NSG3130/ NSG 3130 Exam 4 V2 Final Prep 2026/ 2027 | Nursing Practice II (Galen) | Full Study Guide & Practice Questions

NSG3130/ NSG 3130 Exam 4 V2 Final Prep 2026/ 2027 | Nursing Practice II (Galen) | Full Study Guide & Practice Questions Match the description/definition in Column A with the correct term in Column B. Column A 1. A general term used for a group of disorders characterized by impaired airflow in the lungs ______ 2. An inflammation of the larger airways, increased production of mucus, and chronic cough ______ 3. An enlargement of small air sacs on the distal end of terminal bronchioles ______ 4. A reaction of airways to stimulation by irritants, allergens, pollutants, or cold air through constriction and spasms ______ 5. An infection in the lungs Column B a. Asthma b. Emphysema c. Pneumonia d. Chronic bronchitis e. Chronic obstructive pulmonary disease (COPD) 1. A general term used for a group of disorders characterized by impaired airflow in the lungs ______e. Chronic obstructive pulmonary disease (COPD) 2. An inflammation of the larger airways, increased production of mucus, and chronic cough ______d. Chronic bronchitis 3. An enlargement of small air sacs on the distal end of terminal bronchioles ______b. Emphysema 4. A reaction of airways to stimulation by irritants, allergens, pollutants, or cold air through constriction and spasms ______a. Asthma 5. An infection in the lungs______c. Pneumonia Complete the following: The new graduate nurse is performing tracheal suctioning. Evaluate the following nursing actions. Each row must have only one response option selected. Nurse's Actions Safe/ Appropriate Requires Correction Positioning the unconscious patient flat ○ ○ Using a water-soluble lubricant on first 15 cm of the catheter prior to nasopharyngeal suction ○ ○ Instilling saline into the trachea to help remove secretions ○ ○ Setting the suction at 80 to 120 mm Hg continuous ○ ○ Only suctioning during removal of the catheter ○ ○ Performing nasopharyngeal suctioning after oral suctioning ○ ○ Using clean gloves for the procedure ○ ○ Oxygenating the patient throughout the procedure, as necessary ○ ○ Positioning the unconscious patient flat ○ ○ Requires Correction Using a water-soluble lubricant on first 15 cm of the catheter prior to nasopharyngeal suction ○ ○ Safe Instilling saline into the trachea to help remove secretions ○ ○ Requires Correction Setting the suction at 80 to 120 mm Hg continuous ○ ○ Safe Only suctioning during removal of the catheter ○ ○ Safe Performing nasopharyngeal suctioning after oral suctioning ○○ Safe Using clean gloves for the procedure ○ ○ Requires Correction Oxygenating the patient throughout the procedure, as necessary ○ ○ Requires Correction Identify cardiovascular alterations that can influence oxygenation. Oxygenation can be influenced by atherosclerosis, arterial spasm or malformation, blood clots, dysrhythmias, valvular issues, heart failure, and trauma. What are the possible causes of the following disorders? a. Emphysema— b. Pneumonia— c. Atelectasis— a. Emphysema—caused by smoking, exposure to pollution, or family history b. Pneumonia—caused by an infectious agent or aspiration c. Atelectasis—caused by decreased diaphragmatic movement and hypoventilation Choose the most appropriate responses for the information missing from the statement by selecting from the lists of options provided. The patient with _________a___________ and ___________a_________ may experience ________b___________ as a result of limited thoracic movement. The patient with scoliosis and kyphosis may experience hypoventilation as a result of limited thoracic movement. Need to include the Options box that appears in the chapter. It should be placed underneath the sentence Identify at least five assessment questions that the nurse should ask the patient in regard to cardiopulmonary function. The nurse should ask about chest pain, shortness of breath, dyspnea, weight gain/loss, appetite, dizziness, blood clots, weakness/fatigue, persistent cough, sleep and exercise habits, and a history of smoking or cardiopulmonary disease. For the physical assessment, which areas will the nurse focus on to determine the patient's oxygenation status? For the physical assessment, the nurse should obtain vital signs, auscultate heart and lung sounds, evaluate peripheral pulses, and observe for changes in the skin (hairless, shiny extremities) or structure (barrel chest) that would indicate alterations. Define the following terms: a. Cyanosis— b. Hemoptysis— c. Hypercapnia— d. Arrhythmia— e. Necrosis— f. Hypoxemia— a. Cyanosis—bluish discoloration of the skin related to deoxygenation of hemoglobin b. Hemoptysis—blood in the sputum c. Hypercapnia—an abnormally high level of carbon dioxide in the blood d. Arrhythmia—abnormal rhythms of the heart e. Necrosis—tissue death f. Hypoxemia—low level of oxygen in the blood For the patient with emphysema: a. The results of the forced vital capacity (FVC), forced expiratory volume (FEV1), and forced expiratory flow (FEF) are expected to be _____________ than normal. b. The results of the residual volume (RV) and functional residual capacity (FRC) are expected to be _________ than normal. a. Lower/less than normal. b. Higher/more than normal Identify which of the following statement(s) about laboratory results is (are) accurate. Select all that apply. a. Hemoglobin levels may be elevated for the patient with heart failure. _____ b. The desired value for low-density lipoprotein (LDL) cholesterol is greater than 200 mg/dL. _____ c. Cardiac enzyme levels (T and I proteins) will increase 4 to 6 hours after a myocardial infarction (MI). _____ d. Carbon dioxide levels are increased in patients with chronic obstructive pulmonary disease (COPD). _____ e. Potassium levels will be higher in patients taking diuretics, like furosemide (Lasix). _____ c. Cardiac enzyme levels (T and I proteins) will increase 4 to 6 hours after a myocardial infarction (MI). d. Carbon dioxide levels are increased in patients with chronic obstructive pulmonary disease (COPD). What abnormalities can be found with a chest radiograph? Abnormal findings on a chest radiograph are rib fractures, tumors, pneumothorax, pneumonia, pleural effusion, pericardial effusion, enlarged heart, and atelectasis. What concerns does the nurse have for the patient undergoing a cardiac catheterization? For the cardiac catheterization, the patient will have a contrast dye injected, which could result in an allergic reaction. The nurse also has to monitor for bleeding and circulation to the extremity used for access. Identify at least three nursing diagnoses/hypotheses related to oxygenation. -Ineffective Gas Exchange -Insufficient Airway Clearance -Activity alteration -Altered Breathing Pattern -Ineffective Peripheral Tissue Perfusion Identify at least two related goal/outcome statements for patient oxygenation. -Patient will maintain SpO2 at 92% or greater by the end of the shift. -Patient's lungs will be clear to auscultation within 24 hours. Patient will maintain SpO2 at 92% or greater with activity within 48 hours. -Patient will report decreased fatigue during hospitalization. Patient will demonstrate a breathing cycle that returns to a normal pattern after aerosol treatments. after supplemental oxygen is applied. administered before cardiac catheterization. What measures can the nurse implement to promote a patient's oxygenation? Measures to promote oxygenation include positioning in semi- or high-Fowler position, providing oxygen, maintaining airway clearance, instructing the patient in respiratory exercises (deep breathing, coughing, incentive spirometer use), providing adequate hydration, allowing for rest periods in between activities, and administering medications to improve cardiovascular and pulmonary function. Oxygen saturation should be at a minimum of ____%. 90%. What is required when oxygen is going to be used by a patient at home? The patient needs to have an order from the PCP, be instructed in the proper use and storage of the oxygen, have signs for "No Smoking," and determination of the type of delivery device and tubing. For the Quality and Safety Education for Nurses (QSEN) competency of Teamwork and Collaboration, what other health team members will most likely be involved in the care of a patient with an oxygenation deficit? The health team members involved will most likely be the nurses, respiratory therapist, PCP, speech therapist (aspiration risk), and physical therapist (increase activity tolerance). The patient is admitted to the hospital with an exacerbation of his emphysema. The patient's wife asks why the oxygen level is "not turned up high" to help her husband breathe better. The nurse responds by explaining to the patient's spouse: The nurse should tell the patient's wife that the higher levels of oxygen may create respiratory depression. In patients with emphysema who have high levels of carbon dioxide, low oxygen levels drive respiration. Higher amounts of oxygen will drop the respiratory rate. Indicate safety considerations associated with the oxygen delivery methods pictured: Nasal cannula Indicate safety considerations associated with the oxygen delivery methods pictured: Simple face mask a. Continuous positive airway pressure (CPAP) is used for: b. Barriers to CPAP compliance include: c. What is the difference between CPAP and biphasic positive airway pressure (BIPAP)? a. CPAP is used for treating obstructive sleep apnea and for preventing atelectasis. b. Barriers to compliance are dry nares, skin irritation, claustrophobia, perception of an inability to breathe, and noise of the device. c. BiPAP provides two pressures—higher during inhalation and lower during exhalation, whereas CPAP maintains the same pressure throughout. When would a bag-valve-mask (BVM) be used? A bag-valve-mask (BVM) or Ambu bag is used to ventilate and oxygenate a patient who needs ventilatory support in an emergency situation. What emergency equipment should be in the room of a patient with a tracheostomy? The following equipment should be in the room of a patient with a tracheostomy: • Bag-valve-mask (Ambu bag) • Endotracheal and oropharyngeal suction equipment • Waterproof adhesive tape • An extra tracheostomy care kit • Two extra inner cannulas (one the same size as worn by the patient, and one a size smaller) • Two