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nr_302_final_exam_study_guide., Exams of Nursing

University of LiverpoolNursing

nr_302_final_exam_study_guide.

Typology: Exams

2022/2023

Available from 01/23/2023

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NR 302 FINAL EXAM STUDYGUIDE
Thorax and Lungs
-What data can be gathered on a patient in respiratory distress from general survey only?
-Do they use accessory muscles when breathing? Position-tripod, Barrel chest, Nasal flaring,
color
-Structure and Function: The thorax
-Thoracic cage
-Sternum, 12 pairs of ribs
-12 thoracic vertebrae
-Muscles and cartilage
-Thoracic Cavity
-Mediastinium
-Pleural cavity
-Lung (Apex and base)
Structure and Function: Pleural Membranes
-Parietal pleura-lines the whole cavity
-Visceral pleura-lines the organs
-Pleural space/cavity-both above total
Structure and Function: The respiratory system
-Trachea
-Bronchi
-Bronchioles
-Alveolar Sacs
-Alveoli
Landmarks-Visualize what you cannot see!
-Anterior chest
-Suprasternal notch “U shaped”
-Sternum
-Sternal angle (Angle of Louis) continuous with 2nd rib
-Ribs & intercostals
-Costal angle (at xiphoid) 90 degrees
-Posterior chest
-Vertebra prominence C7
-Spinous processes T1 is 1st rib
-T3 separates upper and lower lobes
-Inferior border of the scapula 8th rib
pf3
pf4
pf5
pf8
pf9
pfa
pfd
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pff
pf12
pf13
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NR 302 FINAL EXAM STUDYGUIDE

Thorax and Lungs

  • What data can be gathered on a patient in respiratory distress from general survey only?
    • Do they use accessory muscles when breathing? Position-tripod, Barrel chest, Nasal flaring, color
  • Structure and Function: The thorax
  • Thoracic cage
    • Sternum, 12 pairs of ribs
    • 12 thoracic vertebrae
    • Muscles and cartilage
  • Thoracic Cavity
    • Mediastinium
      • Pleural cavity
      • Lung (Apex and base)

Structure and Function: Pleural Membranes

  • Parietal pleura-lines the whole cavity
  • Visceral pleura-lines the organs
  • Pleural space/cavity-both above total

Structure and Function: The respiratory system

  • Trachea
  • Bronchi
  • Bronchioles
  • Alveolar Sacs
  • Alveoli

Landmarks-Visualize what you cannot see!

- Anterior chest - Suprasternal notch “U shaped”

  • Sternum
  • Sternal angle (Angle of Louis) continuous with 2 nd^ rib
  • Ribs & intercostals
  • Costal angle (at xiphoid) 90 degrees - Posterior chest
  • Vertebra prominence C
  • Spinous processes T1 is 1 st^ rib
  • T3 separates upper and lower lobes
  • Inferior border of the scapula 8 th^ rib
  • 12 th^ rib

Subjective Data

  • Hypoventilation
  • Cheyne-strokes—fast breathing with apnea (People who are dying)

Time to THINK as a NURSE…

  • Discuss dyspnea and orthopnea
  • What causes pleuritic pain (pleurisy)
  • Differentiate Crepitus vs Fremitus
  • Is abnormal posture or chest shape a concern? Why? Yes
  • Connect nasal flaring & accessory muscle use
  • Atelectasis-collapsed lung
  • Differentiate various colors of sputum
  • What would cause dense of consolidated lung tissue?—Fluid, tumor, mucous, food Case Study Mr. JS is a 70 year- old male with progressive COPD. Reason for seeking care, “I am notgetting air.” He reports smoking 1.5 packs of cigarettes per day since age 16. He presents to the emergency department with complaints of worsening dyspnea, productive cough, chest tightness, chills & fatigue Vital Signs: temp. 101.2 oral, apical heart rate 108, RR 24 labored, B/P 124/78, pulse ox88% on room air (RA)
  • Subjective
    • Chest tightness
    • Dyspnea
    • chills
    • fatigue
  • Objective
    • Vitals
    • Labored
    • productive cough
    • Accessary muscles
    • Tripod
    • Purse lipped breathing
    • Pants unbuttoned
    • malnourished
    • Barrel chest
    • Clubbing/stained nails
    • Anxious

