Gas Exchange
What are the manifestations of someone experiencing hypoxia?
restlessness, confusion and anxiety
What type of wound is associated with sudden pulling sensation and pain?
Evisceration - exiting body.
Immobility, malnutrition, decreased perfusion, altered sensation, dec LOC, friction
What stage of development per Erickson does the adolescent fall into?
Identity vs Identity confusion - sense of self
What to consider for home oxygen safety?
Never smoke around oxygen supplies and keep away from openflames
No Smoking No Open Flames signs in and out of home
Keep heat sources 5 feet away from oxygen system
Keep flammable liquids from oxygen
Don’t use petroleum products, oil or grease on upper chest or face
Aerosol sprays, air fresheners should never be used around oxygen
Use hand sanitizer before handling oxygen therapy
Bedding should be 100% cotton if using 02 while sleeping
Tubing should be no longer 50 feet
Fire extinguisher, smoke detector
Explain the lub dub cycle of the heart?
During systole, the heart contracts, s1 is heard as (lub) when mitral and tricuspid valves close, the heart relaxes, s2 (dub) is heard when aortic and pulmonic valves close
How does the nurse empty a Jackson-Pratt drain?
Open, empty, squeeze the bulb to reestablish suction. The reservoir must be compressed fully after emptied.
What does it mean to heal by first intention?
Occurs in clean lacerations and surgical incisions; closed with skin adhesives or sutures
What age is the baby's weight expected to double by? What age is the baby's weight expected to triple by?
5-6 months. 12 months.
What are nursing interventions for chest tubes?
Vital signs, breath sounds, O2 sats, effort
Keep drainage system below client’s chest
No kinks or occlusions
Monitor water seal and suction chambers
Document the amount, color, consistency ofdrainage
Level of drainage is marked on collectiondevice
Assess insertion site for redness, swelling,pain or subcutaneous emphysem
What are the manifestations of heart failure? Explain difference between left HF and right HF.
Heart failure – not able to meet cardiac output needs. LHF – lung symptoms- hypoxia, crackles, SOB. RHF – body symptoms- edema lower extremities, abdomen, organs
What are the different types of anesthesia and how are they different?
Local Anesthesia: Prevents conduction ofpain impulses by affecting both the motorand sensory nerves at the surgical site. Clientis awake.
Regional Anesthesia: Causes a temporaryloss of feeling in an area of the body. Spinalblocks, epidural blocks. May be awake
General Anesthesia: The use of drugs orinhalants to depress the central nervoussystem. Client is not arousable
Moderate or Conscious Sedation: Permitsthe client to remain relaxed and calm so theycan follow commands without pain oranxiety. Monitor airway and VS– Pams andLams – colonoscopy, cataracts
What are the different types of exudate and what do they look like?
Serous - clear; Serosanguinous - pink; Sanguineous – red/bloody; Purulent – thick, yellow/green
What is the moro reflex??
Put sharp hand clap near infant - infant should startle
What is the difference between cardiac regurgitation and stenosis?
Regurgitation – don’t fully close, blood flows backwards
Stenosis – doesn’t fully open-narrowed and stiff- ventricles have to work harder and enlarge – can result in heart failure
What are the different types of oxygen delivery devices?
Nasal cannula 1- 6 L/min (24-44%)
Simple face mask 5 -8 L/min (40 – 60%) oxygen concentration
Partial rebreather 10-15 L/min (60-90%) - exhale partially intobag, inhaled in. Keep bag inflated.
Non-rebreather mask- 10-15L/min (80-95%) exhaled gases arenot returned to the bag (not for long term, not for COPD orrespiratory failure) Keep bag inflated
Venturi Mask -4-10 L/min (24-50%) can deliver precise amountof oxygen
What are the different types of chronic lower extremity wounds? How do you know the difference?
How would you determine a stage 3 pressure ulcer?
Full-thickness skin loss, adipose visible, dead tissue may be present
What age does object permanence and separation anxiety start?
9 months
Explain ventilation (inhalation and exhalation)
During inhalation, the diaphragm and intercostal muscles contract, creating a negative pressure inside the lungs, and the chest increases in size for inhalation. Air rushes in.
During exhalation, the diaphragm relaxes, the intercostal muscles contract, and exhalation occurs. Air gets pushed out oflungs
Surfactant, a lubricant made in the lungs, keeps the alveoli from collapsing
Explain purse-lipped breathing
The client should inhale through the nose and exhale through the mouth with purse lips to release trapped air, increase resistance, and prevent alveolar collapse.
Circulating - Coordinates the care of the client before, during, and after the surgical procedure, position, consents, time out. Scrub - instrument nurse, utensils, sterility, hand to surgeon
According to the braden scale: what is the lowest risk score vs highest?
20 - lowest, 15-16 mild, 12-14 moderate, <11 (6) - highest
What can the baby do developmentally at 6 months vs 10 months vs 12 months?
6 - pull self to upright position, pick up object with fingers and transfer to other hand, baby teeth come in. 10 - Can sit unsupported, pick up and play with toys, creeping, crawling, waves goodbye, pincer grasp, "mama/dada" 12- Stand and hold onto furniture, begin to walk, understands no, peek a boo, triple the birth weight
Name and describe the different adventitious breath sounds
Crackles – fluid in alveoli- HF, pneumonia
Wheezes – whistling or musical – narrowed airways
Rhonchi – lower pitched- snore- obstruction of mucus- coughing often clears
Stridor – constriction of upper airway on inhalation, obstruction, inflammation – medical emergency