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Flashcards in NR 462: Exam 2 Deck (129):
1

Hypoxia Signs/Symptoms

RAT BED

Early Signs:

  • Restlessness
  • Anxiety
  • Tachycardia/Tachypnea

Late Signs:

  • Bradycardia
  • Extreme Restlessness
  • Dyspnea

2

Important assessments obtained during a focused respiratory assessment include

  • auscultation of lung (breath) sounds.

3

as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration

Crackles

4

Presence of acid-fast bacilli in the sputum indicates

active tuberculosis.

5

decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath

Hypoxia

6

strongly binds to hemoglobin, making it unavailable for oxygen binding and transport

Carbon monoxide

7

When the body cannot meet the increased oxygenation need, what happens?

  • increased metabolic rate
  • breakdown of protein and wasting of respiratory muscles,
  • increasing the work of breathing.

8

Saline has been found to cause more side effects when...

  • suctioning and does not increase the amount of secretions removed.

9

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?

Incentive spirometer

10

What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia?

Fingernails and their base

11

is used to distinguish benign and malignant pulmonary nodules

Positron emission tomography (PET)

12

involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax.

Thoracentesis

13

Postoperatively there is an increased risk for

  • atelectasis from anesthesia
  • restricted breathing from pain.

14

he nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to a 35-year-old female employee. Which question should the nurse ask before administration of this vaccine?

Could you be pregnant now?

15

Clear nasal drainage suggests leakage

  • of cerebrospinal fluid (CSF), presence of glucose
  • A drip pad may be applied, but the patient should not be reassured that this is normal.

16

The patient seeks relief from the symptoms of an upper respiratory infection (URI) that has lasted for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis?

Maxillary Pain

17

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect?

Gastrostomy tube
because the effects of treatment make it difficult to take in enough nutrients orally

18

A patient with a history of tonsillitis complains of difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse?

Contraction of neck muscles during inspiration

19

The school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus?

  • Cover the nose when coughing.

  • Obtain an influenza vaccination.

  • Stay at home when symptomatic.

20

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do

  1. adequate fluid intake
  2. Splint the chest when coughing.
  3. Instruct patient to cough at end of exhalation

21

What precautions is influenza

Droplet

22

What is the perimeter of droplet

5' perimeter

23

A flu patient developed crackles in the lungs, what have they developmed

Pneumonia

24

physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance?

Respiratory Rate 28

25

Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia?

Increased vocal fremitus on palpation, bronchial breath sounds, egophony, and crackles in the affected area

26

What is the priority nursing intervention in helping a patient expectorate thick lung secretions?

Increase fluid intake to 3 L/day if tolerated.

27

An increased risk of pulmonary embolism is associated with

  • obesity
  • malignancy
  • heavy cigarette smoking
  • prolonged air travel with reduced mobility

28


When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication?
 

Antibiotic

29

Hypertension- Nursing Care

 

DIURETIC

  • Daily Weight
  • Intake and Output (I & O)
  • Urine Output
  • Response of BP
  • Electrolytes
  • Take Pulses
  • Ischemic Episodes (TIA)
  • Complications:

 

30

Collapsed Alveoli

Atelectasis

31

Hyptertension Complications 4C's

  • Coronary Artery Disease
  • Coronary Rheumatic Fever
  • Congestive Heart Failure
  • Cerebral Vascular Accident

 

32

Create labs for someone with metabolic acidosis

low pH low HCO3

33

Labs for someone with Metabolic Alkalosis

High pH High HCO3

34

Respiratory Acidosis Labs

  • pH Low
  • PCO2 High

35

Normal Value for HCO3

22-26

36

Normal Value PCO2

34-45

37

Lab values when only partially compensated

all three values will be abnormal. One value will be working harder to compensate.

38

Lab Value when fully compensated

pH will be normal

39

Diseases that can cause Acid Base Imbalances

  • COPD
  • Pulmonary Edema
  • Pneumonia
  • Hyperkalemia-Acidosis,
  • Hypokalemia Alkalosis,

40

Step 1: Blood has cicrulationg through the body, lost its oxygen and collected CO2, where does it enter?

