Exam 2: NSG223/ NSG 223 (Latest 2024/ 2025 Update) Med Surg 2 Exam| Questions and Verified Answers| 100% Correct| Grade A- Herzing
Exam 2: NSG223/ NSG 223 (Latest 2024/
2025 Update) Med Surg 2 Exam| Questions
and Verified Answers| 100% Correct| Grade
A- Herzing
Q: What does hypoventilation and retention of CO2 cause is patients who are hypoxemic?
Answer:
Hydrocarbonate + hypercapnia
Q: What therapy should you expect to see a patient with hypoxemia on?
Answer:
Oxygen therapy FIRST, then oxygen therapy
Q: When do you put oxygen on?
Answer:
When O2 level is 92% and below
Q: What can cause pulmonary edema?
Answer:
Left ventricular failure, acute MI, or chronic HF
Q: What are early signs of pulmonary edema?
Answer:
Early stage is treated with diuretics and reducing preload by placing patients in an upright
position with feet & legs dependent
Q: How do you you reduce preload in patients with pulmonary edema?
Answer:
By placing patient upright position with feet & legs dependent
Q: What is used to treat pulmonary edema?
Answer:
Oxygen — to relieve hypoxemia
Diuretics — promise excretion of sodium and water, furosemide or another loop diuretic given
IV push or as continuous infusion
Vasodilators — Iv nitroglycerin or nitroprusside for symptom relief, contraindicated in patients
who are hypotensive
Q: What teaching is important for patients who are hypoxemic using oxygen therapy?
Answer:
Deep breathing techniques.
Q: For what patients are vasodilators contraindicated for?
Answer:
Hypotensive
Q: Why are vasodilators are used in patients with pulmonary edema?
Answer:
IV nitroglycerin or nitroprusside for symptom relief
Q: Patho phys of respiratory failure
Answer:
Inadequate gas exchange
Q: Hypoxemia patho
Answer:
Decrease in arterial oxygen tension (PaO2) to less than 60 mmHg.
Decrease in arterial O2 saturations
Q: What is hypercapnia?
Answer:
Increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mmHg
Increase in arterial O2
Q: What is the cause of hypoxemic respiratory failure
Answer:
Oxygen failure aka lung failure
O2 < 60 mmHg on 60% oxygen
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Where do you put the stethoscope when assessing lung sounds?
Over tissue, NOT bone
What should you tell a patient before a respiratory assessment?
That they will tire easily
Why do we listen to lung sounds?
To detect adventitious sounds.
What are the different types of lung sounds?
Crackles (crinkled paper) – high pitched, heard during inspiration, not cleared by cough.
Rhonchi (rough) – rumbling, course sounds like a snore, during inspiration or expiration, may clear with coughing or suctioning
Wheeze – musical noise during inspiration or expiration, usually louder during expiration
When do you hold narcotics?
When respirations are less than 8/min
What are the normal number of respirations per minute?
12-20
What is hypoxemia?
Inadequate o2 for metabolism
What are the early signs of hypoxemia?
RAT – restlessness, anxiety, tachycardia/tan homes
Catching early signs is very important in hypoxemia.
What are late signs of hypoxemia?
BED – bradycardia, extreme restlessness, dyspnea
What are signs of hypoxemia in PEDS?
FINES- feeding difficulty, inspiratory strider, nares flares, expiratory grunting, sternal retractions
What are two common conditions associated with hypoxemia
Hydrocarbonate +hypercapnia present due to hypoventilation and retent CO2
What does hypoventilation and retention of CO2 cause is patients who are hypoxemic?
Hydrocarbonate + hypercapnia
What therapy should you expect to see a patient with hypoxemia on?
Oxygen therapy FIRST, then oxygen therapy
When do you put oxygen on?
When O2 level is 92% and below
What can cause pulmonary edema?
Left ventricular failure, acute MI, or chronic HF
What are early signs of pulmonary edema?
Early stage is treated with diuretics and reducing preload by placing patients in an upright position with feet & legs dependent
How do you you reduce preload in patients with pulmonary edema?
By placing patient upright position with feet & legs dependent
What is used to treat pulmonary edema?
