ADVANCED ATI MED SURG FINAL EXAM WITH NGN(ALL NEW UPDATED SOLUTIONS)

3. Notify the provider immediately if symptoms occur, administer oxygen and obtain ABGs Why is a bronchoscopy performed - CORRECT ANSWER 1. Visualization of abnormalities such as tumors, inflammation and strictures 2. Biopsy 3. Removal of foreign bodies and secretions 4. Treat post operative atelectasis What is preprocedure nursing interventions for a bronchoscopy - CORRECT ANSWER What are intraprocedural nursing interventions for a bronchoscopy - CORRECT ANSWER What are post procedure nursing interventions for a bronchoscopy - CORRECT ANSWER The patient is not discharged from the recovery room until adequate cough reflex and respiratory effort are present What are three complications that can occur from a bronchoscopy - CORRECT ANSWER Laryngospasm, pneumothorax, aspiration What are nursing interventions for Laryngospasm spasm and what can decrease the likelihood of laryngeal edema - CORRECT ANSWER 1. Monitor the patient for signs of respiratory distress 2. Maintain a patent airway by repositioning the patient or inserting an oral/nasopharyngeal airway as appropriate 3. Administer oxygen therapy to the patient as prescribed. Humidification can decrease the likelihood of laryngeal edema What are nursing interventions for a pneumothorax - CORRECT ANSWER 1. Assess patient's breath sounds and O2 sat and obtain a follow-up chest x-ray What are nursing interventions for aspiration - CORRECT ANSWER 1. Prevent aspiration and the patient by withholding oral fluids or food until the gag reflex returns 2. Perform suctioning as needed What is a thoracentesis - CORRECT ANSWER Performed to obtain specimens for diagnostic evaluation, instill medication into the plural space, and remove fluid or air from the plural space What are preprocedure nursing interventions for a Thoracentesis - CORRECT ANSWER 1. Obtain preprocedure x-ray as prescribed 2. Position the patient sitting upright with his arms and shoulders raised and supported on pillows and/or on an overbed table and with his feet and legs well supported 3. Instructed patient to remain absolutely still during the procedure and not to cough or talk unless instructed by the primary care provider What are intraprocedural nursing interventions for a thoracentesis - CORRECT ANSWER 1. Monitor the patient's vitals, skin color and O2 sat throughout the procedure 2. Measure and record the amount of fluid removed from the patient's chest (The amount of fluid removed is limited to one L at a time to prevent cardiovascular collapse) 3. Label and send specimens to the Laboratory What are post procedure nursing interventions for a thoracentesis - CORRECT ANSWER 1. Apply a dressing over the puncture site and assess dressing for bleeding/drainage 2. Monitor vitals and respiratory status hourly for the first several hours after 3. Encourage the patient to deep breathe to assist with lung expansion 4. Obtain a chest x-ray (check resolution of effusions, rule out pneumothorax) What are complications of a thoracentesis - CORRECT ANSWER Mediastinal shift, pneumothorax, bleeding, infection What is a mediastinal shift - CORRECT ANSWER Shift of thoracic structures to one side of the body (Monitor VS, auscultate lungs for a decrease in or absence of breath sounds) What is a symptom of pneumothorax - CORRECT ANSWER Diminished breath sounds What are indications of a pneumothorax - CORRECT ANSWER 1. Deviated trachea 2. Pain on the affected side that worsens upon exhalation 3. Affected side does not move in and out upon inhalation/exhalation 4. Increased HR 5. Rapid shallow respirations 6. Nagging cough or feeling of air hunger Chapter 20 - CORRECT ANSWER How long does it take for a patient to exhibit symptoms when exposed to healthcare acquired pneumonia - CORRECT ANSWER 24 to 48 hours What is rhinitis - CORRECT ANSWER Inflammation of the nasal mucosa What is objective data for rhinitis - CORRECT ANSWER 1. Red, inflamed, swollen nasal mucosa 2. Low-grade fever