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VN 36 Med Surg 2 > Test 3 > Flashcards

Test 3 Flashcards

1
Q
  1. Rifampin Kill, hurt, know (K,H,K) (NURSE MIKE VIDEO)
A

• AE: red, orange body fluid are normal
o Wear glasses instead if contacts

• Client education: Oral contraceptive ineffective
o Use non-hormonal back up Birth control

• Nursing Actions: Monitor for Hepatotoxicity (jaundice)

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2
Q
  1. Chest Tube: Reason why they are having it (Slide 29)
A

• Drain fluid, blood or air
• Re-establish a negative pressure
• Facilitate lung expansion

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3
Q
  1. Chest tube nursing considerations (Slide 29)
A

• Monitor Vital Signs
• Monitor chest tube placement
• Provide rest periods
• Assess for abdominal distention (if they have this it can compromise respiratory status: it put pressure on the diaphragm)
• Monitor drainage: 70 ml/within 3 hours is average
• Assess for continual bubbling-is it on (make sure the machine is actually on)

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4
Q
  1. Post op sinus surgery nursing considerations (slide 4)
A

• Observe for repeated swallowing: hemorrhage
• Optic nerve function assessment
• Temperature every 4 hours; pain over involved sinuses
• Administer analgesics as indicated, ice compresses
• Nasal packing and dressing under nares (“moustache” or “drop pad”)

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5
Q
  1. Trach suctioning nursing considerations for Risk (Slide 12)
A

• Risk for Ineffective Airway Clearance

• Risk for Infection

• Risk for Ineffective Management of Therapeutic Regimen

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6
Q
  1. Trach suctioning nursing considerations for risk for ineffective airway clearance
A

o Vital Signs
o Breath sounds
o Assess skin color
o LOC
o Mental status
o Airway patency

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7
Q
  1. Trach suctioning nursing considerations: risk for infection
A

o Monitor stoma
o Provide routine tracheostomy care
o Position

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8
Q
  1. ABGs
A

• Ph: 7.35-7.45 (7.4 is neutral)
• PaCO3: 45-35
• HCO3: 22-26

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9
Q
  1. Emphysema manifestations (Slide 21 &22 & page 266 )
A

• Dyspnea especially- Exertional dyspnea, breathlessness at rest
• Chronic productive cough, pursed-lip breathing
• Expiration difficult, carbon dioxide narcosis
• Use of accessory muscles; Barrel-chested
• Clubbing of the fingers
• Shallow respirations

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10
Q
  1. Emphysema client education (Slide 21 &22 & page 266 )
A

-Success of treatment depends on strict adherence to the treatment regimen.
-Take medication exactly as prescribed. Observe the time intervals between medications.
-Do not skip doses or take more than what is prescribed.
-Maintain close medical supervision.
-Contact the primary provider if adverse drug effects occur, drugs fail to relieve symptoms, new symptoms appear, symptoms become more severe, or signs or symptoms of respiratory infection develop.
-Drink extra fluids as indicated, unless fluids are restricted.
-Avoid respiratory irritants and people with respiratory infections.
-Eat a well-balanced diet.
-Perform breathing exercises as prescribed.
-Take frequent rests during the day. Space activities to prevent fatigue and shortness of breath.
-Avoid dry-heated areas that can aggravate symptoms.
-Humidify inspired air during the winter months.

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11
Q
  1. Emphysema nursing management (Slide 21 &22 & page 266 )
A

• Monitoring: O2 and PaCO2 levels

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12
Q
  1. Asthma manifestations (slide 24)
A

• SOB
• Expiratory
• Wheezing
• Coughing
• Production of thick sputum
• Prolonged expiration

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13
Q
  1. Pleural effusion manifestations (Slide 31 & page 257)
A

• VN will hear decreased breaths sounds (dyspnea)
• Fever
• Pain

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14
Q
  1. Thoracentesis nursing actions (Page 234)
A

• Explain the procedure to the client.Reassure the client that they will receive local anesthesia. Explain that the client will still experience a pressure-like pain
• Assist client to an appropriate position (sitting with arms and head on padded table or in side-lying position on unaffected side).
• Instruct client not to move during the procedure, including no coughing or deep breathing.
• Provide comfort and Inform client about what is happening.
• Maintain asepsis and Monitor vital signs during the procedure
• During removal of fluid, monitor for respiratory distress, dyspnea, tachypnea, or hypotension.
• Apply small sterile pressure dressing to the site after the procedure.
• Position client on the unaffected side. Instruct client to stay in this position for at least 1 hour and to remain on bed rest for several hours.
• Check that a chest X-ray is done after the procedure.
• Record the amount, color, and other characteristics of fluid removed.

