respiratory system

Question 1

TB skin test

Answer 1

negative: redness without induration
positive: induration > 15 mm in healthy individuals

induration > 10 mm in immunocompromised pts

induration > 5 mm in high risk pts (e.g. HIV, organ transplant pts, pt had recent contact with TB)

Question 2

positive for TB

Answer 2

no symptoms –> chest x-ray

symptoms –> sputum culture

Question 3

types of TB

Answer 3

latent and active

Question 4

nursing for TB

Answer 4

airborne precautions, wear N95 mask

Question 5

latent TB

Answer 5

no symptoms, no sputum culture, not transmissible

Question 6

active TB

Answer 6

symptoms, positive sputum culture, transmissible

Question 7

flail chest

Answer 7

paradoxical respirations: chest moves in and out when breathing, pain, SOB, high HR, increased RR, decreased lung sounds

Question 8

nursing for flail chest

Answer 8

elevate HOB 30-45 degrees, O2, DB&C, prep for possible intubation

Question 9

nursing for influenza

Answer 9

lung sounds, fluids, meds (antipyretics, antivirals)

Question 10

pneumothorax

Answer 10

lung collapse due to air in pleural space

Question 11

types of pneumothorax

Answer 11

open, tension

Question 12

open pneumothorax

Answer 12

opening in chest area

Question 13

tension pneumothorax

Answer 13

injury to chest

Question 14

S/S of pneumothorax

Answer 14

no lung sounds on that area, SOB, pain, increased RR

Question 15

nursing for pneumothorax

Answer 15

chest dressing, O2, elevate HOB 30-45 degrees, prep for chest tube insertion

Question 16

nursing for asthma

Answer 16

airway patent, meds (corticosteroids to open airway)

Question 17

types ofCOPD

Answer 17

emphysema and bronchitis

Question 18

emphysema

Answer 18

damaged alveoli leading to impaired gas exchange

Question 19

bronchitis

Answer 19

airway filled with mucus

Question 20

s/s of COPD

Answer 20

wheezing, crackles heard upon auscultation of lung sounds, barrel chest,, respiratory acidosis

Question 21

nursing for COPD

Answer 21

keep SpO2 88-92%, administer meds (bronchodilators), ABG

Question 22

causes of pneumonia

Answer 22

bacterial, viral, fungal, aspiration

Question 23

nursing for pneumonia

Answer 23

C+S, droplet precautions, O2, LOC, DB&C, elevate HOB 30-45, chest physiotherapy to break up secretions, ensure good fluids, meds (antibiotics)

Question 24

PE

Answer 24

blockage in pulmonary artery

Question 25

s/s of pulmonary embolism

Answer 25

blood tinged sputum, SOB, high HR, high RR

Question 26

nursing for pulmonary embolism

Answer 26

elevate HOB, O2, ABG, meds (anticoagulants)

Question 27

empyema

Answer 27

pus in lungs

Question 28

nursing for empyema

Answer 28

elevate HOB, O2, DB&C, meds (antibiotics), drainage (e.g. via chest tube)

Question 29

pleural effusion

Answer 29

fluid in pleural space that stops lungs from being able to fully expand

Question 30

s/s of pleural effusion

Answer 30

SOB, decreased lung sounds in that area when auscultating,

Question 31

nursing for pleural effusion

Answer 31

elevate HOB, monitor lung sounds, prep for thoracentesis

Question 32

ventilator alarms

Answer 32

high pressure --> increased secretions, tube kinked, pt coughing low pressure --> tube disconnected, pt stopped breathing

Question 33

types of O2 delivery

Answer 33

nasal prongs: 1-6 L/min, can be used long-term face mask: 5-8 L/min, short-term O2, emergencies Venturi mask: 4-10L/min, respiratory failure partial rebreather mask: 6-15 L/min non-rebreather mask: 60-100%, deteriorating resp status

Question 34

chest tube suction type

Answer 34

wet and dry suction

Question 35

suction control chamber

Answer 35

wet: suction regulated by height of water dry: set by dial

Question 36

removal of chest tube

Answer 36

Valsalva maneuver and hold breath

Question 37

nursing for chest tube

Answer 37

keep system below pt

Question 38

if chest tube dislodged

Answer 38

cover with sterile dressing on all sides so air cannot get in

Question 39

drainage

Answer 39

colour, amount

Question 40

normal chest tube drainage

Answer 40

less than 100 cc/hr

Question 41

water seal chamber

Answer 41

water should fluctuate with every inspiration and expiration

Question 42

if no fluctuation in water seal chamber

Answer 42

kink, expanded lung

Question 43

how air leak shown?

Answer 43

bubbling if pt has pneumothorax, then intermittent bubbling is okay

Question 44

lung sounds

Answer 44

``` fine crackles: crackling, popping coarse crackles: crackling, popping wheeze: high pitched, musical sound ronchi: snoring stridor: life-threatening, obstruction in airway ```

Question 45

diseases with crackles

Answer 45

pneumonia, heart failure, pulmonary | edema

Question 46

diseases with wheezes

Answer 46

asthma

Question 47

nursing for wheezing

Answer 47

meds (albuterol)

Question 48

diseases with ronchi

Answer 48

bronchitis

Question 49

diseases with stridor

Answer 49

aspiration of foreign object, anaphylaxis, | epiglottitis