extra outer cannulas (one the same size as worn by the patient, and one a size smaller) with obturators • Scissors • Velcro tracheostomy tube holder and/or ties • Oxygenation equipment What is observed with the following? a. Electrocardiogram (ECG) b. Echocardiogram a. ECG—used to determine electrical activity in the heart. b. Echocardiogram—used to observe for movement of blood in the heart and to measure cardiac output. Indicate interventions that can be used to promote cardiopulmonary function. Interventions to assist patients with cardiopulmonary function include: • Diets high in fiber and low in fat • Exercise • Medications • Chest physiotherapy • Antiembolism stockings • Sequential compression device • Smoking cessation • Immunizations • Chest tubes, tracheostomies, airways, suctioning • Stress management Identify at least three classifications of medications that are expected to be part of the treatment for: a. Pulmonary disease b. Cardiovascular disease Medications to be expected are: a. Pulmonary disease—bronchodilators, anticholinergic agents, corticosteroids, vaccines, antibiotics, mucolytic therapy, leukotriene modifiers b. Cardiovascular disease—diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, beta blockers, calcium channel blockers, alpha-1 antagonists, alpha-2 agonists, vasodilators, antiarrhythmics, anticoagulants An unlicensed assistive personnel (UAP) is checking on the patient with a nasopharyngeal airway who has oxygen in place and requires frequent suctioning. What do you tell the UAP to report to you regarding this patient's status? The UAP is instructed to report on the following: • Changes in vital signs, respiratory status, or level of consciousness • Pain or discomfort noted by the patient • Skin breakdown • Excessive secretions • Difficulties encountered with any of the treatments The patient who needs nasotracheal suctioning has an excessive amount of secretions. How does the nurse ventilate this patient before suctioning? For a patient with excessive secretions, presuctioning ventilation is done with a tracheostomy oxygenation mask set for 100% FiO2 for several respiratory cycles. The nurse recognizes that suctioning through the patient's nares is contraindicated for the patient who has which of the following? Select all that apply. a. Epistaxis _____ b. Chronic obstructive pulmonary disease _____ c. Coagulation disorder _____ d. Reactive airway disease _____ e. An upper neck injury _____ f. Hypertension _____ a. Epistaxis c. Coagulation disorder d. Reactive airway disease e. An upper neck injury To clear the suction catheter and check that the suction is functioning, the nurse uses: Sterile normal saline solution is used to clear and check the suction catheter Diet therapy for the patient with cardiopulmonary disease should include: Diet therapy includes a high-fiber, low-fat, and usually a modified-sodium diet (cardiovascular alterations). Identify the pressure to be set for airway suctioning. Suction should be set at 80 to 120 mm Hg continuous. Identify the correct sequence for cleaning the tracheostomy once the sterile field and solutions are prepared. a. Gently clean the outer area of the tracheostomy from the stoma outward. b. Clean the inner cannula, if nondisposable. c. Apply sterile gloves. d. Pat the outer area of the tracheostomy dry with sterile gauze. e. Dip the cotton swab into the sterile normal saline solution. c. Apply sterile gloves. e. Dip the cotton swab into the sterile normal saline solution. a. Gently clean the outer area of the tracheostomy from the stoma outward. d. Pat the outer area of the tracheostomy dry with sterile gauze. b. Clean the inner cannula, if nondisposable. For a patient with a chest tube, indicate what the nurse should do for the following: a. Positioning for a patient with a pneumothorax— b. Bubbling in the water-seal chamber— c. Drainage is collecting in the coiled tube— d. The chest tube is pulled out— e. Assessment of the drainage system should be done at least every _____ hours or per agency policy. a. Semi-Fowler position is used for a pneumothorax. b. Notify the PCP if bubbling is occurring in the water-seal system. c. Lift up the tubing to clear the drainage. Do not lift the system above chest level. d. Immediately cover the insertion site with an occlusive dressing. Notify the PCP immediately. e. Every 4 hours is a minimum period of assessment. Which of the following is an invasive diagnostic test? a. ECG b. Echocardiogram c. Chest radiograph d. Cardiac catheterization d. Cardiac catheterization The patient has experienced a myocardial infarction resulting in damage to the left ventricle. A possible complication the patient may experience that the nurse is alert to is which of the following? a. Jugular neck vein distention b. Pulmonary congestion c. Peripheral edema d. Liver enlargement b. Pulmonary congestion Which one of the following actions is appropriate for a patient with a chest tube? a. Milking or stripping the tubing to remove drainage. b. Keeping the drainage collection device above chest level. c. Monitoring the patient every 8 hours. d. Reinforcing the dressing as needed. d. Reinforcing the dressing as needed. All