Medical Surgical Nursing Review Questions Part 5

Establish that the client is unresponsive is done by calling the patient’s name and if he responds in some degree then there is a conscious part remaining. Assess the client’s airway is the second priority after establishing the responsiveness of the patient.Call for help is the third appropriate thing to do in this scenario.See if anyone saw the client fall is a part of a background check of the factors that may contribute to the client’s current state.

Use oxygen during meals improves gas exchange helps in preventing undue fatigue during eating. Eating foods high in sodium does not increase sputum liquefaction. Perform exercise after respiratory therapy enhances appetite, is not recorded to have been increasing the appetite of patients.Cleanse the mouth of dried secretions reduces the risk of infection, does not answer the question being asked about the nutritional needs of the patient with COPD.

C - “ Inhale this medication after other asthma sprays” in order to provide the desired effect which relaxes the bronchial muscle by acting on beta2 – adrenergic receptors. A - Use of medication is advised before a strenuous activity rather than at bedtime. B - Rest periods in between inhalation is needed. D - “Notify the health care provider if you need the drug more often “ is not appropriate since Albuterol is not an addicting substance.

D - Prevent exacerbation of COPD, increased delivery of oxygen may also trigger exacerbations, spacers are used to regulate the entering air to the client. A - Decrease administration time of the medication is not the purpose of the spacer. B - Increase client compliance is not the primary purpose of the spacer, it may only be secondary. C - Improve aerosol delivery in clients who are not able to coordinate the MDI spacers won’t help clients with MDI.

Tachypnea in children may develop in number of hours only. Bradycardia and general pallor does not include in the symptoms, while irritability might qualify as a symptom however it is a general symptom.

Call the health care provider as soon as possible since this is a surgical emergency. The major goal is to prevent pneumothorax. Checking for subcutaneous emphysema in the upper torso won’t solve the problem. Reposition the client to a position of comfort is impossible since the client at that time might be gasping for air. Check for any increase in the amount of thoracic drainage is also impossible.

Diffuse expiratory wheezing is caused by the constriction of the bronchial tree. Loose productive cough is a result of an active secretion of mucus in the lungs. No relied from inhalant is irrelevant. Fever and chills are general symptoms.

Maintaing alveolar surface tension is the primary problem of a premature infant with respiratory distress syndrome since the baby lacks surfactant which helps the lungs inflate with air and keeps the air sacs from collapsing. Stabilizing the thermoregulation is the next priority nursing care since babies like this has trouble in regulating their own temperature as they depend more on brown fat. The next would be beginning the normal pulmonary blood flow and regulating the intracardiac pressure.

Confining the percussion to the rib cage area will enable the secretions to loosen properly. Scheduling the therapy 30 minutes after meals will induce vomiting. Teaching the child not to cough during the treatment will make the treatment not effective. Placing the child in a prone position for therapy will not help the secretion to loosen.

Avoid smoking near the client since oxygen is combustible and it may catch fire immediately.Turn off oxygen during meals will not help the patient, continuous air flow is needed for this client.Adjust the liter flow to 10 as needed, the limit of COPD patients is 2-3 liters per minute, a higher air flow may hinder the patient to have a drive in breathing.Remind the client to keep mouth closed won’t help the him having an adequate ventilation.

Ineffective airway clearance related to increased tracheobronchial secretions is the appropriate nursing diagnosis since the tracheostomy is indicated to make a passageway for an open airway. Impaired verbal communication related to absence of speaking ability is expected since a tracheostomy is inserted. Risk for impaired skin integrity related to ttracheostomy incision could be second priority. Alteration in comfort: pain related to tracheostomy can least priority.

Temperature denotes the internal changes.

C - Apical Pulse of 112, tachycardia means that the child reacts with the albuterol and may mean informing the physician for this and asking for an adjustment with the given dosage. A - Lethargy and fatigue may mean lack of oxygen. B - Edema is the lower extremities is not a part of the side effects of albuterol. D - Temperature of 101 degrees Farenheit is a normal temperature for a child.

A patient in sickle-cell crisis will develop hyper haemolytic crisis immediately compromising the IV access. The next patient to see is a patient complaining of a leaky colostomy bag. A patient with leukemia who has received one-half unit of packed cells would be the third since he may need reevaluation of his hemodynamic status after transfusion. Then the last thing to see is the patient scheduled for a bronchoscopy.

Expectorating bright red secretions denote active bleeding. A heart rate of 88 beats per minute is normal for an 8-year-old child. 30 ml of dark brown secretions is normal since it is a part of the blood lost during the surgery. Infrequent swallowing may denote that the anesthesia has not worn off.

Partial non-re breather mask delivers the highest oxygen concentration from 95% to 100% by means of other mechanical ventilation. The venturi mask delivers oxygen concentrations varying from 24% to 40% or 4 to 6 liters per minute.Nasal cannula delivers oxygen concentrations varying from 2 to 6 liters per minuteSimple face mask delivers oxygen concentration from 5 to 8 liters per minute.

Position of the trachea in the sternal notch denotes the proper access of the airway for proper respiration. Presence of breath sounds bilaterally is impossible to hear since the surgical procedure done was done as a removal of the lung. Amount and consistency of sputum is not necessary for the time of procedure. Increase in pulse pressure is not relevant in the nature of the case.

Inserting the suction catheter until resistance is met, then withdraw it slightly, apply suction intermittently as the catheter is withdrawn is the correct way of suctioning avoiding injury to the area. The rest of the options does not pertain to the correct procedure.

Upon awakening, cough deeply and expectorate into a container is the appropriate instruction since it confines the specimen without too much exposure. The other options are vague when it comes to understanding.

Viral pneumonia with atelectasis involves as compromised lung since atelectasis is caused by a blockage of the air passages (bronchus or bronchioles) or by pressure on the outside of the lung.Spontaneous pneumothorax with a respiratory rate of 38, the patient here still has continuous source of oxygen even though the respiratory rate is faster than normal.Tension pneumothorax with slight tracheal deviation to the right means that there is trapped air in the pleural space, this could be managed with maintaining a patent airway through suctioning. Acute asthma with episodes of bronchospasm, since it is acute it only happens for a short time and it entitles for a shorter treatment.

A - “ The inhaler can be used whenever I feel short of breath” is the best answer since the client knows now when to use the medication and its best indication. B - “I should rinse my mouth after using the inhaler” maybe correct in some degree but it does not supply that the client understands the indication of the prescribed drug. C - “If I forget a dose, I can double up on the next dose” Double dose is not advised. D - “I should not use the spacer with my Azmacort” Azmacort was designed to have a spacer to provide ease for usage.

Hacking, non productive cough since there is an inflammation of the airways .Bronchial breath sounds in outer lung fields. Decreased tactile fremitus means pleural effusion.Hyper resonance of areas of consolidation may mean emphysematous lung.

An elderly woman discharged from the hospital three days ago with pneumonia is the priority since the case was infectious and the case may have recurred. A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis could be the next patient to check. An elderly man who used all his diuretic medication and is expectorating pink tinged mucus. A new mother is breastfeeding her two day old infant who was born five days could be the least to attend to.

D - Swallowing patterns will enable the nurse to know if there is active bleeding, the more the child swallows the more bleeding happens. A. Offering an ice cream every 2 hours is not appropriate at this time. B - Placing the child in a supine position will increase the risk of aspiration of blood from the surgical site. C - Allowing the child to drink through a straw is impossible since initially the child is placed on NPO.

Open the client’s airway is the priority nursing action since the problem is in the respiratory system. Checking the carotid pulse is the second step, then giving two rescue breaths and the last thing is delivering 5 abdominal thrusts.