Adult Nursing Unit 1 Exam Notes Sun Aug 31st 2025
Chapter 10 ABGs only
Focus on basic reading and interpretation of arterial blood gasses. Be sure to think of causes and treatment as well as nursing
measures to support the patient.
(We are not doing compensation until next semester).
Chapter 17 Assessment of Respiratory Function
Understand health assessment specific to respiratory conditions. Link this into your other chapters as you study. Think about
percussion and other assessments that maybe you aren't as familiar with. Be sure to relate the patient history. Understand trends in
vitals and patient symptoms that would alert you that there is a respiratory issue. Be sure to look at lab values related to the
respiratory system as well as diagnostics. Think about any preparation, precautions, or post-procedure complications for
diagnostic tests. Diagnostic examples: ABGs, pulse oximetry, bronchoscopy, thoracoscopy.
Chapter 18 Upper Respiratory
Know how to care for and prevent the following conditions: viral-rhinitis, rhinosinusitis, pharyngitis. Understand care and
treatment of sleep apnea as well as risk factors. Outline care for epistaxis and nasal fractures. Be sure to understand how to care
for patients with laryngeal cancer (signs and symptoms are important to know) and those that have laryngectomy (think post-op
care).
Chapter 19 Lower Respiratory
Understand how to prevent and manage atelectasis. Think about ways to help prevent problems with the lungs like IS, oxygen,
nebulizers, etc. Be sure to understand risk factors and how to prevent aspiration. Be sure you understand the care of patients with
lower respiratory infections such as bronchitis, pneumonia, and TB. This could even include medications for these conditions.
Understand care of pleurisy. Know risk factors, signs and symptoms, and how to care for patients with lung cancer. Understand
care of a patient with a tracheostomy. Understand care of a patient with an endotracheal tube.
Save for next semester: Mechanical ventilation, ARDs, respiratory/chest trauma, chest tubes.
Chapter 20 Chronic Pulmonary Disease
Know all about COPD and Asthma. Think signs and symptoms, treatment, nursing care, and self-management strategies. Know
patient education on oxygen use at home.
Chapter 17
Q Recognize components of a focused assessment that should be included when collecting data on adults who have alterations
in gas exchange and respiratory function. (p.1377 for Table)
Adult Nursing Unit 1 Exam Notes Sun Aug 31st 2025
Chapter 10
Q Identify the laboratory and diagnostic tests used to evaluate respiratory function and related nursing implications. (ABGs,
pulse oximetry, bronchoscopy, thoracoscopy).
Bronchoscopy
Q Discuss the correct use and functioning of therapeutic devices that support oxygenation.
Chapter 18
Q Outline nursing management for patients with upper airway inflammation and infections.
Q Rhinosinusitis
Q Pharyngitis
Q Outline the nursing care for a patient with obstruction or trauma of the upper airway.
Obstructive sleep apnea
Q Epistaxis
The nurse monitors the patient’s vital signs, assists in the control of bleeding,
and provides tissues and an emesis basin to allow the patient to expectorate
any excess blood. It is common for patients to be anxious in response to a
nosebleed. Blood loss on clothing and handkerchiefs can be frightening, and
the nasal examination and treatment are uncomfortable. Assuring the patient in
a calm, efficient manner that bleeding can be controlled can help reduce
anxiety. The nurse continuously assesses the patient’s airway and breathing as
well as vital signs. On rare occasions, a patient with significant hemorrhage
requires IV infusions of crystalloid solutions (normal saline) as well as cardiac
and pulse oximetry monitoring.
Q Nasal fracture
Q Explain the nursing management for care of patient with laryngeal cancer undergoing a laryngectomy.
Chapter 19
Q Identify patients at risk for atelectasis and the nursing interventions related to its prevention and treatment.
Q Nursing interventions related to atelectasis prevention and treatment:
Q Explain nursing measures to prevent aspiration in at risk patients.
Q Apply the nursing process for care of the patient with a lower respiratory tract infection.
Bronchitis, Pneumonia, Influenza, Tuberculosis.
Q Influenza
Seasonal influenza, or “flu,” occurs as an epidemic, usually in the fall and winter months. It is a highly contagious acute viral
infection that occurs in children and adults of all ages. Influenza can be caused by one of several virus families, and this can vary
yearly. Adults are contagious from 24 hr before manifestations develop and up to 5 days after they begin.
Assessment; Expected Findings
Severe headache and muscle aches
Chills
Fatigue, weakness
Severe diarrhea and cough (avian flu)
Fever
Hypoxia (avian flu)
Diagnostic Procedures
Although viral culture and other laboratory tests are available to confirm the diagnosis, the CDC recommends testing only if the
results will be used to make treatment decisions.
Patient-Centered Care
Nursing Care
Maintain droplet and contact precautions for hospitalized clients who have pandemic influenza.
Provide saline gargles.
Monitor hydration status, intake, and output.
Administer fluid therapy as prescribed.
Monitor respiratory status.
Medications
