198 Nursezone Med-surg Nursing Final Coaching (By Doc Tacs) Part 3 (25 To 46)

During the immediate post-op period, the priority nursing diagnosis would be "Ineffective airway clearance related to bronchial secretions." This is because the client's tracheostomy is producing large amounts of sputum, indicating that there may be a blockage or difficulty in clearing the airway. Ensuring effective airway clearance is crucial to prevent complications such as respiratory distress or infection. Addressing this nursing diagnosis would involve interventions such as suctioning, promoting coughing and deep breathing, and providing humidification to help loosen and clear the bronchial secretions.

Restlessness is an early sign of hypoxia. When the body is not receiving enough oxygen, the brain and other organs are deprived of oxygen, leading to restlessness and agitation. This is the body's way of trying to increase oxygen intake. Bradycardia, hypotension, and glycosuria are not specific signs of hypoxia and are not related to the patient's condition in this situation.

The patient's traumatic injury, specifically the fractures sustained, can place her at risk for developing ARDS. Traumatic injuries can lead to inflammation and damage to the lungs, which can trigger the development of ARDS.

Given the patient's history of multiple fractures and signs of hypoxemia, the most appropriate medical treatment plan would be to prescribe mechanical ventilation. This is because mechanical ventilation can help improve oxygenation and ventilation in patients who are unable to breathe adequately on their own. It can provide support to the patient's respiratory system, ensuring that sufficient oxygen is delivered to the body and carbon dioxide is removed effectively.

Kussmaul's respiration is characterized by abnormally deep, gasping respiration. It is commonly seen in patients with diabetic ketoacidosis (DKA), which can occur in poorly controlled diabetes. In DKA, the body produces high levels of ketones as a result of the breakdown of fatty acids for energy. This leads to an acidotic state, causing Kussmaul's respiration as the body tries to compensate for the increased acidity by increasing the depth and rate of breathing. Given the patient's poorly controlled diabetes and the presence of abnormally deep, gasping respiration, Kussmaul's respiration is the most likely explanation.

The expected outcome of impaired gas exchange related to lung surgery is for the patient to exhibit a pulse oximetry of 94% or above. This indicates that the patient is receiving adequate oxygenation and their gas exchange is improving. The other options, such as reporting loss of chest pain, assuming the semi-fowler's position, and requesting pain medication frequently, are not directly related to gas exchange and do not indicate improvement in the patient's respiratory status.

Tracheal deviation to the left is indicative of tension pneumothorax, a life-threatening condition where air accumulates in the pleural space and causes the lung to collapse. This can result in the trachea being pushed to the opposite side of the affected lung. It is a significant sign of deterioration as it suggests that the condition is worsening and immediate intervention is required to prevent further complications.

The correct answer is relieve anxiety and tension. Diazepam is a benzodiazepine medication that is commonly used to treat anxiety and tension. By administering diazepam IV before chest tube insertion, the doctor aims to help the patient relax and reduce any feelings of anxiety or tension they may be experiencing. This can help make the procedure more comfortable for the patient and potentially reduce any associated stress or fear. Diazepam does not directly alleviate pain, increase respiratory rate, or increase muscle activity, so these options are not the primary purpose for administering the medication in this situation.

Performing the Valsalva maneuver involves forcibly exhaling against a closed airway, which increases intra-abdominal and intrathoracic pressure. This increased pressure can help prevent air from entering the pleural cavity when the chest tube is removed. By creating positive pressure in the thoracic cavity, the Valsalva maneuver can help to keep the pleural cavity sealed and prevent the entry of air.

In the case of acute laryngotracheobronchitis (LTB), there is a risk of complete obstruction of the airway. Emergency intubation is necessary in such cases to secure the airway and ensure adequate oxygenation and ventilation. This procedure involves inserting a tube into the trachea to bypass any obstruction and allow for the passage of air. It is crucial for the nurse to have emergency intubation equipment readily available to promptly address any potential airway obstruction and ensure the client's safety and well-being.