  • Right Atrium of the heart through the Vena Cava

41

Step 2: Right Atrium Contracts and pumps blood through which valves?

Tricuspid valve and right ventricle

42

Step 3 of 9: The Right Ventricle pumps blood where?

  • Through the pulmonary artery into the lungs

43

 Step 4: What do the tiny blood vessels (capillaries) in the lungs do?

 

absorb CO2 from blood and replace it with oxygen

44

Step 5: oxygenated blood flows through the pulmonary vein and into where?

  • Left Atrium

45

Step 6: Oxygenated blood pumps throu the mitral valve and into where?

Left Ventricle

46

Once the blood has gone through the aortic arch, what are the option for where blood can be pumped?

  • thru carotid artery into the brain
  • auxiliary arteries into the arms
  • aorta and into the torso/legs

47

Step 8: Blood moves through the arteries, then through capillaries, where does it return?

Veins

48

Step 9: What is the last step of the cardiac cycle?

Deoxygenated blood will return to the heart

49

this pumps blood to pulmonary circulation

right ventricle

50

pumps blood to the systemic circulation

 

left ventricle

51

this is a valve between LA & LV

Mitral Valve

52

Valve betwee RV & Pulmonary Aorta

pulmonic valve

53

Contraction of Myocardium

Systole

54

Relaxation of Myocardium

 Diastole

55

Normal Value for Mean Arterial Pressure

Must be greater than 60

56

as the average pressure in a patient's arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure (SBP).

Mean Arterial Pressure

(CO X Systemic Vascular Resistance) + Central Venous Pressure

57

Amount of blood ejected from the left ventricle with each beat

Stroke Volume

58

How much output of blood does the heart put out

4-6 liters

59

peptide hormone secreted by the cardiac that in pharmacological doses promotes salt and water excretion and lowers blood pressure

natriuretic peptide

60

this hormone lives in the Atria

a- natriuretic peptide

61

This hormone lives in the ventricle

B-natriuretic peptide

62

What happens to heart function in older adults?

  • the heart muscles decrease
  • become stiff
  • Need for pacemakers

63

What drug are older adults are less sensitive to?

Beta Adrenergic Agonist Drugs

64

Define Preload

  • How much the heart stretches before it contracts
  • higher the preload, the harder the heart has to work

65

What is another name for preload

End Diastolic Volume

66

Define Afterload

  • the tension developed in the wall of the left ventricle during ejection.

67

Good Cholesterol

HDL

68

Bad Cholesterol

LDL

69

Why would you test CBC for a patient with Anemia?

  • would have low red blood cells
  • would have a hard time carrying oxygen
  • Tachycardia

70

Define Hypertension

Force exerted by the blood against the walls of the blood vessel. No symptoms. (sys above 140, diastole above 90)

71

Modifiable Risk factors of hypertension

  • sodium intake
  • smoking
  • stress

72

Non Modifiable Risk factors for hypertension

  • Family History
  • African American

73

Symptoms of Hypertension

  • "silent killer"
  • Any damage from high BP
  • dizziness
  • Headache, pressure in the brain
  • Fatigue
  • Dyspnea
  • Problems w/ retina

74

Assessing someone with Hypertension

  • Health HX
  • Phys Exam
  • BP in both arms
  • Manual BP
  • Patient should be seated quietly for 5min
  • Take 2 Measurements

75

Goal for patient with Hypertension

  • Control BP
  • Reduce CVD Risk Factors

76

Nursing Inverventions for someone with Hypertension

  • empathy
  • motivation/adherence to therapy
  • consider cultural beliefs
  • Taking meds

77

Menu for someone with Hypertension

  • DASH diet
  • Fish every week
  • Fruits, Vegetable
  • Lots of Water
  • Potassium
  • Low Sodium

78

What is a hypertension Crisis?

  • Diastolic blood pressure above 140.

  • Not taking meds or undermedicated.

  • Treat it with IV. Monitor bp.