Antivirals: Amantadine, rimantadine, ribavirin oseltamivir, zanamivir, peramivir can be prescribed for treatment of influenza.
Duration of the influenza infection can be shortened by antivirals such as the oral inhalant zanamivir and the oral tablet
oseltamivir. In cases of pandemic influenza, these medications may be distributed widely among the population.
Client Education: Begin antiviral medications within 24 to 48 hr after the onset of manifestations.
Influenza vaccines: Quadrivalent and trivalent vaccines are prepared yearly depending upon the suspected strain of influenza
expected to appear.
Yearly vaccination is encouraged for everyone older than 6 months of age.
Clients who have a history of pneumonia, chronic medical conditions, and those over age 65, pregnant women, and health
care providers are at higher risk and require vaccination.
Interprofessional care
Respiratory services should be consulted for respiratory support.
Community health officials are notified of influenza outbreaks.
State and federal public health officials are consulted for containment and prevention directives during pandemic influenza.
Client Education
Obtain an annual influenza immunization when vaccines become available.
Reduce the risk for spreading viruses by thoroughly washing hands and following cough etiquette.
Avoid places where people gather. Avoid close personal contact (handshaking, kissing, and hugging).
If flu manifestations develop, increase fluid intake, rest and stay home from work or school.
Avoid travel to areas where pandemic influenza is identified.
Be aware of public health announcements and activation of the early warning system by public health officials in case of
pandemic influenza.
Q Tuberculosis
Nursing Actions
Obtain three early-morning sputum samples.
Wear personal protective equipment when obtaining specimens.
Samples should also be obtained in a negative airflow room.
Diagnostic Procedures: Mantoux test
A client will have a positive intradermal TB test within 2 to 10 weeks of exposure to the infection.
An intradermal injection of an extract of the tubercle bacillus is made. It should be read in 48 to 72 hr.
An induration (palpable, raised, hardened area) of 5 mm is considered a positive test for clients who are at high risk (have HIV,
had recent contact with someone who has TB, have positive chest x-ray, or immunosuppressed).
An induration of 10 mm or greater in diameter indicates a positive test for clients who are at moderate risk (born in a country
where TB is common, have a substance use disorder, work in a high-risk area such as a laboratory of congregate setting, have
medical conditions which place them at high risk, or are younger than 5 years old).
An induration of 15mm or more indicates a positive test for clients who have known risk factors for TB.
A positive Mantoux test can indicate that the client has developed an immune response to TB. It does not confirm that active
disease is present.
Clients who have had a positive Mantoux test or have received a Bacillus Calmette-Guerin vaccine within the past 10 years can
have a false-positive Mantoux test. These clients need a chest x-ray or QuantiFERON-TB Gold test to evaluate the presence of
active TB infection. QEBP
Clients experiencing immunocompromise can demonstrate anergy, or lack of response to Mantoux testing, even if M.
tuberculosis is present in the body. In this case, other diagnostic testing is indicated to rule out infection.
Individuals who have latent TB can have a positive Mantoux test and can receive treatment to prevent development of an
active form of the disease.
Clients who are immunocompromised (such as those who have HIV) and older adult clients should be tested for TB. Clients
starting immunosuppressive therapy (such as tumor necrosis factor antagonists) should be tested for TB prior to starting
treatment.
Client Education: Return for a reading of the injection site by a health care personnel between 48 and 72 hr.
Nursing Care
Administer heated and humidified oxygen therapy as prescribed.
Prevent infection transmission.
Wear a N95 HEPA filter or powered air purifying respirator when caring for clients
who are hospitalized with TB.
Place the client in a negative-airflow room, and implement airborne precautions.
Use barrier protection when the risk of hand or clothing contamination exists.
Have the client wear a surgical mask if transportation to another department is necessary. The client should be transported
using the shortest and least busy route.
Teach the client to cough and expectorate sputum into tissues that are disposed off by the client into provided plastic bags or
no-touch receptacles.
Administer prescribed medications.
Promote adequate nutrition.
Encourage fluid intake and a well-balanced diet for adequate caloric intake.
Encourage foods that are rich in protein, iron, and vitamins C and B.
Provide emotional support.
Q Summarize nursing measures for patients with pleural conditions.
Nursing measures for clients with pleural conditions, such as pleural effusion or pneumothorax, focus on monitoring respiratory
status, managing pain, and providing specific care for chest tube drainage systems. The primary goal is to improve oxygenation,
promote lung re-expansion, and prevent complications.
Respiratory management and assessment