Oxygen — to relieve hypoxemia
Diuretics — promise excretion of sodium and water, furosemide or another loop diuretic given IV push or as continuous infusion
Vasodilators — Iv nitroglycerin or nitroprusside for symptom relief, contraindicated in patients who are hypotensive
What teaching is important for patients who are hypoxemic using oxygen therapy?
Deep breathing techniques.
For what patients are vasodilators contraindicated for?
Hypotensive
Why are vasodilators are used in patients with pulmonary edema?
IV nitroglycerin or nitroprusside for symptom relief
Patho phys of respiratory failure
Inadequate gas exchange
Hypoxemia patho
Decrease in arterial oxygen tension (PaO2) to less than 60 mmHg.
Decrease in arterial O2 saturations
What is hypercapnia?
Increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mmHg
Increase in arterial O2
What is the cause of hypoxemic respiratory failure
Oxygen failure aka lung failure
O2 < 60 mmHg on 60% oxygen
True or false: hypoxemic respiratory failure is acute, lasting from minutes to hours.
True
True or false: chronic hypoxemic respiratory failure lasts several days or longer.
True.
What are the causes of respiratory failure?
Ventilation-perfusion mismatch.
Shunt
Diffusion
Alveolar hypoventilation
What is hypercapnic respiratory failure?
AKA ventilation failure (pump failure)
It is caused by an imbalance between ventilator supply or demands
O2 >45 mmHg and pH <7.35
What are the causes of hypercapnic respiratory failure?
Imbalance between ventilators supply and demand
Airway/alveoli (emphysema, asthma, cystic fibrosis)
CNS (drug OD, brain stem infarction, spinal injury
Chest wall and neuromuscular conditions
Can a patient have both hypoxemic respiratory failure and hypercapnic respiratory failure at the same time?
Yes
What are the diagnostic studies for respiratory failure?
1st – history and physical assessment
Most definitive — ABG analysis
What is the most definitive diagnostic study for respiratory failure?
ABG analysis
What is the treatment of respiratory failure?
Bronchodilators to reduce inflammation
Corticosteroids to reduce pulmonary congestion
Diuretics, nitrates if HR present
IV antibiotics if treating underlying pulmonary infection
Benzodiazepines and narcotics to reduce anxiety, pain, agitation
pulmonary embolism (PE) patho phys
Refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart; common disorders of DVT
DVT pathophysiology
A related condition, refers to thrombus formation in the deep veins, usually in the calf or thigh but sometimes the arm, especially in patients with peripherally inserted central veins
VTE (venous thromboembolism)
Is a term that includes both DVT and PE
the biggest concern of VTE is the clot breaking off
What is the treatment of a pulmonary embolism
1 priority is to give the patient oxygen via nasal cannula to relieve hypoxemia, respiratory distress, and central cyanosis
What is the surgical management for patients who have pulmonary embolisms?
Surgical embolectomy indicated for massive PE or hemp dynamic instability or contraindications to thrombolytic therapy
Inferior Vena Cava (IVC) filter
May be inserted in patients who have contraindications to therapeutic anti coagulation or in recurrent PE occurs
When is a inferior vena cava filter recommended?
If the patient has recurrent PEs
How do you prevent thrombus formation?
Encourage ambulation,
Acting + passive exercises if bedridden
Advise patients not to lie or sit for prolonged periods, cross legs, or west constrictive clothing
Intermittent pneumatic compression (IPC) devises – sleeves place on legs that inflate
Keep patient supine, legs should not dangle, feet resting on floor or chair
DONT leave IV Caths in for long periods of time
All increase venous flow and decrease venous stasis
What are the signs and symptoms of anPE
Extremities evaluated for warmth, redness, inflammation
Pleurititc chest pain, hemoptysis, shortness of breath and collapse, features of DVT, hypotension, tachypnea, raised jugular venous pressure, focal chest signs
1 is shortness of breath, anxiety, fever, tachycardia, cough, diaphoresis, syncope, hemoptysis
What is long term treatment for pulmonary embolism?
Long term: Warfarin (Coumadin)
What labs does a patient on warfarin need and how often do they need them?
They need their labs drawn for INR and they have a higher risk for bleeding risks
What is given if INR is high and there is a risk for bleeding?