of the following patients are experiencing increased respiratory secretions and require intervention to assist in their removal. Postural drainage with chest percussion is indicated and appropriate for the patient experiencing which of the following? a. Thrombocytopenia b. Cystic fibrosis c. Osteoporosis d. Spinal fracture b. Cystic fibrosis The nurse is working on a pulmonary unit at the local hospital. The nurse is alert to one of the early signs of hypoxia in the patients, which is a. cyanosis. b. restlessness. c. a decreased respiratory rate. d. a decreased blood pressure. b. restlessness. In teaching a patient about an upcoming diagnostic test, the nurse identifies that which one of the following uses an injection of contrast material? a. Cardiac catheterization b. Pulmonary function test c. Echocardiography d. Electrocardiogram a. Cardiac catheterization At a community health fair, the nurse informs the residents that the pneumococcal vaccine is recommended for patients a. only older than 65 years. b. aged 40 to 60 years of age. c. of any age who have a chronic lung disease. d. in any age group who are currently experiencing flulike symptoms. c. of any age who have a chronic lung disease. The unit manager is orienting a new staff nurse and evaluates which of the following as an appropriate technique for nasotracheal suctioning? a. Placing the patient in a supine position b. Preparing for a clean or nonsterile technique c. Suctioning the oropharyngeal area first, then the nasotracheal area d. Applying intermittent suction for 10 seconds during catheter removal d. Applying intermittent suction for 10 seconds during catheter removal The patient has chest tubes in place after thoracic surgery. In working with a patient who has a chest tube, the nurse should a. keep the drainage collection device upright. b. clamp off the tubes except during patient assessments. c. maintain the patient in a supine position. d. remove the tubing from the connection to check for adequate suction power. a. keep the drainage collection device upright. The patient has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, an appropriate action by the nurse is to do which of the following? a. Suction continuously for 30-second intervals b. Increase the amount of suction pressure to 200 mm Hg c. Replace the oxygen and allow rest in between suctioning passes d. Complete a number of suctioning passes until the catheter comes back clear c. Replace the oxygen and allow rest in between suctioning passes A patient with a chest tube in place is being transported via stretcher to another room closer to the nurse's station. During transport, the chest tube pulls out from the pleural space. The nurse immediately a. clamps the tube. b. tells the patient to hyperventilate. c. covers the site with an occlusive dressing. d. pushes the tube back into the chest opening. c. covers the site with an occlusive dressing. The patient is admitted to the medical center with a diagnosis of right-sided heart failure. In assessment of this patient, the nurse expects to find a. dyspnea. b. confusion. c. dizziness. d. peripheral edema. d. peripheral edema. A flow rate of oxygen of 2 L/minute is providing what percent of oxygenation? a. 24% b. 28% c. 32% d. 36% b. 28% The nurse is working with a 72-year-old patient who has had left-sided congestive heart failure for several years. The patient is admitted to the hospital with dyspnea and peripheral edema. a. What medical treatment does the nurse anticipate for this patient? b. Which independent nursing actions can be implemented to assist the patient to achieve necessary oxygenation? a. The nurse anticipates that the patient will have the following interventions: • Diuretics • Antiarrhythmic • Potassium supplements (depending on the diuretic ordered) • Reduced-sodium diet • Oxygen—2 L/min via nasal cannula • Possible fluid restriction • Possible stool softeners to decrease straining b. The nurse can assist the patient by: • Elevating the head of the bed • Assessing vital signs and activity tolerance • Evaluating response to oxygen therapy • Elevating the lower extremities when the patient is out of bed • Monitoring daily weights and intake and output • Providing rest periods between activities • Assisting with ADLs as needed • Assessing peripheral edema and providing skin care • Administering medications and observing response • Instructing in respiratory exercises to clear pulmonary secretions, as tolerated The nurse is working on a respiratory care unit in the hospital. On entering the room of a patient with emphysema, it is noted that the patient is experiencing respiratory distress. The nurse should first a. instruct the patient to breathe rapidly. b. place the patient in the supine position. c. go to contact the physician. d. provide oxygen at 2 L/minute via nasal cannula. d. provide oxygen at 2 L/minute vi When air collects in the pleural space, it is known as a hemothorax. True False False This should be a pneumothorax Postural drainage is the drainage by gravity of secretions from various lung segments. True False True Suctioning is aspirating secretions through a catheter connected to a suction