The Respiratory System
Respiratory gases are carried mostly in the bloodstream by the _______
Erythrocytes (RBC)
List three common symptoms of sinusitus
Headache, Purulent nasal drainage, Malaise, Non productive cough, Tenderness over sinuses, Upper dental pain, Fever
The nurse observes that a patient is having severe respiratory distress, what action would you delegate to the PCT?
Obtaining the Ambu bag
(The nurse would stay with the patient, call the provider and set up suction)
A nurse is caring for a client who is experiencing respiratory distress, what early manifestations of hypoxemia should the nurse recognize?
Pale skin and elevated blood pressure
Evaluation of the effectiveness of deep breathing and coughing is best done by....
Auscultating the lungs bilaterally before and after
When depressed, secretions are retained and pneumonia may occur
Cough reflex
Why is strep screening done when tonsillitis is identified?
Identify if streptococcus is present which can lead to rheumatic fever, glomerulonephritis
Safety factors for administering oxygen to your COPD patient include....
Carefully titrating oxygen
A nurse is assisting with the plan of care for a client who has respiratory distress, what interventions should the nurse include
Provide emotional support, encourage patient to cough, perform oral suction as needed
The patient has chest congestion and you instruct him to increase fluid intake, what is the best rationale?
Fluid helps to thin secretions
Controlled by movement of diaphragm and muscles in chest wall
Inspiration and expiration
Warning signs of cancer of the larynx include
Hoarseness or sore throat lasting 2 weeks or longer, pain with swallowing,difficulty swallowing, hemoptysis, and enlarged cervical neck nodes
A nursing intervention that can best help prevent atelectasis in the patient with compromised lung function is....
Have the patient, turn , cough, and deep breathe every 2 hours
A nurse is monitoring a group of clients for increased risk for developing pneumonia, which clients would you expect to be at risk?
A nurse is reinforcing teaching for a COPD patient who has a new albuterol prescription, what would you want to hear from the patient that indicates they understand the medication S/S?
I can have an increase in my heart rate after taking this medication
Why is the potential for aspiration greater in the elderly person?
Elderly have a weaker cough, thoracic wall rigidity and decreased ciliary movement
The nurses chief concern for the post op tonsillectomy patient is...
Hemorrhage
What is a major intervention to prevent further lung damage in the patient with chronic respiratory disease
Convince the patient to quit smoking
A nurse is caring for a patient who has a O2 of 91% on RA, exhibits audible wheezes, and is using accessory muscles when breathing. Which medication would you expect to administer?
Beta 2 agonist (dilates bronchioles)
A nurse is reinforcing teaching to a patient on how to perform pursed lip breathing, what should the nurse include in the teaching?
Take a deep breath in through your nose
Why is obtaining a history of smoking and alcohol intake pertinent to a respiratory assessment?
Smoking and alcohol intake over many years is a risk for cancer of the layrnx
The priority assessment for any patient with any problems of the upper airway is...
Adequacy of oxygentation
A post op patient suddenly and unexpectedly becomes very anxious and complains of dyspnea, What is the priority nursing action?
Assess for othery symptoms
A nurse is getting data from a patient experiencing an acute asthma attack. What findings would indicate the patients respiratory status is declining?
Wheezing, Retraction of sternal muscles, Ineffective cough
A nurse is reinforcing teaching to a client who has TB. What should the nurse include?