Assessment Reveals

Inspection:

  • Pt. is leaning forward in TRIPOD position
  • RR 24 labored and shallow, lips appear cyanotic
  • Using accessory muscles of the neck & shoulders (hypertrophied)
  • “Barrel-shaped” chest with costal angle > 90 degrees
  • Productive cough: thick yellow – green sputum Palpation:
  • Decreased chest expansion on right side
  • Decreased fremitus throughout with Increased tactile fremitus over right lower lobe (RLL) Percussion:
  • Hyper resonance over lung fields
  • Dull over RLL Auscultation:
  • Decreased breath sounds throughout
  • Crackles over RLL
  • Bronchophony, egophony-bleeding goat, whispered pectoriloquy-loud RLL CALCULATE THIS PATIENT’S PACK YEAR HISTORY 81 years!!!!!

Nursing Diagnoses

  • Self-care deficit: Bathing and hygiene
  • Impaired gas exchange
  • Ineffective tissue perfusion
  • Activity intolerance
  • Ineffective health maintenance
  • Anxiety
  • Nutrition: less than body requirements Test your knowledge The nurse is performing the respiratory assessment on a pt. with pneumonia. The pt. is asked to say “ninety-nine” & through the stethoscope the nurse hears the words clearly over the LLL. How will the nurse document the findings? 1. Bronchophony 2. Tactilefremitus 3. Crepitus 4. Egophony Apt. has developed a deep vein thrombosis (DVT) and the nurse is alert for the potential development of a pulmonary embolism (PE). Which findings would suggest s/s of PE?
    1. Non-productive cough & abdominal pain
    2. HTN & afebrile
    3. Bradypnea & bradycardia 4. Chest pain & dyspnea Which of the following patient’s is at greatest risk to develop atelectasis and pneumonia?
    4. Pt. w/ a hx of smoking 2 PPD that quit 2 yrs. ago
    5. Pt. who is ambulatory q 4 hrs. 3. Pt. who is post- operative requiring “splinting(hold together)-hug pilow” secondary

to pain

  • Diet & exercise
  • Smoking/stress Specific S&S
  • Chest pain
  • palpations
  • edema
  • cyanosis
  • orthopnea/difficulty
  • dizziness/syncope

Objective Data

- Inspection of pt.: - General appearance, jugular veins, carotid arteries, hands & fingers, chest - Palpation of precordium: - Pulsation or heave, carotid pulses, apical impulse - Percussion : - Cardiacborder (*SEE P. 480) - Auscultation : - Carotid arteries, Heart sounds & Apical heart rate, pulse deficit

Auscultation: Five listening points of the heart

Aortic: 2 ICS/RSB Pulmonic: 2 ICS/LSB Erb’s: 3ICS/LSB Tricuspid: 4ICS/LSB Mitral: 5ICS/LMCL

Normal Heart Sounds

- S1:

  • Closure of AV valves – “LUB” heard loudest at apex - listen at tricuspid & mitral points S2:
  • Closure of semilunar valves - “DUB” heard loudest at base - listen at Pulmonic and Aortic points.

Time to think as a nurse

What is tissue perfusion?

