Question 1

Ineffective Airway Clearance Causes

Accepted Answer

Ineffective cough Foreign object aspiration Respiratory muscle fatigue Severe Bronchospasm Thick/ tenacious secretions

Question 2

Ineffective Airway Clearance Signs and Symptoms

Accepted Answer

Abnormal Breathing sounds Abnormal RR, Rhythm, Depth Dyspnea Excessive Secretions Hypoxemia Ineffective or Absent cough Orthopnea

Question 3

Ineffective Airway Clearance Interventions if due to tenacious secretions?

Accepted Answer

Encourage Fluids Humidifier Mucolytic CPT

Question 4

Ineffective Airway Clearance Interventions if due to cough?

Accepted Answer

Teach proper coughing technique Quad and Huff techniques If both are ineffective, require suctioning

Question 5

Ineffective Airway Clearance Intervention if due to foreign body aspiration?

Accepted Answer

Abdominal Thrusts

Question 6

Impaired Gas Exchange Causes

Accepted Answer

Conditions that causes collapse of alveoli Altered oxygen carrying capacity of the RBCs High altitudes Hypo/ Hyperventilation

Question 7

Impaired Gas Exchange Signs and Symptoms

Accepted Answer

Hypoxemia Hypoxia Abnormal Breathing pattern Altered ABG Restless Cyanosis Dyspnea Coughing Nasal Flaring Use of accessory muscles

Question 8

Impaired Gas Exchange Interventions

Accepted Answer

Raise HOB to high fowler's position Administer O2 Ambulate as tolerate TCDB Position in tripod if acute distress occurs

Question 9

Ineffective Breathing Pattern Causes

Accepted Answer

Trauma Brain damage Pain Obstruction Anxiety Ascites Fluid overload

Question 10

Ineffective Breathing Pattern Signs and Symptoms

Accepted Answer

Abnormal rate and rhythm Bradypnea/ Tachypnea Nasal Flaring Orthopnea Pursed Lip Breathing Accessory Muscle use

Question 11

Ineffective Breathing Pattern Interventions

Accepted Answer

Position Upright IS Diaphragmatic Breathing Suction as Needed Mechanical Ventilation may be required Pursed lip breathing

Question 12

Impaired Tissue Perfusion Causes

Accepted Answer

Arterial Disease Venous Insufficiency Heart failure Local injury Embolism Compartment Syndrome Hypovolemia

Question 13

Impaired Tissue Perfusion Signs and Symptoms Cardiopulmonary

Accepted Answer

Chest pain Acute Respiratory distress Dyspnea Pallor Decreased O2 Stats

Question 14

Impaired Tissue Perfusion Signs and Symptoms Cerebral

Accepted Answer

ALOC

Question 15

Impaired Tissue Perfusion Signs and Symptoms GI

Accepted Answer

Decreased Peristalsis

Nursing Diagnoses Flashcards

(26 cards)