1. List 4 common symptoms of PNA the nurse might note on physical exam.
1. Tachypnea, fever with chills, productive cough, bronchial breath sounds
2. State 4 nursing interventions for assisting the client to cough productively.
2. Deep breathing, fluid intake increased to 3 liters/day, use humidity to loosen secretions, suction airway to stimulate coughing
3. What symtoms of PNA might the nurse expect to see in an older client?
3. Confusion, lethargy, anorexia, rapid respiratory rate
4. What should the O2 flow rate be for the client with COPD?
4. 1 to 2 liters per nasal cannula, too much O2 may eliminate the COPD clent's stimulus to breathe. A COPD client has a hypoxic drive to breathe.
5. How does the nurse prevent hypoxia during suctioning?
5. Deliver 100% oxygen (hyperinflating) before and after each endotracheal suctioning.
6. During mechanical ventilation, what are 3 major nursing interventions?
6. Monitor client's respiratory status and secure connections, establish a communication mechanism with the client, keep airway clear by coughing/suctioning.
7. When examining a client with emphysema, what physical findings is the nurse likely to see?
7. Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in lung fields.
8. What is the most common risk factor associated with lung cancer?
8. Smoking
9. Describe the preoperative nursing care for a client undergoing a laryngectomy.
9. Involve family/client in manipulation of tracheostomy equipment before surgery, plan acceptable communication method, refer to speech pathologist, discuss rehab program.
10. List 5 nursing interventions after chest tube insertion.
10. Maintain a dry occlusive dressing to chest tube site at all times. Check all connections every 4 hours. make sure Bottle III or end chamber is bubblig. Measure chest tube drainage by marking level on outside of drainage unit. Encourage use of incentiv
11. What immediate action should the nurse take when a chest tube becomes disconnected from a bottle or suction apparatus? What should the nurse do if a chest tube is accidentally removed from the client?
11. Place end in container of sterile water. Apply an occlusive dressing and notify healthcare provider STAT.
12. What instructions should be given to a client following radiation therapy?
12. Do NOT wash off lines; wear soft cotton garments, avoid use of powders/creams on radiation site.
13. What precautions are required for clients with TB when placed on respiratory isolation?
13. Mask for anyone entering room; private room; client MUST wear mask if leaving room.
14. List 4 components of teaching for the client with TB.
14. Cough into tissues and dispose immediately into special bags. Long-term need for daily medication. Good handwashing technique. Report symptoms of deterioration, i.e., blood in secretions.