machine or wall suction outlet. True False True Hyperoxygenation involves giving the clients breaths that are 1 to 1.5 times the tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag. True False False Hyperinflation rather than hyperoxygenation Hyperinflation can be done with a manual resuscitation bag or through the ventilator and is performed by increasing the oxygen flow (usually to 100%) before suctioning and between suction attempts. True False False Hyperoxygenation rather than hyperinflation Which type of mask delivers oxygen concentrations varying from 24% to 40% or 50% at liter flow of 4-10L per minute? a. Nonrebreather b. Venturi c. Simple face d. Partial rebreather b. Venturi Which of the following is NOT a factor that determines adequate ventilation? a. Clear airways b. Adequate pulmonary compliance and recoil c. An intact endocrine system(It also needs an intact central nervous system and respiratory center) d. An intact thoracic cavity capable of expanding and contracting c. An intact endocrine system(It also needs an intact central nervous system and respiratory center) Eupnea is best defined as: a. A normal respiration b. A rapid rate c. An abnormally slow respiratory rate d. The cessation of breathing a. A normal respiration Which of the following is marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea? a. Biot's (cluster) respirations b. Orthopnea (Inability to breath unless sitting up) c. Cheyne-Stokes respirations d. Kussmaul's respirations (Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly DKA, but also kidney failure) c. Cheyne-Stokes respirations The nonrebreather mask delivers the highest oxygen concentration possible (95-100%) by means other than intubation or mechanical ventilation, at liter flows of ______ L per minute. a. 2-6 b. 5-8 c. 6-10 d. 10-15 d. 10-15 A nurse is evaluating a nursing student's understanding of endotracheal tubes. Which of the following indicates a need for further teaching? a. Endotracheal tubes are most commonly inserted for clients who have general anesthetics or for those in emergency situation where mechanical ventilation is required. b. An endotracheal tube is inserted by the primary care provider, nurse, or respiratory therapist with specialized education. c. An endotracheal tube is inserted through the mouth or the nose and into the trachea with the guide of a laryngoscope. d. The client is able to speak while an endotracheal tube is in place but is unable to swallow. d. The client is able to speak while an endotracheal tube is in place but is unable to swallow. The spouse of a client is explaining to the nurse what she learned about a cough reflex. Which of the following indicates a need for further teaching? The spouse states: a. The epiglottis and glottis (vocal cords) close. b. A large inspiration of approximately 3.5 L occurs. (It is 2.5 L) c. Nerve impulses are sent through the vagus nerve to the medulla. d. A strong contraction of abdominal and internal intercostal muscles dramatically raises the pressure in the lungs. b. A large inspiration of approximately 3.5 L occurs. (It is 2.5 L) A nurse is evaluating a nursing student's understanding of oxygen therapy precautions. Which of the following statements indicates a need for further teaching? a. Place cautionary signs reading "No Smoking: Oxygen in Use" on the client's door, at the foot or head of bed, and on the oxygen equipment. b. Be sure that electric monitoring equipment, suction machines, and portable diagnostic machines are all grounded. c. Make known the location of fire extinguishers, and make sure personnel are trained in their use. d. The use of volatile, flammable materials, such as oils, greases, alcohol, ether, and acetone (e.g., nail polish remover) near clients receiving oxygen is acceptable with a primary care provider's order. d. The use of volatile, flammable materials, such as oils, greases, alcohol, ether, and acetone (e.g., nail polish remover) near clients receiving oxygen is acceptable with a primary care provider's order. Which of the following actions is NOT appropriate for the nurse providing tracheostomy care? a. Clean the lumen and entire inner cannula thoroughly using a brush or pipe cleaners moistened with sterile normal saline. b. Rinse the inner cannula thoroughly in the sterile normal saline. c. After rinsing, gently tap the cannula against the inside edge of the sterile saline container. d. Put on sterile gloves. Keep your non-dominant hand sterile during the procedure. (keep your dominant hand sterile—not your non-dominant hand) d. Put on sterile gloves. Keep your non-dominant hand sterile during the procedure. (keep your dominant hand sterile—not your non-dominant hand) A nurse is evaluating a nursing student's understanding of oxygen therapy precautions. Which of the following statements indicates a need for further teaching? a. Be sure that electric monitoring equipment, suction machines, and portable diagnostic machines are all grounded. b. Place cautionary signs reading "No Smoking: Oxygen in Use" on the client's door, at the foot or head of bed, and on the oxygen equipment. c. The use of volatile, flammable materials, such as