hyperventilation, if someone is blowing off too much CO2 they become more Correct Answer- Alkaline,
respiratory alkalosis
if a patient's lung are not
... [Show More] functioning very well and they are unable to remove or blow off CO2 very well,
the CO2 will build up in their system becoming Correct Answer- acidic, respiratory acidosis
Perfusion Correct Answer- is adequate arterial blood flow through the peripheral tissues (peripheral
perfusion) and blood that is pumped by the heart to oxygenate major body organs (central perfusion)
upper respiratory tract Correct Answer- nose, sinuses, pharynx, larynx
Lower respiratory tract Correct Answer- Lungs,Trachea, two mainstem bronchi, lobar, segmental, and
subsegmental bronchi; bronchioles; alveolar ducts; alveoli
common cause of respiratory ailments Correct Answer- Cigarette smoke
Nursing care of a patient experiencing upper respiratory system disorders Correct Answer- maintaining a
patent airway to allow adequate ventilation and oxygenation.
Along with a focused respiratory assessment, the nurse will utilize information obtained from the
patient and family during the admission history interview. Information regarding the patient's history of
upper respiratory disorders, smoking, and environmental exposures will be utilized to determine the
necessary testing and treatment
Normal Changes in Aging Adults Correct Answer- Alveoli function decreases
Ability to cough decreases
Lungs loose residual volume, vital capacity and gas exchange decreases.
Respiratory muscles atrophy
Vascular resistance increases, capillary flow decreases
Susceptibility to infection increases.
The turbinates Correct Answer- three bones that protrude into the nasal cavities from the internal
portion of the nose
increase the total surface area for filtering, warming, and humidifying inspired air before it passes into
the nasopharynx.
The paranasal sinuses Correct Answer- air-filled cavities within the bones that surround the nasal
passages
Lined with ciliated membrane, the sinuses provide resonance to speech, decrease the weight of the
skull, and act as shock absorbers in the event of facial trauma..
Fremitus refers to vibratory tremors that can be felt through the chest by palpation, Increased fremitus
may indicate Correct Answer- compression or consolidation of lung tissue, as occurs in pneumonia.
Lung sounds Correct Answer- Bronchial
Bronchovesicular
Vesicular
Adventitious sounds Correct Answer- Crackles
Wheezes
Rhonchus
Pleural friction rub
Other Indicators of Respiratory Adequacy Correct Answer- Cyanosis, decreased capillary refill, clubbing
of nails in fingers, level of consciousness, Chest Circumference, Anxiety, Dyspnea Orthopnea, General
Appearance
Diagnostic Assessment of lungs Correct Answer- Laboratory assessment
- RBC
- ABG- is a blood gas and this tells us the acid base balance of the patient
- Sputum- can tell us if microorganisms are growing in the lung - describe color, clarity, and any odor
Imaging assessment
- x-rays-Xrays show us areas of opaque which usually indicate pneumonia/consolidation of fluid
-CT- computed tomography. Lung nodules, areas of fluid buildup
Other noninvasive diagnostic assessments
- Pulse oximetry-circulating O2- tells us oxygen levels in the tissues- usually fingers, toes, or earlobes
- Capnometry and capnography-how much CO2 is leaving the lungs.
-PFTs-Lung function- tell us how well the lungs function at moving air in and out
- Exercise testing-Exercise tolerance
Invasive Diagnostic Assessment Correct Answer- -Endoscopic examinations
-Bronchoscopy- is a camera that looks at the airway passages
-Thoracentesis- can remove fluid buildup from the lung
-Lung biopsy- is used to diagnose some lung diseases or cancer
Which assessment finding for an older adult patient does the nurse ascribe to the natural aging process?
Correct Answer- A.Tightening of the vocal cords
B.Decrease in residual volume
C.Decrease in the anteroposterior diameter
D.Decrease in respiratory muscle strength
D. As a person ages, vocal cords become slack, changing the quality and strength of the voice; the
anteroposterior diameter increases; respiratory muscle strength decreases; and the residual volume
increases.
The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will have what
percent of oxygen dissociate from the hemoglobin molecule? Correct Answer- A.25%
B.50%
C.75%
D.100%
ANS: B
Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse tissues.
Under normal conditions, 50% of hemoglobin molecules completely dissociate their oxygen molecules
when blood perfuses tissues that have an oxygen tension (concentration) of 26 mm Hg. This is
considered a "normal" point at which 50% of hemoglobin molecules are no longer saturated with
oxygen.
Which assessment finding does the nurse interpret that is associated most closely with lung disease?
Correct Answer- A.Cough
B.Dyspnea
C.Chest pain
D.Sputum production
ANS: A
Cough is a main sign of lung disease. Dyspnea (difficulty in breathing or breathlessness) is a subjective
perception and varies among patients. A patient's feeling of dyspnea may not be consistent with the
severity of the presenting problem. Sputum production may be associated with coughing and indicate
an acute or chronic lung condition. Chest pain can occur with other health problems, as well as with lung
problems.
Head and Neck Cancer Correct Answer- Squamous cell carcinoma and slow growing
Begins with mucus that is chronically irritated, becoming tougher and thicker
Leukoplakia and erythroplakia lesions
Spreads to local lymph nodes, muscle and bone, then to liver or lungs.
Risks of head and neck cancer Correct Answer- •Tobacco use
•Alcohol use
•Voice abuse
•Chronic laryngitis
•Exposure to chemicals
•Poor hygiene
•Long-term gastroesophageal reflux disease
•Oral infections with human papillomavirus
Assessment: Noticing- head and neck cancer Correct Answer- Lumps in mouth, throat, neck
Difficulty swallowing
Color changes in mouth or tongue
Oral lesion or sore that does not heal in 2 weeks
Persistent, unilateral ear pain
Persistent/unexplained oral bleeding
Numbness of mouth, lips, or face
Change in fit of dentures
Hoarseness or change in voice quality
Persistent/recurrent sore throat
Shortness of breath
Anorexia and weight loss
Change in fit of dentures
Burning sensation when drinking citrus or hot liquids
The priority interprofessional collaborative problems for patients with head and neck cancer include
Correct Answer- Potential for airway obstruction [Show Less]