NURS 3000 Exam 4 Study Guide Questions With Correct
Answers.
Nursing interventions for pt receiving O2 via nasal cannula(nose prongs)
-Assess for signs of O2 impairment
-Ensure proper functioning and rate of O2
Nursing interventions to promote circulation and oxygenation in hospitalized
patients
-Teach effective coughing and Deep breathing
-TCDB(Turn, Cough, Deep Breathe every 2 hrs.
-Postural drainage with percussion(Chest Vest)
-Hydration
-Assuming Fowler's or High Fowler's position
-Ambulation
Priority nursing actions for a patient exhibiting s/s of impaired oxygenation
-Ambulation
-TCBD
-NPPV(Noninvasive Positive Pressure Ventilation)
-O2 therapy(treat as drug/med
-Incentive spirometry
-Updraft treatments
-Postural drainage with percussion(Chest Vest)
-Meds: Broncholdiators, Steriods, and expectorants
-Elevate HOB
-Positioning: Fowler's, High Fowlers, Orthopneic
Priority short-term goals for a patient exhibiting s/s of impaired oxygenation
-Exhibit signs of increased oxygenation
-Maintain patient airway
-Maintain and improve pulmonary ventilation and oxygenation
-Prevent risk associated with skin and tissue breakdown
Independent nursing interventions to maintain a patent airway in a patient with
Ineffective Airway Clearance
-TCBD
-Elevate HOB
-Increase fluids
Fowler's position
Therapeutic communication with a patient who uses CPAP
Explain to the patient that is a type of Noninvasive ventialtion treatment to maintain
adequate breathing( used in acute and chronic respiratory failure, pulmonary edema,
COPD, and obstructive sleep apnea)
-Nurse's primary role in caring for patients using CPAP or BiPAP devises is to ensusre
optimal functioning and use of the device since it may need to be used nightly for the
remainder of their lives
Actions for a patient experiencing sudden onset chest pain while ambulating
, -Have pt. to sit or rest and takes things slow
-Reduce anxiety
-Stop ambulating
What is Atelectasis? How would it affect the lung sounds?
A collapse of a portion of the lung; results in decreased or absent gas exchange/ the
lungs cannot fill with enough air, and the oxygen level in your blood may go down
O2 administration in patients with COPD; What's important to remember?
-(MCD)mucus clearance device-client inhales slowly(keeps cheeks firm) , exhales fast
through the device, causing the steel ball to move up and down
-Nasal cannula: 2L/min, above 6 L/min the pt, swallows air and the FiO2 is not
increased
-CPAP: ensure functioning and use of the device, need to be used nightly for the
remainder of their lives
- COPD pt have chronic hypercapnia and there incentive to breath comes from
hypoxemia
-Sustained maximal inspiration devices (SMIs), measure the flow of air inhaled
through the mouthpiece
-Designed to mimic natural sighing or yawning by encouraging the pt to take
long, slow deep breaths
Incentive Spiometer
Pt teaching in using incentive spirometer:
-Hold or place the SMI in an upright position
-Exhale normally
-Seal your lips tightly around the mouthpiece
-Take in a slow, deep breath
-If you have difficulty breathing only through the mouth, a nose clip can be used
-Remove the mouthpiece and exhale normally
-Relax and take several normal breaths before using it again
-Repeat procedure several times and 4 or 5 times hourly
-Clean the mouthpiece with water and shake it dry
Hyperkalemia-priority nursing assessments
-Assess for cardiac arrhythmias and flaccid muscle paralysis(weakness)
*Administer diuretics/other meds such as glucose and insulin as ordered
-Hold potassium supplements and K+ conserving diuretics
-Monitor serum K+ levels carefully
S/S of Deficient Fluid Volume
-Decreased urine volume (<30 mL/hr)
-Postural hypotension
-Decreased turgor
-Dry mucous membranes, sunken eyeballs, decreased tearing
-Weak pulse(bradycardia) or rapid(tachycardia
-Weight loss
-Decreased cap. refill, central venous pressure, blood pressure, tissue turgor
-Increased specific gravity of urine, hematocrit, and BUN
Answers.
