
