oils, greases, alcohol, ether, and acetone (e.g., nail polish remover) near clients receiving oxygen is acceptable with a primary care provider's order. d. Make known the location of fire extinguishers, and make sure personnel are trained in their use. c. The use of volatile, flammable materials, such as oils, greases, alcohol, ether, and acetone (e.g., nail polish remover) near clients receiving oxygen is acceptable with a primary care provider's order. The nonrebreather mask delivers the highest oxygen concentration possible (95-100%) by means other than intubation or mechanical ventilation, at liter flows of ______ L per minute. a. 2-6 b. 10-15 c. 5-8 d. 6-10 b. 10-15 The spouse of a client is explaining to the nurse what she learned about a cough reflex. Which of the following indicates a need for further teaching? The spouse states: a. A large inspiration of approximately 3.5 L occurs. (It is 2.5 L) b. The epiglottis and glottis (vocal cords) close. c. A strong contraction of abdominal and internal intercostal muscles dramatically raises the pressure in the lungs. d. Nerve impulses are sent through the vagus nerve to the medulla. a. A large inspiration of approximately 3.5 L occurs. (It is 2.5 L) Which of the following is NOT a factor that determines adequate ventilation? a. Adequate pulmonary compliance and recoil b. An intact thoracic cavity capable of expanding and contracting c. An intact endocrine system d. Clear airways a. Adequate pulmonary compliance and recoil A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 5, 3, 1, 2, 4, 6 b. 4, 5, 1, 2, 3, 6 c. 3, 1, 2, 5, 4, 6 d. 1, 2, 3, 4, 5, 6 a. 5, 3, 1, 2, 4, 6 What is the process by which an individual learns by observing the behavior of others? a. trial and error b. positive reinforcement c. modeling d. imitation c. modeling Which one of the following examples is an evaluation of a psychomotor skill? a. Patient maintains eye contact with the nurse b. Patient is able to discuss the side effects of medications c. Patient uses a walker correctly d. Patient has planned a menu within the therapeutic diet c. Patient uses a walker correctly A client sets a goal with their nurse to lose 100lbs. The client was told to lose 35lbs on their own first, to be eligible for gastric band surgery, which should help them lose the remainder of the weight. The client is apprehensive, but went ahead and scheduled the surgery for 5 months out, intending to lose the weight in that timeframe. What stage of health behavior change is this client in? a. Action b. Contemplation c. Preparation d. Pre-contemplation b. Contemplation A nurse is caring for a patient who suffered a spinal cord injury following a motor vehicle accident. The patient, although a paraplegic from his accident, participates in the Paralympics, is a motivational speaker, and has a family with kids. The patient considers himself healthy. What model of health is this patient demonstrating? a. Clinical b. Eudemonistic c. Adaptive d. Health-Wellness Continuum c. Adaptive A nurse is busy and assigns a LPN to a client with a new tracheostomy. During the shift, the trach dislodges and the client experiences respiratory distress. Which of the rights of delegation was violated in this scenario? a. Right task b. Right circumstances c. Right direction d. Right person b. Right circumstances Which of the following is NOT a factor that determines adequate ventilation? a. Adequate pulmonary compliance and recoil b. An intact thoracic cavity capable of expanding and contracting c. An intact endocrine system d. Clear airways a. Adequate pulmonary compliance and recoil To prevent postoperative complications, the nurse assists the client with coughing and deep breathing exercises. This is best accomplished by implementing which of the following? a. Coughing exercises 1 hour before meals and deep breathing 1 hour after meals. b. Forceful coughing as many times as tolerated. c. Huff coughing every 2 hours or as needed. d. Diaphragmatic and pursed-lip breathing 5 to 10 times, four times a day. c. Huff coughing every 2 hours or as needed. Rationales a. Deep breathing and coughing should be performed at the same time. Only at meal times is not sufficient. b. Extended forceful coughing fatigues the client. c. Correct. Huff coughing helps keep the airways open and secretions mobilized. d. Diaphragmatic and pursed-lip breathing are techniques used for clients with obstructive airway disease. While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by the nurse is most appropriate? a. Assist the client to ambulate back to bed. b. Reconnect the tube to the water seal. c. Assess the client's lung sounds with a stethoscope. d. Have the client cough forcibly several times. b. Reconnect the tube to the water seal. Rationales a. Assisting the client back to bed is a possible intervention after the system is reconnected. b. Correct. The tube should be reconnected to the water seal as quickly as possible. c. Assessing the client's lungs is a possible intervention after the system is reconnected. d. Incorrect. The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has a. Anemia. b. An infection. c. A fractured rib. d. A tumor of the medulla. a. Anemia. Rationales a. Correct. Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues. b. This may be true but it would depend on where the infection is located. c. A fractured rib would interrupt transport of oxygen from the atmosphere to the airways. d. Damage to the medulla would interfere with neural stimulation of the respiratory system. Which term does the nurse document to best describe a client experiencing shortness of breath when lying down who must assume an upright or sitting position to breathe more comfortably and effectively? a. Dyspnea b. Hyperpnea c. Orthopnea d. Acapnea c. Orthopnea Rationales a. Incorrect. b. Incorrect. c. Correct. Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea. d. Incorrect. Components of the heart the pump the electrical system the vascular system the blood volume serum lipid levels fats can clog blood vessels and decrease blood flow. LDL should be less than 130. HDL greater than 45. total cholesterol lower than 200. Serum Electrolytes can affect the conduction of the heart Hemoglobin An iron-containing protein in red blood cells that reversibly binds oxygen. Creatinine kinase and troponin is elevated with cardiac cell death. usually indicates an MI Preload amount of blood and pressure in the ventricle at the end of diastole. Increases due to increase of volume. Afterload the resistance that has to be exceeded for the ventricle to eject the blood during systole. Increases due to HTN or vasoconstriction. cardiac output heart rate x stroke volume Lifespan considerations -HR goes down in older adults -heart loses muscle tone which causes decrease of cardiac output -BP will trend up with age -Irregularities in infants and children in common -atherosclerosis is the build up of plaque in the vascular walls. more common in older adults -HTN typically elevates in older populations African American and hispanic populations are more likely to develop chronic HTN and heart diseases Geriatric concerns -blood vessels are less elastic -impaired valves due to stiffness causing a decrease in CO -Decreased baroreceptor response Non-modifiable risk factors age, race, family, gender ethnicity Modifiable risk factors lifestyle, diseases, and stress metabolic syndrome A syndrome marked by the presence of usually three or more of a group of factors: -central obesity -increased triglycerides -elevated cholesterol levels -hypertension -hyperglycemia C-reactive protein A nonspecific protein, produced in the liver, that becomes elevated during episodes of acute inflammation or infection. elevated homocysteine levels ndicates presence of atherosclerosis and is a predictor of who is at risk Ischemia an inadequate blood supply to an organ or part of the body, especially the heart muscles. How do you know if there is not enough blood being received in the tissue? Check temp, color, appearance, cap refill, etc of peripheral extremities tissue ischemia point at which tissues receive insufficient oxygen and perfusion which can then result in gangrene or amputation Anemia A condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume. Can be due to chronic bleeding or maybe deficient in iron or folate in the diet myocaridal infarction condition characterized by dead tissue areas in the myocardium; caused by interruption of blood supply to the area; heart attack Sign of MI Sudden, crushing, substernal chest pain which often radiates to back, neck, jaw, and right shoulder MONA Morphine Oxygen Nitroglycerin Aspirin What causes MI smoking, lack of exercise, high cholesterol, and unhealthy diet, stress, cardiomegaly enlargement of the heart heart failure a chronic condition in which the heart is unable to pump out all of the blood that it receives Left sided heart failure causes -HTN -Obesity -Previous MI -Diabetes -Family history -Substance abuse -Valvular disease -Cardiomyopathy -CAD right sided heart failure -Left ventricle failure -pulmonary hypertension -COPD -ARDS Left sided heart failure 1. Pnea, SOB 2. Crackles 3. Oliguria 4. Frothy Sputum 5. Displaced Apical Pulse (Hypertrophy) right sided heart failure 1. Jungular Vein Distention 2. Ascending Dependent Edema 3. Weight Gain 4. Hepatomegaly (Liver Enlargement) 5. Ascites 6. weight gain 7. fatigue chronic heart failure clinical manifestations FACES Fatigue Limitation of Activities Chest congestion/cough Edema Shortness of breath MAKE CARDS ON STUFF IN BLUE venous stasis a condition of slow blood flow in the veins, usually of the legs varicose veins tedhose will help it If patients telemetry pulse is off first assess the patient and apical pulse check stickers Atherosclerosis diet low saturated fat diet, cholesterol lowering agents given before meals fibers TED hose (compression stockings) long, tight fitting stockings that place mild static pressure on the legs to prevent blood from clotting. Wears them due to inactivity Blood thinner teaching blood clots could occur and then leads to stoke or PE Fluid overload med Furosemide/lasiks sedentary lifestyle a way of life that involves little physical activity and sits a lot high lipids/ cholesterol DVT symptoms calf pain worries about it dislodging could end up in lungs, ask if any chest pain/ lung pain trouble breathing Right sides heartfaulure edema legs, feet, hands, peripheral edema crackles in lung left side heart failure Troponin lab value indicates MI Pt complains of fatigue and not being as active anemia. look at HGb levels Modifiable risk factors for HF stress Excess fluid volume and struggling to breath while laying back in bed elevate the bed (high/semi foulers). hypoxemia deficient amount of oxygen in the blood *Hypoxia leads to hypoxemia* Hypoxia Lack of oxygen in the whole body S/S of hypoxia increased pulse, shallow respirations, dyspnea, increased restlessness, cyanosis, nasal flaring, retractions When do lungs fully inflate? 