79

#1 Drug for Hypertension

Diuretics

80

Right Sided Heart Failure

  • Chronic Respiratory Problems
  • Ascites
  • Cor Pulmonal
  • Weight Gain
  • MI
  • Ab Pain
  • JVD
  • Hepatomegaly
  • Peripheral Edema

81

Left Sided Heart Failure

  • Most Common
  • Pulmonary Congestion
  • Crackles
  • Poor Oxygenation
  • S3, Increase Afterload
  • Irregular Palpitations
  • Pulmonary Edema
  • Diastolic and systolic dysfunction
  • Blood backing up into right atria

82

Diastolic Failure

  • Ventricles become stiff, cannot relax
  • Normal Ejection Fraction
  • Low BP
  • Low Cardiac Output
  • Pulmonary Congestion
  • Poor Exercise Tolerance

83

Systolic Fairure

  • Ventricles Swell
  • Decrease in left ventricular ejection fraction

84

Normal Ejection Fraction

55%

85

Difference between Left Sided Heart Failure Vs. Right Sided Heart Failure

  • RT- Peripheral Edema
  • LF- Pulmonary Edema

86

Diagnostic Testing for Heart failure

  • BNP
  • ANP
  • Creatnine Kinase
  • Troponin
  • Fibronogen
  • Chest Xray
  • EKG
  • Coronary Angiogram
  • Echogram

87

What is the exercise stress test for heart failure

  • Put them on a treadmill 5 min
  • walk test
  • pass/fail

88

Clinical Manifestation of Acute Decompensated Heart Failure

  • Dyspnea,
  • orthopnea
  • fatigue
  • Paroxysmla Nocturnal dyspnea
  • Waking up feeling like their suffocations, because of reabsorption of fluid.
  • Persistent dry cough.
  • Frothy (bubbly) blood tinged sputum (pink).
  • Cyanoisis
  • Clammy Skin

89

sample list of vital signs for a patient in distress ADHF

  •  Irregular pulse
  • low urine put
  • Weight gain
  • Fluid retention
  • Anorexia

90

Nursing Diagnosis for a patient with heart failure

  • Activity Intolerance

  • Fluid Volume Excess

  • Impaired Gas exchange.

91

Goals for a patient with Heart Failure

  • Decrease Intravascular Volume (diuretics)
  • Decrease Preload
  • Decrease After load (vasodilation)
  • Reduce Anxiety

92

Patient positions for a patient with high fowlers

High Fowlers

93

Aneurism Definition

weakend blood vessel

94

What are outcomes of ventricular dysfunction

  • Diminished Quality of Life
  • Reduced Exercise Tolerance

95

Ejection Fraction Definition

  • Fraction of blood pumped out for the ventricle with each heart beat
  • Applies to right and left
  • SV/End Diastolic Volume

96

Complications of Heart Failure

  • Pleural Effusion
  • Fatal Dysrrythmias
  • AFib
  • Respiratory Acidosis

97

Define Ventilator Acquired Pneumonia

  • 48 hours after intubation, before the onset of the event

98

Aspiration Pneumonia Definition

  • Aspirated something into their lungs

  • Decreased LOC

99

Hospital Acquired Pneumonia

  • Occurring 48 hours or longer after admission
  • Not incubating at time of hospitalization

100

Causes of Pneumonia

  • Smoking
  • Secondhand smoke
  • Asthmna
  • Genes
  • pollution and fumes

101

COPD Patient Assessment

  • Use Pursed Lipped Breathing
  • Use Oxygen as prescribed
  • Close ended question
  • High Fowlers, Orthopnea, Tripod
  • Chest percussions
  • Respiratory Rate
  • Lung Sounds
  • Heart Rate increased
  • Sputum culture in the morning
  • 6-8 wks deep breathing exercises

102

Nutrition w/ COPD patient

  • adequate fluid intake
  • Small meals more frequently

  • Avoid foods that cause gas

  • High Calorie

  • High Protein diet

  • Instructo to cough at end of exhalation

103

Signs of COPD

  • productive cough for 3 or more months in each of 2 successive years
  • Dyspnea
  • Chronic Fatigue
  • Bluish Red Color Skin
  • Pulmonary Hypertension

104

Describe the patient with advance COPD and Cor Pulmonale

  • Damaged to lung tissue

  • Acute respiratory failure

  • Depression/anxiety.

