HESI Medical Surgery Practice

HESI Medical Surgery Practice Thoracentesis What Position you going to place them in? - Answer- Upright leaning over table to increase lung expansion Metabolic Acidosis Respirations - Answer- Kussmaul respirations Wheezing - Answer- are short high pitched sounds made on expiratory Abnormal Breathe sounds - Answer- used to describe bronchial or bronchovesicular sounds heard in the peripheral lung fields. Adventitous sounds - Answer- are extra breath sounds that are abnormal. The presence of bronchovesicular breath sounds in the peripheral lung fields is described as? - Answer- abnormal lung sounds To prepare the patient for a thoracentesis, the nurse positions the patient - Answer- sitting upright with the elbows on an over-the-bed table. Bronchoscopy - Answer- After procedure keep the patient NPO until gag reflux returns. Hypoxemia - Answer- PaO2 is at 55% and SpO2 is 88 What test do you use to verify pulmonary embolus? - Answer- CT scan A patient with an SaO2 of 85% has a PaO2 of 50mm Hg. This indicates? - Answer- shift to the left in the oxygen-hemoglobin dissociation curve that could be caused by hypothermia. Normal Arterial Blood Gases - Answer- pH 7.35-7.45, PaO2 80-100mm Hg, SaO2 95%, PaCO2 32-48 mm Hg, HCO3- 22-26 mEq/L To determine when the patient with a tracheostomy tube can be effectively swallow, the nurse deflates the cuff and? - Answer- has the patient drink a small amount of blue-colored water, observing for coughing and colored secretions. When obtaining a health history from a patient with possible cancer of the mouth, the nurse would expect the patient to report? - Answer- Heavy tobacco and alcohol use. The most normal functioning method of speech restoration in the patient with a total larynectomy is - Answer- a voice presthesis A patients tracheostomy tube becomes dislodged with vigorous coughing. The first action by the nurse is to? - Answer- attempt to replace the tube What will the nurse teach a patient with pneumonia? - Answer- Deep breathing and coughing Fine Crackles - Answer- short-duration, discontinuous, high pitched sounds heard just before the end of inspiration. In pneumonia or heart failure. Coarse Crackles - Answer- long duration, discontinuous, low pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa; evident with inspiration. COPD, heart failure, and pneumonia. Absent breath sounds - Answer- no sound evident over entire lung or area of lung. Pleural effusion or lobectomy Peritonsillar abscess - Answer- is a complication of acute pharyngitis or acute tonsillitis when bacterial infection invades one or both tonsils. The tonsil may enlarge sufficiently to threaten airway patency. Also known as the hot potato voice. The patient experience a high fever, leukocytosis, and chills. Sputum Test for TB - Answer- 3 seperate sputum test over 3 days. Airborne precautions until 3 negative sputum samples. HEPA mask required. INH - Answer- latent TB and treat 6 to 9 months. Rifampin side effects and considerations - Answer- Hepatitis, thrombocytopenia, orange discoloration of bodily fluids (Sputum, urine, sweat, tears). BCG or Bacille Calmette-Guerin - Answer- Immigrants have been vaccinate in parts of the world with high TB. Do not give TB test only chest x-ray. A patient with pneumonia has a nursing diagnosis pf ineffective airway clearance related to pain, fatigue, and thick secretions. An appropriate nursing intervention for the patient is to - Answer- Encourage fluid intake of 3L/day Diagnose Pulmonary Emboli - Answer- with at CAT scan or MRI Hypothermia - Answer- SPO2 96%. What is the nurse going to do? Turn oxygen up. Symptom of primary pulmonary hypertension - Answer- dyspnea with exertion. Sepsis - Answer- 2 blood draws from 2 different sites before start ABT. Pseudomonis - Answer- thick green mucous.