Vitamin K
acute respiratory distress syndrome (ARDS) patho phys
Severe: characterized by alveolar damage that results in hypoxemia that is unresponsive to supplemental oxygen
Associated factors in development if ARDS
Direct injury to lungs: smoking, pneumonia, aspiration, inhaling toxins, drowning, embolism
Or indirect injury to lungs (shock)
Nursing management for ARDS
Patient is critically ill and requires close monitoring in ICU. If patient is on ventilator then will need frequent assessment, monitoring, and repositioning
Repositioning patient improves ventilation + perfusion in lungs & enhances secretion drainageC closest monitor patient for deterioration in o2 status with position changes
What position should you place a patient with ARDS in to improve ventilation?
Prone position (upright position by RN) leaning, legs dangles, decreases venous return shunting blood away from the lungs
True or false: patients may be anxious and fight the ventilator
True
If PEEP can’t be maintained despite using sedatives, whag is given to the patient that will paralyze them?
Vecuronium (paralytic agent)
Takes effect in 3-5 minutes, lasts 25-45 minutes
Allow the patient to ventilate easier, paralyzes them so they appear unconscious, can’t breath, talk, blink independently although they are awake and able to hear
Used for the shortest time possible
RELAXES vocal cords
What is the “train-of-four” test?
It is used to measure the level of neuromuscular blockade
Four consecutive stimuli are delivered along the path of the nerve and response of the muscle is measured. Tells us whether stimuli are effectively blocked. If no twitches, then muscle is effectively blocked.
What is the medical management for ARDS?
Supplemental oxygen used as patient begins initial sporran, then endotracheal intubation and mechanical ventilation are intimated.
How do you treat respiratory acidosis
With sodium bicard
How do you treat respiratory alkalosis:
Have patient inhale 5% of CO2 or rebreather expired air
What are normal ranges for hemoglobin and hematocrit?
HbG: women: 12.0-15.5) men are 14.5-17.5
HcT: 35%-47% and for men it’s 39-40
Dehydration is commonly seen in?
Older adults on lots of diuretics
What is a normal sodium level:
135-145 mEq/L
Suctioning
FVD and hyponatremia
Hypernatremia
: when sodium bicarbonate is administered to the patient with acid-base imbalance. It increases the risk for having hypernatremja
What do you give to patients who have hyperkalemia?
Kayexalate — polystyrene. If the insulin is too high then we result to insulin after works
Medication is brown tan and smells bad
Insulin moves potassium back into the cell. From ECF to ICF
Magnesium:
1.5-2.5
What will develop with hypermagnesium
Renal failure
Hypomagnesemia
Associated with neuromuscular irritability which suggests that a patient may be at risk for seizures
VTE
Is a tweak that includes both DVT and PE
What is the #1 treatment of PE?
The first priority is oxygen via nasal cannula to relieve hypoxemia, respiratory distress, and central cyanosis’
When is a inferior Vena cava (IVC) filter used?
It is used if the patient has a contraindication to anticoagulants, or if the patient has had a recurrent PE
What is a inferior vena cava filter?
It provides a screen in the IVC, allowing bood to pass through while large emboli from pelvis or lower extremities are blocked or fragmented before reaching the lung
Patient ARDS is critically I’ll and requires close monitoring in ICU — true or false and
true
What position are patients with ARDS put in?
The prone position, this improves oxygenation. Devices, specialty beds assist RN in placing patient in this position.
Place the patient in a prone position (upright
What is the prone position and why?
Upright position, leaning, legs dangling, decreases Venous position return by shunting blood away from the lungs
True or false: patients may be anxious and fight the ventilator
True
What is PEEP?
positive end expiratory pressure
If PEEP cannot be maintained patient with ARDS despite sedatives, what is commonly used?
Paralytic agents, typically vecuronium
Vecuronium
Takes effect in 3-5 minutes and lasts about 25-44 minutes
Allows patient to ventilate easier, paralyzes them so they appear unconscious, can’t breath, talk, blink independently although they are awake and can’t hear
Reassure patient that this feeling is temporary and used for the shortest time possible
This relaxes the vocal cords
Use a train of four method
What is the train of four?
It is used to test the level of neuromuscular blockade
4 consecutive stimuli are delivered along the path of a nerve and the response of the muscle is measured to detect if the nerve is blocked effectively
How do you know if a nerve is effectively blocked?
Using the train of 4 — if there are no twitches then 100% of the receptors are blocked
When is endotracheal intubation for ARDS?
