Review for 1166 midterm exam revised Oct 2010

1. Review for 1166 midterm examrevised Oct 2010 By Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP

2. Question • You are reading the chart and you need to find the patient’s current Vital Signs prior to giving inhaled Beta II bronchodilator. • Where would you look?

3. answer • I would first go to the NURSE’S GRAPHIC SHEET where she charts her scheduled VS. • I would also check the respiratory therapist’s charting for the last VS with the last treatment • I will also do my own VS prior to starting a medication because I know that VS change from minute to minute

4. Question • Where in the patient’s chart would you go to find out what diseases the doctor wants to test the patient for?

5. answer • I would go to the DOCTOR’S PROGRESS NOTES where the doctor’s SOAP charting will be found with his PLAN. • I could also look in the PHYSICIANS ORDERS to see what kind of lab work the doctor has already ordered.

6. Question • Where in the chart would you go to find out what the doctor wants you to do for this patient right now?

7. answer • I would go to the PHYSICIAN’S ORDERS to find the current orders I need to do my patient care.

8. Question • Your patient has a HR that is 138 bpm, his blood pressure is 118/75 mmHg and his RR is 18 bpm. • Are the VS normal?

9. answer • a HR that is 138 bpm is elevated • his blood pressure at 118/75 mmHg is WNL • his RR at 18 bpm is WNL.

10. question • If the doctor has ordered a ultrasonic mist Q 4 hours by aerosol mask with air and you gave the last one at 2 PM, when is the next one due?

11. answer • We would give the next Ultrasonic at 6 PM

12. question • If the doctor orders an MID with Atrovent [ipratropium bromide] TID, how often would you do this in a 24 hour period

13. answer • TID is 3 x a day; Generally we will only do this while the patient is awake so breakfast, lunch and dinner time are reasonable

14. question • Your patient is getting a SVN with 2.5 mg of Albuterol in 2. 5 ml of normal saline. • What would be an indication for this medication?

15. answer • It is given to treat or prevent bronchospasm associated with asthma or COPD • The normal saline will act as a wetting agent to help loosen secretions; normal saline also dilutes the Albuterol so that the drug will last 10-12 minutes • Normal saline is less irritating to the airways than sterile water

16. question • Your patient is a 2 year old toddler whose Sp02 is 88% on Room air. He has retractions, nasal flaring and is breathing rapidly. • You would recommend?

17. answer • Supplementary 02 for a child this age would be best accomplished by placing the child inside a mist tent [mist tent/croup tent/02 tent are all different names for the same device.] • nasal cannula for this-sized child are available

18. Question • If you want to find out the patient’s diagnosis, you could get this information out the chart at what point?

19. answer • I would check the DOCTOR’S PROGRESS NOTES where the doctor will place his educated guess into the A [appearance] portion of the SOAP • I would check the PHYSICIANS’ ORDERS for orders that hint at the diagnosis—for instance: if the PHYSICIANS’ ORDERS include glucose measurements after meals and insulin shots obviously, this patient has diabetes. • if the patient has bronchodilators ordered there is some problem with the lower airways that results in bronchospasm

20. question • Your PHYCICIAN’s ORDERS include the phrase “check pulse ox and keep Sp02 above 93%.” • On room air [Fi02 21] your patient’s Sp02 is 96% with a HR 88 bpm and a RR of 12 bpm. This patient’s major concern is making the TV work correctly and making sure his lunch comes on time. • What will you do?

21. answer • I would record the Sp02, Fi02 and the HR and RR in my Respiratory Care charting and not start 02. • Because there was no frequency on the pulse oximeter order, I would not repeat the Sp02 unless the patients VS were to worsen-- in which case I want to make sure the Sp02 is above 93% because I do have an order for that.

22. question • If your patient has increased wheezing and rhonchi, what would this do to his WOB?

23. answer • His WOB would increase as his driving pressure increases; this could be seen as retractions, and nasal flaring and increased work of the muscles of both the abdomen and the chest wall. He would most likely have increased RR and increased HR

24. question • Your patient who has diminished BBS in the basal areas of the lung and who has diffuse crackles. What is the effect of this on this patient WOB?

25. answer • The diminished basal breath sounds imply that the basal alveoli are collapsed [atelectasis] & this will require increased driving pressure to re-inflate these stiffened lung units. • The crackles also imply that there is atelectasis. • This patient’s WOB is increased due to decreased lung compliance.

26. question • Your patient has intercostal retractions and is breathing fast. • Might she be in respiratory distress? • What might you recommend?

27. answer • Yes, she is showing s/s of increased WOB • I would measure her RR, HR and get a Sp02 • I would listen to her BBS • Because the AARC Clinical Practice Guidelines state that I can start 02 for s/s of increased WOB, I could safely recommend 1-2 lpm nasal cannula--until I know more.

28. question • To assess a patient for a need for SVN with Albuterol, you would recommend what?