When providing tracheostomy care, it is important to clean the stoma with equal parts saline solution and hydrogen peroxide. This helps to prevent infection and remove any debris or secretions that may be present around the stoma. Washing the suction catheter with soap and water is not necessary for tracheostomy care. Suctioning the patient first using low wall suction may be done if there is excessive secretions, but it is not the main priority in tracheostomy care. The disposable inner cannula should be replaced as needed, but it does not need to be replaced daily.

ARDS stands for Acute Respiratory Distress Syndrome, which is a severe lung condition that can occur after an injury or illness. One of the classic findings in a patient with ARDS is hypoxia resistant to oxygen therapy. This means that despite receiving supplemental oxygen, the patient's oxygen levels in the blood remain low. This is because ARDS causes damage to the lungs, leading to impaired gas exchange and difficulty in getting enough oxygen into the bloodstream. Therefore, hypoxia resistant to oxygen therapy is a characteristic feature of ARDS.

A 19 year old male college student who sustained fractures on the right side of the thorax would likely exhibit shallow, painful breathing as an initial clinical manifestation. The fractures can cause pain and restrict the movement of the chest, leading to shallow breathing. The pain associated with the fractures can also make breathing painful. This manifestation is expected due to the injury and can help guide the nurse in assessing and managing the patient's condition.

Excessive bubbling in the water-seal chamber indicates an air leak in the chest drainage system. This could be a result of a disconnection or a loose connection in the system, which can compromise the effectiveness of the chest drainage. It is important to report this immediately as it can lead to complications such as pneumothorax or tension pneumothorax. Prompt action is necessary to prevent further damage and ensure proper functioning of the chest drainage system.

The correct answer is to check to see if the tracheostomy cuff is inflated. If the tracheostomy cuff is inflated, it may be obstructing the patient's airway and causing the coughing episodes. Deflating the cuff can help alleviate the obstruction and improve the patient's ability to swallow without coughing.

Washing off the marks placed on the skin to guide radiation therapy can lead to inaccurate targeting of the radiation beams, which can result in ineffective treatment. It is important for the patient to keep the marks intact to ensure that the radiation is delivered precisely to the intended area.

The patient's poor appetite and weight loss can be attributed to anorexia, which can be caused by radiotherapy, anxiety, and the disease itself. Eating high calorie foods can help increase the patient's calorie intake and provide the necessary nutrients to combat weight loss.

Erythromycin is the safest antibiotic to administer to a client with pneumonia who is allergic to penicillin. This is because erythromycin belongs to a different class of antibiotics called macrolides, which have a different chemical structure than penicillin. Therefore, the likelihood of cross-reactivity or an allergic reaction is minimal.

The development of pulmonary edema in patients with ARDS is due to damage to the alveolocapillary membrane. This membrane separates the alveoli (air sacs) in the lungs from the capillaries (tiny blood vessels), and is responsible for the exchange of oxygen and carbon dioxide. When this membrane is damaged, fluid leaks from the capillaries into the alveoli, leading to pulmonary edema. This can occur in conditions such as ARDS, where there is widespread inflammation and injury to the lungs.

The observation of lung re-expansion on chest x-ray would most likely indicate that the patient's chest tube should be removed. This suggests that the fractures on the right side of the thorax have healed and the lung has re-expanded, reducing the need for the chest tube. The other options, such as the amount of chest tube drainage, cessation of pain and dyspnea, and absence of fluid fluctuation in the water-seal chamber, may be important factors to consider but do not directly indicate that the chest tube should be removed.

The most severe complication among tracheostomized patients during the first 72 hours is tube dislodgment. This is because if the tracheostomy tube becomes dislodged, the patient may experience difficulty breathing or complete obstruction of the airway, which can lead to respiratory distress or even respiratory arrest. Prompt intervention is necessary to reposition or replace the tube to ensure proper airflow and prevent further complications.

A cherry red color to the mucous membranes is most indicative of possible carbon monoxide poisoning. Carbon monoxide binds to hemoglobin in the blood, preventing oxygen from binding, resulting in tissue hypoxia. The cherry red color is caused by the increased amount of deoxygenated hemoglobin in the blood. This clinical manifestation is a characteristic sign of carbon monoxide poisoning.