Nursing interventions for pt receiving O2 via nasal cannula(nose prongs)
-Assess for signs of O2 impairment
-Ensure proper functioning and rate of O2
Nursing interventions to promote circulation and oxygenation in hospitalized
patients
-Teach effective coughing and Deep breathing
-TCDB(Turn, Cough, Deep Breathe every 2 hrs.
-Postural drainage with percussion(Chest Vest)
-Hydration
-Assuming Fowler's or High Fowler's position
-Ambulation
Priority nursing actions for a patient exhibiting s/s of impaired oxygenation
-Ambulation
-TCBD
-NPPV(Noninvasive Positive Pressure Ventilation)
-O2 therapy(treat as drug/med
-Incentive spirometry
-Updraft treatments
-Postural drainage with percussion(Chest Vest)
-Meds: Broncholdiators, Steriods, and expectorants
-Elevate HOB
-Positioning: Fowler's, High Fowlers, Orthopneic
Priority short-term goals for a patient exhibiting s/s of impaired oxygenation
-Exhibit signs of increased oxygenation
-Maintain patient airway
-Maintain and improve pulmonary ventilation and oxygenation
-Prevent risk associated with skin and tissue breakdown
Independent nursing interventions to maintain a patent airway in a patient with
Ineffective Airway Clearance
-TCBD
-Elevate HOB
-Increase fluids
Fowler's position
Therapeutic communication with a patient who uses CPAP
Explain to the patient that is a type of Noninvasive ventialtion treatment to maintain
adequate breathing( used in acute and chronic respiratory failure, pulmonary edema,
COPD, and obstructive sleep apnea)
-Nurse's primary role in caring for patients using CPAP or BiPAP devises is to ensusre
optimal functioning and use of the device since it may need to be used nightly for the
remainder of their lives
Actions for a patient experiencing sudden onset chest pain while ambulating
, -Have pt. to sit or rest and takes things slow
-Reduce anxiety
-Stop ambulating
What is Atelectasis? How would it affect the lung sounds?
A collapse of a portion of the lung; results in decreased or absent gas exchange/ the
lungs cannot fill with enough air, and the oxygen level in your blood may go down
O2 administration in patients with COPD; What's important to remember?
-(MCD)mucus clearance device-client inhales slowly(keeps cheeks firm) , exhales fast
through the device, causing the steel ball to move up and down
-Nasal cannula: 2L/min, above 6 L/min the pt, swallows air and the FiO2 is not
increased
-CPAP: ensure functioning and use of the device, need to be used nightly for the
remainder of their lives
- COPD pt have chronic hypercapnia and there incentive to breath comes from
hypoxemia
-Sustained maximal inspiration devices (SMIs), measure the flow of air inhaled
through the mouthpiece
-Designed to mimic natural sighing or yawning by encouraging the pt to take
long, slow deep breaths
Incentive Spiometer
Pt teaching in using incentive spirometer:
-Hold or place the SMI in an upright position
-Exhale normally
-Seal your lips tightly around the mouthpiece
-Take in a slow, deep breath
-If you have difficulty breathing only through the mouth, a nose clip can be used
-Remove the mouthpiece and exhale normally
-Relax and take several normal breaths before using it again
-Repeat procedure several times and 4 or 5 times hourly
-Clean the mouthpiece with water and shake it dry
Hyperkalemia-priority nursing assessments
-Assess for cardiac arrhythmias and flaccid muscle paralysis(weakness)
*Administer diuretics/other meds such as glucose and insulin as ordered
-Hold potassium supplements and K+ conserving diuretics
-Monitor serum K+ levels carefully
S/S of Deficient Fluid Volume
-Decreased urine volume (<30 mL/hr)
-Postural hypotension
-Decreased turgor
-Dry mucous membranes, sunken eyeballs, decreased tearing
-Weak pulse(bradycardia) or rapid(tachycardia
-Weight loss
-Decreased cap. refill, central venous pressure, blood pressure, tissue turgor
-Increased specific gravity of urine, hematocrit, and BUN