29. answer • I would listen to BBS for wheezing or prolonged exhalation • I would check the patient’s history for asthma, COPD or other disease associated with bronchospasm • I would measure the HR and RR for s/s of increased WOB • I would look at the patient for visible s/s of increased WOB • I would look at the chest for increased AP diameter or observe the patient’s assumption of the tripod position needed to use accessory muscles of inspiration • I would percuss the chest for hyper-resonance associated with air-trapping • I would palpate the belly for tensing of the abdominal muscles during a forced exhalation with accessory muscles

30. question • If your patient has BBS with prolonged exhalation in the RML and rhonchi over the RUL what would you recommend?

31. answer • I would give Albuterol by SVN to treat the bronchospasm that is manifested by prolonged exhalation • The normal saline in the SVN would help loosen the secretions associated with the rhonchi

32. question • Your patient just pulled an endotracheal tube out of his throat. Immediately after this, his RR rises to 32 bpm from 12 bpm, his HR is 110 bpm from 77 and you see that he has supraclavicular retractions. • When you listen to his breath sounds you hear a sound associated with upper airway obstruction. What is this sound?

33. answer • Stridor is a sound associated with laryngeal swelling. • We would also hear this with a child who is suffering from croup • The cough would be ‘barky’

34. question • You started a 45% entrainment mask on a patient and after 15- 20 minutes you note that the RR is still 26 bpm and that the Sp02 is still 88%. • You have checked the function of the device. What do you recommend right now?

35. answer • Fi02 45% is not enough; raise it to 50% and reassess the VS and the Sp02 • Suggest an ABG if this change doesn’t increase the Sp02 to above 90% • Listen to BBS for other problems that need to be dealt with such as bronchospasm

36. question • Your patient is on an bland aerosol mask at 60%. Her RR is 12 bpm and her HR is 88 bpm, Her Sp02 is 100%. • What do you recommend at this time?

37. answer • Because Fi02 is at toxic levels, we need to get the Fi02 down. • I suggest we decrease the Fi02 from 60% to 50% and recheck the Sp02 & VS • Keep decreasing the Fi02 every 30 minutes as long as the Sp02 is above 95% and as long as the patient shows no s/s of increased WOB or hypoxemia

38. question • Your patient is breathing shallowly, and is complaining of pain during inspiration over the lower right chest wall. • When you attempt to percuss the patient, he recoils and c/o pain and tenderness over the lower right chest wall • On auscultation, you hear a rubbing on inspiration. • The nurse recommends you give the SVN with 2.5 mg Albuterol about 30 minutes early • You reply?

39. answer • No, I would not give the SVN early, because this breath sound is associated with a pleuritic problems such as effusion or pleurisy-- not bronchospasm. • We need to notify the doctor of this change

40. question • Your patient’s skin is pale, cool and damp. His capillary refill is 3 seconds and his pulse rate is rapid and irregular. • The EMS wants to start him on Incentive spirometry • You recommend?

41. answer • We need to get a systemic blood pressure by cuff because this is a cardiovascular issue & we need to call the doctor • We need to assess the patient’s LOC • We need to start this patient on 02 for possible increased work of the heart • We need to watch this patient carefully for possible s/s of a need for CPR

42. question • Your patient has a disease that places him in RESPIRATORY ISOLATION. • How will you prepare to go into the room

43. answer • Wash hands & place gloves [we do this with everyone] • Place mask on to protect myself • Keep my patient inside the room with the door shut to protect other folks from the infection • If a ‘laminar flow’ room is available place, patient inside one.

44. question • Your patient has a Sp02 that is only 90% on 8 lpm nasal cannula and the doctor wants to keep his Sp02 above 93%. • What do you recommend?

45. answer • We need to raise the flow rate from 8 lpm to 9 lpm to get the Sp02 up…..but we cannot go that high on a nasal cannula. • At this point, we might switch to a simple mask at 9 lpm…but that can only get to Fi02 50% which isn’t much higher than a 8 lpm N/C which can only get to 45% • We might recommend an entrainment mask at 50% because the N/C & a simple mask are both low flow systems which will deliver less 02 as the patient’s minute ventilation rises • We need to follow up with repeat Sp02, VS and consider calling the doctor for an ABG if this change doesn’t fix the Sp02

46. question • Dullness to percussion and crackles are associated with what disorders?

47. answer • Alveolar consolidation is associated with dullness to percussion • Atelectasis is associated with crackles • This could be due to some alveolar involvement such as pneumonia, pneumonitis or congestive heart failure

48. Question • There is hyper-resonance to percussion and you see a patient with an increased AP diameter. • What disorders are associated with these?

49. answer • these s/s are associated with air-trapping with is associated with airway obstructions from such diseases such as in asthma, COPD. • If you listen to the chest you most likely will hear expiratory wheezes, some course crackles from fluid in the airways and maybe distant breath sounds. You may hear prolonged exhalation time

50. question Your patient has a Pa02 of 45 mmHg on an entrainment mask at 35%. To correct his hypoxemia [get the Pa02 to 80 mmHg] what Fi02 should you select?