  • Anger.

  • Pulmonary Hypertension.

105

right sided heart failure caused from pulmonary hypertension. Caused from COPD

Cor Pulmonale

106

nursing diagnosis for a patient with advanced respiratory diseases.

  • Hyperthermia Related to Infectious Illness,
  • ineffective airway clearance,
  • pneumonia
  • pulmonary embolism
  • Activity Intolerance
  • Inadequate Nutrition
  • Social Isolation
  • Impaired Gas Exchange.
  • Anxiety.
  • Risk for Infection
  • Ineffective Coping
  • Fatigue.
  • Ineffective Breathing Pattern
  • Insomnia

107

movement of air into and out of lungs

Ventilation

108

Movement of blood through the lungs. Blood clot blocks

Perfusion

109

movement of gases between the lung and blood. Heart Failure.

Diffusion

110

Maximum airflow rate during forced expiration.

Peaked Expiratory Flow rate, (every asthma patient)

111

the greatest volume of air that can be expelled from the lungs after taking the deepest possible breath

vital capacity

112

measures how much air a person can exhale during a forced breath.

Forced Expiratory Volume

113

Define Stage 1 Hypertension

SBP between 140 and 159 mm Hg or DBP between  90 and 99 mm Hg.

114

Define Stage 2 Hypertension

SBP 160 mm Hg higher or DBP 100 mm Hg or higher.

115

Treating Heart Failure Mneumonic

  • Upright
  • Nitrates
  • Lasix
  • Oxygen
  • Ace Inhibitors
  • Digozin
  • Fluids (decrease)
  • Afterload (decrease)
  • Sodium Restriction
  • Test (Dig, ABG, K)

116

CORE measures x4

  1. Angiotensin Converting Enzyme Inhibitor LVSF
  2. LVG assessment
  3. Smoking cessation counceling
  4. HF discharge instructions

117

A patient with an acid-base imbalance has an altered potassium level. The nurse recognizes that the potassium level is altered because:

 

Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells.

118

A patient has the following arterial blood gas (ABG) results: pH 7.48, PaO2 86 mm Hg, PaCO2 44 mm Hg, HCO3 29 mEq/L. When assessing the patient, the nurse would expect the patient to experience:

Hypertonic muscles with cramping.

119

What is elastic recoil

Negative pressure in the lungs. Suctioning

120

Acid Base imbalances from Lung Diseases

  • COPD
  • Pneumonia
  • Pulmonary Edema
  • Pulmonary Embolism

121

Acid Base Imbalances From Kidney Disease

  • DiabetesHypertension, kidney disease, nephrotoxic drugs, congenital renal disease

122

myocardial muscle protein released after injury or infarction

Troponin

123

What happens to a patient's acid base imbalance when in cardiac arrest

Acidosis

124

Describe the purpose of pursed lip breathing in the COPD Patient

To reduce overall work of brathing

125

A patient with heart disease has developed pulmonary edema w/ difficulty breathing. The nurse notes that the patient is breathing at a rate of 28/min and has oxy sat of 90% on room air.  Which best describes the first response of the nurse?

administer oxygen through a face mask to correct saturation levels

126

Causes for dyspnea

  • obesity
  • Heart Disease
  • Arrhythmias
  • Asthma
  • COPD
  • Bronchiectasis

127

A nurse is reviewing principles of good nutrition for a patient w COPD. What suggestion regarding nutrition would support the health of the patient w/ COPD

Achieve and maintain a healthy weight

obesity contributes to complications of COPD

128

This is a type of heart catheterization procedure. A type of dye that's visible by an X-ray machine is injected into the blood vessels of your heart.

Coronary Angiogram

129

This is an enzyme found in the heart, brain, skeletal muscle, and other tissues. Increased amounts are released into the blood when there is muscle damage.

Creatnine Kinase