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Medical-Surgical

Terms in this set (143)

List 4 common symptoms of pneumonia the nurse might note on physical exam.
-tachypnea
-fever w/ chills
-productive cough
-bronchial breath sounds
State 4 nursing interventions for assisting the client to cough productively
-encourage deep breathing
-increase fluid intake to 3L/day
-use humidity to loosen secretions
-suction airway to stimulate coughing
What symptoms of pneumonia might the nurse expect to see in an older client?
-confusion
-lethargy
-anorexia
-rapid resp rate
How does the nurse prevent hypoxia during suctioning?
deliver 100% O2 (hyperinflating/hyperoxygenating) before and after each endotracheal suctioning
During mechanical ventilation, what are 3 major nursing interventions?
-monitor pt's resp status and secure connections
-establish a communication mechanism
-keep airway clear by coughing/suctioning
When examining a patient with emphysema, what physical findings is the nurse most likely to see?
-barrel chest
-dry/productive cough
-decreased breath sounds
-dyspnea
-crackles in lung fields
What is the most common risk associated with lung cancer?
smoking (cigarettes/ marijuana)
Describe what preop nursing care is important to include for a patient undergoing a laryngectomy.
-involve fam/pt in manipulation of trach equipment before surgery
-plan acceptable communication methods
-refer to speech pathologist
-discuss rehab program
List 5 nursing interventions after chest tube insertion.
-maintain a dry occlusive dressing
-keep all tubing connections tight and taped
-monitor pt's clinical status
-encourage pt to breathe deeply periodically
-monitor fluid drainage, mark time of measurement/fluid level
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?
-place end of tube in sterile water at 2cm level
-apply an occlusive dressing and notify HCP
What instructions should be given to a client after radiation therapy?
-do NOT wash off lines
-wear soft cotton garments
-avoid use of powders/creams on site
What precautions are required for patients w/ TB when placed on respiratory isolation?
-mask for anyone entering room
-private room assignment
-pt must wear mask if leaving room
List 4 components for teaching patients w/ TB.
-cough into tissues and dispose immediately in biohazard bags
-long term need for daily meds
-good handwashing
-report symptoms of deterioration (blood in secretions)
Differentiate between ARF and CRF.
ARF: often reversible, abrupt deterioration of kidney function
CRF: irreversible, slow deterioration of kidney function, characterized by increased BUN and creatinine. Dialysis required eventually.
During the oliguric phase of renal failure, protein should be severely restricted. What is the rationale for this restriction?
toxic metabolites the accumulate in the blood (urea, creatinine) are derived mainly from protein catabolism.
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