When the hypoxemia progresses, endotracheal intubation and mechanical ventilation are initiated
What does PEEP do?
Peep increases functional residual capacity and reserves alveolar collapse by keeping the alveoli open, resulting in improved arterial oxygenation and reduced severity of the V/Q imbalance
Ventilator associate pneumonia
Occurs in 70% of patients with ARDS
Commonly develops after 48 hours or more of mechanical ventilation
Most cases result from aspiration of bacteria from mouth or GI tract
This complicated ARDS patients recovery, requires longer duration of ventilation, longer staying
Pharmacological management of ARDS
ARDS causes pulmonary edema, so we give looo diuretics — Furosemide
NORMAL arterial blood pH
7.35-7.45
normal ABG O2
Measures partial pressure of oxygen that is dissolved in plasma
80-100
Normal ABG CO2 level
Partial pressure of CO2 in arterial blood 35-45
Normal ABG HCO3
22-26
What are the three lines of defense the body has for fluid imbalance
1st line of defense = buffers
Acts as sponge, soaks up hydrogen ions when too much present — squeezes them out when too little are present
2nd line of defense = respiratory system
After hypo/hyperventilating changes amount of CO2, compensated within seconds after change in pH.
If the patient has COPD, this fails and patient only has 2 lines of defense
3rd line of defense = renal system
More powerful, kicks in 24-48 hours, kidneys move bicarb, form acids, form ammonium which all can increase excretion and reabsorption rates of acids or bases, depending of the direction of the PH
If the patient has kidney disease, this system fails. If the patient has COPD + kidney disease the patient is in trouble
What lab levels do acute and chronic metabolic acidosis?
Calcium. Metabolic acidosis can result in low calcium levels
What can low calcium lead to, and why is it important to be supplemented before correcting acidosis?
Low calcium can result in tetany and death, so it should be supplemented prior to correcting acidosis
Chronic metabolic acidosis is associated with?
Hypocalcemia. Treat this before chronic metabolic acidosis is treated to avoid tetany resulting from any increase in pH and decrease in ionized calcium
What is given with metabolic acidosis?
Alkalizing agents
Acute and chronic metabolic alkalosis
Metabolic equal, respirations normal
What symptoms should you focus on?
Tingling of fingers and toes can indicate patients has this
Chronic metabolic alkalosis due to long-term loss of acid (long-term use of diuretics
What is a common cause of metabolic alkalosis
vomiting or gastric suction
Acute and chronic respiratory acidosis
Respiratory opposite
What conditions lead to chronic respiratory acidosis?
Emphysema, sleep apnea, bronchitis, obesity can impair gas exchange and can cause retention of carbon dioxide with leads to respiratory chronic respiratory acidosis (can not get rid of these diseases)
COPD and respiratory acidosis
Gradually accumulate CO2 over prolonged days to months, may not develop symptoms of hypercapnic due to compensatory renal changes have time to occur
Acute and chronic respiratory alkalosis
Caused by hyper ventilation — patient blows off excessive amounts of carbon dioxide which creates an alkaline environment
As an RN it is my job to monitor for respiratory acidosis
How do you treat metabolic acidosis?
Treat with sodium bicarbonate
Correct respiratory impairment
How do treat respiratory alkalosis?
Treat by having patient inhale 5% CO2 or rebreathe their expired air
When do hemoglobin and hematocrit levels change?
At age 65+
What are normal ranges for hemoglobin?
Women: 12.0-15.5
Men: 13.5 – 17.5
What are normal hematocrit levels?
Women: 35-47%
Men: 39-50%
Fluid volume deficit — aka dehydration are common in what patients?
Patients who are 65+ and on diuretics
What can suctioning lead to?
Fluid volume deficit and hyponatremia
What is normal sodium levels?
135-145
What is a concern when administering sodium bicarbonate to a patient with an acid-base imbalance?
Hypernatremja
How does insulin affect potassium?
It moves the potassium from ECF back into the ICF
How do you treat metabolic alkalosis?
Treat it with an infusion of sodium chloride plus potassium chloride
Severe cases – infused .1% hydrochloric acid of ammonium chloride
Why is insulin given to patients with hyperkalemia?
Insulin is given if the patient does not respond to kayexalate.