HESI Med Surg Hints/Study Guide, 2022

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HESI Med Surg Hints/Study Guide, 2022-Why does fever cause dehydration? - excessive fluid loss due to diaphoresis increased temperature increased metabolism increase O2 demands clients at... high risk for pneumonia - -altered LOC -depressed or absent gag and cough reflexes -susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized individuals -brain injury -drug overdose -stroke victims -immunocompromised Where are bronchial breath sounds located? - areas of density or consolidation early signs of cerebral hypoxia - Irritability and restlessness pneumonia preventives - 1) Older adults: flu shots; pneumonia immunizations; avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols); no smoking 2) Immunosuppressed and debilitated persons: Flu shots, pneumonia, immunizations, infection avoidance, sensible nutrition, adequate intake, balance of rest and activity 3) Comatose and immobile persons: Elevation of head of bed to feed and for 1 hour after feeding; frequently turning 4) Patients with functional or anatomic asplenia*: Flu and pneumonia immunizations asplenia - absence of normal spleen function and is associated with serious infection risks primary cause of COPD - smoking signs of worsening COPD - hypoxemia hypercapnia respiratory acidosis Which bed position facilitates a productive cough and comfort? - semi-Fowler high-Fowler pink puffer - barrel chest indicative of emphysema caused by use of accessory muscles to breath oxygen intake is still adequate for perfusion blue bloater - chronic bronchitis insufficient oxygenation leads to generalized cyanosis and right-sided heart failure diets for respiratory dysfunction - soft mechanical key to respiratory status - assessment of breath sounds visualization of client if breath sounds are clear but the client is cyanotic and lethargic, adequate oxygenation is not occurring s/s of laryngeal cancer - tongue and mouth often appear white, gray, dark brown, or black and may appear patchy tracheostomy care - cleansing the inner cannula suctioning applying clean dressings i pact of laryngectomy on air humidification - the natural humidifying pathway is gone for the client secretions thicken and crust patient teaching for coughing with laryngectomy clients - teach glottal stop technique: - take deep breath - momentarily occlude the tracheostomy tube - cough - simultaneously remove the finger from the tube assessment for TB skin test - a positive test is exhibited by an induration of 10mm or greater after 48-72 hours Which type of vaccine of invalidates a TB test? - bacillus Calmette-Guerin (BCG) leads to false positive; must do chest radiograph patient teaching for TB - - long term drug therapy (6+ months) - drug adherence is vital (public health hazard can result from premature termination) patient teaching for rifampin - (TB drug) reduces effectiveness of oral contraceptives orange-tinted body fluids stains contact lenses patient teaching for isoniazid - (TB drug) increased phenytoin (Dilantin) levels patient teaching for ethambutol - (TB drug) check vision before starting therapy and then monthly course of treatment may be 1-2 years patient teaching for drug combination to treat TB - teach reasoning for increased compliance resistance to drugs develops slowly if several are being used at once Why are chest tubes not used following the resection of large lung tumors? - it is helpful if the mediastinal cavity, where the lungs used to be, fills up with fluid this helps to prevent the shift of the remaining chest organs into filling the empty space What should you do if a chest tube becomes disconnected from the box? - do not clamp place the end of the tube in a container of sterile water What should you do if a chest tube becomes disconnected from the patient? - cover with dray sterile dressing cover 3 sides; do not occlude notify the provider What does tidaling in the chest tube indicate? - fluctuations in the fluids will occur if there is no external suction this is a good indicator that the system is intact if fluctuations cease, check for kinked tubing, accumulation of fluid, or client repositioning 4 common symptoms of pneumonia - Tachypnea, fever with chills, productive cough, bronchial breath sounds 4 nursing interventions for assisting the client to cough productively - deep breathing 3L/day fluid in take humidifier suction airway symptoms of pneumonia in an older client - Confusion, lethargy, anorexia, rapid respiration rate How does the nurse prevent hypoxia during suctioning? - deliver 100% oxygen before and after suctioning During mechanical ventilation, what are 3 major nursing interventions? - monitor respiratory status and secure connections establish a communication mechanism with the client keep airway clear by coughing and suctioning physical findings with emphysema - barrel chest dry/productive cough decreased breath sounds dyspnea crackles Describe preoperative nursing care for a client undergoing a laryngectomy - invovle family in manipulation of equipment before surgery plan communciation methods refer to speech pathologist discuss rehab program 5 nursing interventions after chest tube insertion - 1. Maintain a dry occlusive dressing on chest tube 2. Keep all tubing connections tight 3. Keep all tubing connections taped 4. Monitor client's clinical status 5. Encourage the client to breathe deeply periodically. What instructions should be given to a client following radiation therapy? - Do not wash off lines; wear soft cotton garments; avoid use of powders and creams on radiation site. What precautions are required for clients with TB when placed on respiratory isolation? - A mask for anyone entering room; private room; client must wear mask if leaving room. [Show More]

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