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204 Critical Respiratory Flashcards | StudBud
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204 Critical Respiratory
204 Critical Respiratory
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1
the RN has a pt w/ a pneumo. a large clot is noted in the tubing. Which other assessment finding req. immediate action
increasing pain at the insertion site
a downward trend in blood pressure
decreased water in the suction control chamber
fluctuations int he water seal chamber
2
MD is inserting PA catheter. Which of these findings would indicate a complication from the catheter insertion?
tracheal deviation from midline
vesicular breath sounds noted on auscultation
inspiration phase is greater than expiration
diaphragmatic excursion of 3cm
3
Which of these individuals is at risk for a primary spontaneous pneumothorax?
a patient with an 18 year history of emphysema
a pt w/ a penetrating chest wound that makes a sucking sound
a 6ft, 135lb male who smaokes
a pt in the ICU on a vent
4
A pt w/ a pneumonis has sudden onset sharp pain on one chest wall. Dyspneic + low O2 sat. You give O2, then what?
auscultate lungs bilaterally
assess cap refill
lower HOB
take a full set of vital signs
5
An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?
listen to their lungs
suction the ETT
ensure all connections are patent
Determine if the ETT is kinked
6
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
assess for other manifestations of hypoxia
tell the client to take deep slow breaths
obtain a new oximeter from central supply
change the sensor on the pulse oximeter
7
You're moving your pt from the ED to step down who has a chest tube. What would you do in prep for transport?
secure the chest tube unit on the gurney
clamp the chest tube with a padded hemostat
stabilize the chest tube drainage unit on the patients bed
disconnect the chest tube unti during transport
8
During assessment, the RN notes paradoxical lung movements. This finding is consistent with what health problem?
pleurisy
flail chest
pneumonia
pneumothorax
9
Your pt has a pneumo w/ subq emphysema. Which assessment finding validates this statement?
asymmetric chest wall expansion during inhalation
a grating sound auscultated over the mediastinum
a crackling sensation when the chest is palpated
diminished breath sounds bilaterally
10
When caring for a pt who has a pneumo, which of these actions should the RN include in the patient’s plan of care?
encourage the patient to deep breathe and cough regularly
vigorously massage the tube Q2 hours
change the insertion site dressing daily using aseptic technique
empty the drainage chamber every shift and record the amount
11
A pt w/ TB is dyspneic. Significant JVD. Which assessment would you perform immediately?
auscultate the heart for extra heart sounds
check bilateral pulses
palpate the upper chest for crepitus
palpate for tracheal deviation
12
A RN finds a client anxious, SOB, chest pain, and having a blood pressure of 88/52. What action is the priority?
provide reassurance
take a full set of vital signs
notify the rapid response team
assess lung sounds
13
Patient has a PE and is receiving O2. The student asks why their O2 is not improving despite their O2 tx. What response?
breathing so rapidly interferes w/ oxygenation
the blood clot interferes with perfusion of the lungs
the pt needs immediate intubation and mechanical ventilation
maybe the client has resp. distress syndrome
14
A pt receiving IV heparin therapy. Which lab value could indicate a serious side effect has occurred?
Plt 82,000
RBC 4.8
WBC 8.7
Hg 14.2
15
The healthcare provider is caring for four patients. Which patient should be assessed first?
a pt w/ 7/10 pain and 91% O2
pt w/ RR of 28 and asymmetrical chest wall movement
pt w/ bilateral crackles, fever, and purulent sputum
pt in a tripod position and breathing through pursed lips