  • enough O2 in system-can send o2 to all body tissues. Ability of heart to pump o
  • List modifiable & non-modifiable risk factors
  • Differentiate between apical pulse & apical impulse (impulse what I feel)
  • What is the relationship between carotid artery bruit and dizziness?
  • Obstruction Nursing Diagnoses
  • Acute Pain—evidence is patient has pain 10/
  • Fatigue
  • Anxiety
  • Decreased Cardiac Output
  • Fear Test your knowledge… The nurse is performing CPR on an adult pt. What is the correct hand position on the pts. chest?
    1. Upper half of the sternum
    2. Two finger widths below the sternal notch 3. Two finger widths above the xiphoid process
    3. Over the xiphoid

Chapter 20 Peripheral Vascular System and Lymphatic System

Function of Peripheral Vascular System Arteries

  • Transport O2 and blood via the heart to the organs and tissue capillaries ( perfusion )
  • Have a smooth muscle layer that contracts and relaxes in response to changes in blood volume
  • Arterial pulse reflects the pumping of the heart during systole Veins
  • Transport deoxygenated blood from capillaries to the right side of the heart
  • Thinner walls makes veins more distensible; can accumulate large amounts of fluid
  • Have one way valves that allow blood to flow against gravity and return to the heart

Function of Lymph System

  • Retrieve excess fluid from tissue spaces and returns to the bloodstream. Damage to this systemor removal of nodes results in lymphedema
  • Lymph nodes filter out micro-organisms (such as bacteria) and foreign substances such as toxins.
  • Superficial lymph nodes are primarily located: - Head & neck - Axillary - Epitrochlear - Inguinal

Subjective Data-Venous

  • Pain in legs? Does walking increase pain? Laying down increase pain?
  • Numbness and tingling?
  • Varicose Veins?
  • Edema

Objective Data Arterial Insufficiency

Inspection

  • Skin is pale & shiny
  • Hair loss distribution
  • Absent or weak pulse
  • Cool temperature - No edema

Objective Data Venous Insufficiency

Inspection

  • Swollen leg
  • Darkened hyperpigmentation at ankle
  • Ulcers on leg and ankle Palpation
  • Moderate to severe pitting edema
  • Palpable pulse (depending on edema)
  • Hard skin, normal temperature

Objective Data Collection

- CMS checks : Arterial Check C irculation, M otion, and S ensation Together with the: - 5 P’s: 1. Pain 2. Pulse 3. Pallor 4. Parasthesia 5. Paralysis - Remember the edema scale (0-4) and pulse scale(0-3)? - Perform the Allen Test (assess hand perfusion) The Homan’s Sign (not used during assessment anymore!) Arterial ulcer - Round, approximated, pink/pale base, open up artery break down cause no o Venous Ulcer - Generally on ankles, medial or lateral, skin opens, and drains dark break down because old blood stagnate - Elevate leg

Time to THINK as a NURSE…

Cluster and connect the cues:

  • Immobility
  • Peripheral arterial disease (PAD)
  • Skin integrity

Test yourknowledge

You are the nurse assessing a pt. s/p femoral-popliteal bypass graft. Which of the assessment findings indicate a complication?

  1. BP 110/80, HR 86, RR 20 unlabored
  2. Small amt. of dk. red blood on dressing 3. Decrease in pulse quality of the operative leg

Palpation

  1. Small amt. of swelling of the operative leg
  • Earwax build up
  • Hearing aides in-battery
  • Stand in front-to read lips
  • Try to lower tone
  • Noise
  • Privacy
  • Scenario Mr. Johnson is an 86 - year-old who presents with hearing loss. We are going to set him up at the sink to wash his face and brush his teeth.

Older adults who are cognitively impaired – Dementia—Alzheimer’s

  • Simple sentences-avoid long explanations
  • One question
  • Allow time-don’t rush them
  • Attentive
  • Include family
  • Use pictures
  • Use gestures
  • Scenario Mrs. Scott is 78 years old. She has cognitive impairments. She does not like people touching her. We are going to take Mrs. Scotts blood pressure and listen to her heart and lungs.

Older adults who cannot speak Clearly-Aphasia, dysarthria, muteness)

  • Listen attentively
  • Be patient
  • Ask yes/ no questions
  • Allow time
  • Communication aids
  • Scenario Mrs. Applehoff is a 68 - year-old who presents with a left CVAand right sided weakness. She is trying to tell the nurse she needs something.