2 weeks after birth Respiratory Functioning in the Older Adult more ridged, decreased exchange, fragile mucosa membrane, decreased strength in chest, decreased endurance, compromised lung expansion, GERD, aspiration risk Medications that cause respiratory depression narcotics, benzoprines, anti anxiety meds plurisy inflammation of the pleura atelectasis collapsed lung causing reduced or absent gas exchange crackles (rales) popping sounds heard on auscultation of the lung when air enters diseased airways and alveoli; occurs in disorders such as bronchiectasis or atelectasis, COPD, or pulmonary edema from CHF Rhonchi Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways. Wet airway/lung Wheezing High pitched sound heard in the lungs with asthmatics or lung disease. Severely constricted or inflamed airways. EXHALE stridor Harsh or high-pitched respiratory sound, caused by an obstruction of the air passages. Upper respiratory. Medical emergency. INHALE Kussmaul respirations Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body. DKA or renal failure Place patients head to the side when suctioning tracheostomy and endotracheal tubes/cleaning are STERILE procedures only apply suction for 5-10 seconds Nasal cannula 24-45% O2 at 2-6 L very drying to membrane. Can humidify face mask 40-60% O2 at 5-8L Do not place on hypercapnia patients on because they retain CO2 too much. This can cause respiratory depression. BiPAP/CPAP what two types of oxygen delivery devices would be recommend for patient with obstructed sleep apnea, COPD, or pulmonary edema. Keeps a positive pressure to keep airway open and not collapsed. Room air is ____% oxygen. 21 Anything above room air is considered a medical administration and needs an order CPAP (continuous positive airway pressure) provides continuous positive airway pressure; that is, it provides the same pressure during both inhalation and exhalation BiPAP (bilevel positive airway pressure) • It uses two pressures: a higher pressure during inhalation and a lower pressure during exhalation. COPD Chronic emphysema or bronchitis frequent respiratory infections barrel chest cystic fibrosis A genetic disorder that is present at birth and affects both the respiratory and digestive systems. thick/sticky mucus chronic hypoxia decreased absorption of vitamins and minerals If a patient is not breathing and does not have a pulse, which oxygen delivery device will be used first? Bag-valve-mask unit (Ambu bag) If a patient is having fluid overload in lungs (pulmonary edema) that is indicated by difficulty breathing and fine crackles in lung sounds, what should be done? Administer the IV diuretic to get fluid out What could happen as a result of chronic AFIB? Stokes due to blood clots being formed Why are chest tubes used? They are inserted to drain the pleural space and reestablish negative pressure for proper lung expansion Also to release air or fluid in lungs How often are chest tube drainage systems drained out? Hardly ever. Just to reduce the chance of more air getting in lungs When a patient has a DVT, what should be the most important question to ask? Ask for any chest pain or SOB to check for PE postural drainage use of body positioning to assist in removal of secretions from specific lobes of the lung, bronchi, or lung cavities Patients with cystic fibrosis, bronchiectasis, COPD, abscesses, or difficulty removing respiratory secretions would benefit from this. What is a normal lab finding in patients with CHF and pitting edema? Low percent of HCT. Hemodilution is normal when there is fluid excess. pulmonary veins Deliver oxygen rich blood from the lungs to the left atrium pulmonary artery artery carrying oxygen-poor blood from the heart to the lungs If a patients heart rate suddenly increases dramatically, what will occur? Decrease in cardiac output The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? increased preload If pt has a decreased preload, what should the nurse administer? IV fluids The S1 sounds indicate the closure of the aortic and pulmonic valves closing The S2 sounds indicate the closure of the tricuspid and mitral valve closing Which valve allows oxygen-poor blood to leave the right ventricle to enter the lungs for oxygenation? pulmonic These two vessels come together to form the superior vena cava Right and left brachiocephalic veins As the adult ages baroreceptors become less responsive Donor type A Receiver type A or O Donor type B Receiver type B or O Donor type AB Receiver type A, B, AB, and O Donor type O All receivers