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15
Q
  1. Thoracentesis nursing actions; monitor signs (Page 234)
A

o Increased respiratory rate
o Asymmetry in respiratory movement
o Syncope or vertigo
o Chest tightness
o Uncontrolled cough or cough that produces blood-tinged or frothy mucus
o Tachycardia
o Hypoxemia.

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16
Q
  1. COPD nursing interventions (slide 20)
A

• Vaccination against complicating illnesses such as influenza and pneumonia
• Bronchodilator’s
• Raising the foot of the bed
• Humidifier’s in dry settings
• Can lead to right sided heart failure
• Increase water intake to thin secretions
• High protein diet
• Cough every 2hours to clear secretions

17
Q
  1. Nosebleed nursing interactions (Slide 32)
A

• Tilt head forward
• Apply pressure and ice pack
• If unable to stop can insert tampon
• Cauterization if needed

18
Q
  1. Salmeterol K,H,K (DRUG CARD)
A

Use: Asthma and COPD “Long acting

Manifestations:
• Tachycardia
• Toss and turn (restlessness at night)
• Tremors

Client education:
• Don’t take it at night
• Never used alone, always with other medication

19
Q
  1. Pulmonary embolism manifestations (slide 27)
A

• Immediate onset: pain
• Tachycardia
• Dyspnea
• Fever
• Cough
• Blood-streaked sputum
• Cyanosis
• Irregular heart rate
• Wheezing
• FOID

20
Q
  1. Pulmonary embolism nursing actions (slide 27)
A

• Prevention of DVT to prevent PE

• Nursing priorities is always O2

21
Q
  1. Cystic Fibrosis client education (slide 26)
A

• Engage in daily aerobic exercises

22
Q
  1. Pyrazinamide K,H,K (pharm book page 121)
A

Adverse reactions:
• HEPATOTOXICITY (monitor LFT and jaundice)
• Nausea/vomiting
• Epigastric distress
• Myalgia
• Rash

Contraindication
• Acute gout and gout medication (allopurinol “Zyloprim”, colchicine, or probenecid)

Client education:
• Taken with food

23
Q
  1. Pneumonia nursing intervention (slide 16)
A

• Respiratory assessment:
o Lung Sounds (definite dx is chest x-ray)
o Pulse oximetry
o ABGs

• Coughing and sputum assessment: position
o Semi-FOWLER’S (raise head of bed)

• Pneumococcal vaccine

24
Q
  1. Fractured ribs nursing interventions(Slide 32)
A

• Airway management
• Emergency treatment
• Pain management
• Incentive spirometer
• Splinting devices like pillows with deep breathing and coughing
• Want to maintain expansion so no devices that constrict.

25
Q
  1. Lung Cancer manifestations early (Slide 31)
A

o Chronic cough
o Dyspnea
o Hemoptysis
o Shoulder or chest pain
o Intermittent temperature
o Reoccurring respiratory infections

26
Q
  1. Lung Cancer manifestations late (Slide 31)
A

o Bone pain
o Chest pain
o Dysphagia
o Blurred vision
o Weight loss
o Pleural effusion-VN will hear decreased breath sounds

27
Q
  1. Isoniazid K,H,K (DRUG CARD & NURSE MIKE)
A

Used for Active TB

Manifestations:
• Peripheral neuropathy (report numbness, tingling, or ataxia in the extremities)
• Hepatotoxicity (Monitor AST & ALT, jaundice, dark urine, fatigue)

Client education:
• NO ETOH
• Take VB6 supplements 25-50mg daily (Interferes with B6 absorption)

28
Q

Ethambutol: (NURSE MIKE)

A

• Report blurred vision or color changes
• Client education: routine eye exams

29
Q
  1. Trach Care
A

• Gather supplies & put on gloves
• Remove oXygen source if necessary
• Dip cotton tipped applicator or gauze sponge in cup or basin w/sterile saline & clean stoma under faceplate.
• Use each applicator or sponge only once, moving from stoma site outward
• Pat skin gently dry 4x4 gauze sponge
• Slide non cotton 4x4 dressing under the faceplate
• Change the trach collar
• Make sure to always hold faceplate when inserting the tabs of the collar
• Check the fit of the trach collar (should be able to fit one finger between the neck & collar), also make sure client can flex neck comfortably
• Reapply oxygen source if necessary
• Reassess the patients respiratory status (RR, respiration effort, oxygen sat & lung sounds)

VN 36 Med Surg 2 (11 decks)

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