Nur 235 Exam 3: Questions With Insightful Solutions
Focused Respiratory Assessment Right Ans - •Chief complaint
•Visual inspection
•Auscultation
•Vital signs
•Pain
•Continuous pulse oximetry
•Blood gas
•Sputum and/or Culture
•X-ray
•Pulmonary function test
What are some nursing interventions/Considerations in pediatric respiratory
patients? Right Ans - Positioning
Pulse Ox
Suction/CPT/Incentive spirometry
O2
Meds
Emergency Preparedness
What are some priority respiratory assessment points? Right Ans - Signs of
distress? (tachypnea, accessory muscles, chest rise, coloring?)
Expected vital sign ranges.
Signs/Symptoms related to a specific disorder.
Adventitious breathing sounds
(What do they tell you?)
What oxygen saturation necessitates a nursing intervention? Right Ans - <
95% SPO2
What considerations are necessary when delivering cool mist in an acute care
environment? Right Ans - - Temp Checks for hypothermia
- Oxygen flow at 4-5L/Min
What are the priority actions to ensure airway patency and optimal lung
expansion? Right Ans - - Clear patients airway
,- Elevate the HOB
What nursing interventions should be applied for any pediatric patient
admitted with a respiratory concern? Right Ans - Continuous Pulse Ox
What are the bacterial Respiratory conditions? Right Ans - -Acute
Streptococcal Pharyngitis
-Bacterial epiglottitis
-Bacterial pneumonia
Bacterial Epiglottitis & SSx Right Ans - Bacterial infection of the epiglottis
that swells and blocks the airway
Drooling
Agitation
Muffled voice
No cough
Inspiratory Stridor
What is the priority intervention for Bacterial Epiglottitis? Right Ans -
Airway management
intubation
protect airway (NO tongue blades)
Continuous Pulse Ox
What is the recommended testing for Bacterial Epiglottitis? Right Ans -
Neck radiograph
What is the initial medication/treatment for Bacterial Epiglottitis? Right
Ans - O2
IV fluids
antibiotics
Education on immunization "Hib"
Why is Bacterial Epiglottitis considered a medical emergency? Right Ans - -
Risk of airway compromise
-Immediate intervention!
, What is acute streptococcal pharyngitis? Right Ans - Strep throat, bacterial
infection of the upper airway
Pharyngitis, tonsillitis, fever, positive gabhs
What are some symptoms of Acute Streptococcal Pharyngitis? Right Ans - -
Sore Throat
-difficulty swallowing
-mouth odor
-tonsillar exudate
What is the recommended testing method for Acute Streptococcal
Pharyngitis? Right Ans - Throat culture
What are the priority interventions for Acute Streptococcal Pharyngitis?
Right Ans - -Meds = Penicillin, amoxicillin
-Analgesics
COMPLIANCE! Can lead to Rheumatic Fever!
Pneumonia SSx Right Ans - - ↑ Temp
- ↓ O2
- Tachypnea
Accessory muscle use
pallor
cyanosis
cough
chest pain
adventitious breath sounds
What tests are commonly used for diagnosing pneumonia? Right Ans - - X-
ray (infiltrates)
- nasopharyngeal swab
What are the priority interventions for managing pneumonia? Right Ans -
Continuous Pulse Ox
O2
Fluids
Focused Respiratory Assessment Right Ans - •Chief complaint
•Visual inspection
•Auscultation
•Vital signs
•Pain
•Continuous pulse oximetry
•Blood gas
•Sputum and/or Culture
•X-ray
•Pulmonary function test
What are some nursing interventions/Considerations in pediatric respiratory
patients? Right Ans - Positioning
Pulse Ox
Suction/CPT/Incentive spirometry
O2
Meds
Emergency Preparedness
What are some priority respiratory assessment points? Right Ans - Signs of
distress? (tachypnea, accessory muscles, chest rise, coloring?)
Expected vital sign ranges.
Signs/Symptoms related to a specific disorder.
Adventitious breathing sounds
(What do they tell you?)
What oxygen saturation necessitates a nursing intervention? Right Ans - <
95% SPO2
What considerations are necessary when delivering cool mist in an acute care
environment? Right Ans - - Temp Checks for hypothermia
- Oxygen flow at 4-5L/Min
What are the priority actions to ensure airway patency and optimal lung
expansion? Right Ans - - Clear patients airway
,- Elevate the HOB
What nursing interventions should be applied for any pediatric patient
admitted with a respiratory concern? Right Ans - Continuous Pulse Ox
What are the bacterial Respiratory conditions? Right Ans - -Acute
Streptococcal Pharyngitis
-Bacterial epiglottitis
-Bacterial pneumonia
Bacterial Epiglottitis & SSx Right Ans - Bacterial infection of the epiglottis
that swells and blocks the airway
Drooling
Agitation
Muffled voice
No cough
Inspiratory Stridor
What is the priority intervention for Bacterial Epiglottitis? Right Ans -
Airway management
intubation
protect airway (NO tongue blades)
Continuous Pulse Ox
What is the recommended testing for Bacterial Epiglottitis? Right Ans -
Neck radiograph
What is the initial medication/treatment for Bacterial Epiglottitis? Right
Ans - O2
IV fluids
antibiotics
Education on immunization "Hib"
Why is Bacterial Epiglottitis considered a medical emergency? Right Ans - -
Risk of airway compromise
-Immediate intervention!
, What is acute streptococcal pharyngitis? Right Ans - Strep throat, bacterial
infection of the upper airway
Pharyngitis, tonsillitis, fever, positive gabhs
What are some symptoms of Acute Streptococcal Pharyngitis? Right Ans - -
Sore Throat
-difficulty swallowing
-mouth odor
-tonsillar exudate
What is the recommended testing method for Acute Streptococcal
Pharyngitis? Right Ans - Throat culture
What are the priority interventions for Acute Streptococcal Pharyngitis?
Right Ans - -Meds = Penicillin, amoxicillin
-Analgesics
COMPLIANCE! Can lead to Rheumatic Fever!
Pneumonia SSx Right Ans - - ↑ Temp
- ↓ O2
- Tachypnea
Accessory muscle use
pallor
cyanosis
cough
chest pain
adventitious breath sounds
What tests are commonly used for diagnosing pneumonia? Right Ans - - X-
ray (infiltrates)
- nasopharyngeal swab
What are the priority interventions for managing pneumonia? Right Ans -
Continuous Pulse Ox
O2
Fluids