Continuous monitoring: Frequently assess the client's vital signs, including respiratory rate, effort, rhythm, and
oxygen saturation (SpO2). Also, monitor heart rate and blood pressure for signs of compromise.

Auscultate lungs: Listen for breath sounds, noting any decrease or absence over the affected area, and monitor for
adventitious sounds.

Promote lung expansion:
o
Positioning: Elevate the head of the bed (high-Fowler's position) to help lung expansion and improve
ventilation. For unilateral effusions, a lateral position with the head of the bed at 45 degrees may improve
oxygenation.
o
Breathing exercises: Encourage and assist the client with deep breathing, coughing, and using an incentive
spirometer to prevent atelectasis.

Oxygen therapy: Administer supplemental oxygen as prescribed to address hypoxia.
Pain management

Assess pain: Use a pain scale to determine the severity and characteristics of pleuritic chest pain.

Administer medication: Provide prescribed analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs) for
pleuritic pain, or stronger pain medications for severe cases.

Non-pharmacological measures:
o
Splinting: Teach the client to splint the chest with a pillow when coughing to minimize pain.
o
Positioning: Help the client find a position of comfort.
o
Rest: Provide a calm environment and adequate rest periods to conserve energy.
Patient education

Condition and treatment: Explain the underlying cause of the pleural condition, the treatment plan, and the goals of
care.

Signs of worsening: Instruct the client and family on signs and symptoms to report, such as increasing shortness of
breath, fever, increased pain, or signs of infection at the drain site.

Post-procedure care: If a chest tube or pleural catheter is inserted, provide detailed instructions on home care,
including drainage management and wound care.

Lifestyle changes: Recommend smoking cessation and provide resources, as smoking increases the risk of some
pleural conditions.
Q Identify the nursing care of a patient with an endotracheal tube or a tracheostomy.
Q Relate the modes of therapy and related nursing management of patients with lung cancer.
Nursing care for patients with lung cancer focuses on managing both the physiological and psychological impacts of the disease
and its treatments, including optimizing respiratory function, alleviating pain and fatigue, preventing complications like infection,
and providing robust emotional and educational support. A comprehensive approach involves thorough patient assessment,
tailored education, symptom management for both cancer-related and treatment-related side effects, and coordinated care with
the multidisciplinary oncology team.
Key Nursing Priorities

Respiratory Management:

Oxygenation: Administer oxygen as prescribed and monitor for signs of hypoxemia and hypercapnia,
such as restlessness and changes in mentation.

Airway Clearance: Promote a patent airway and effective cough, and educate patients on airway
clearance techniques.

Positioning: Implement positioning techniques, such as elevated head of the bed, to improve lung
expansion and breathing.

Symptom Management:

Pain: Assess and administer analgesics for pain, particularly those related to bone metastasis, and evaluate
their effectiveness.

Fatigue: Address and help manage fatigue, a common symptom of lung cancer and its treatments.

Nausea and Vomiting: Prevent and manage gastrointestinal side effects, such as nausea, often associated
with chemotherapy.

Psychosocial Support:

Emotional Well-being: Provide psychological support, reduce anxiety and fear, and refer to support
groups and counseling services.

Patient Education: Educate patients and families about the disease, treatment processes, medication
management, and potential complications to improve treatment adherence and coping.
Nursing Interventions

Health Promotion:
Encourage healthy lifestyle modifications, including weight management, physical activity, healthy diet, and
smoking cessation.

Infection Prevention:
Monitor for and prevent respiratory infections, as patients with lung cancer are at increased risk.

Nutritional Support:
Collaborate with dietitians to ensure adequate nutritional intake, which supports overall health and treatment
outcomes.

Coordination of Care:
Work with the entire healthcare team, including oncologists, primary care physicians, and social workers, to ensure
comprehensive and coordinated care.
Assessment and Monitoring
Comprehensive Assessments:
.Conduct thorough assessments including subjective and objective data related to dyspnea, pain, changes in
mentation, and respiratory status.
Assess for and prevent complications such as respiratory infections, aspiration, and treatment -related adverse events.
Chapter 20
Q Apply the nursing process for care of patients with COPD.
Q Develop an education plan for patients with COPD.
Q Apply the nursing process for care of patients with asthma.
Q Develop asthma self-management strategies.
Q Provide patient education regarding home care considerations for patients receiving oxygen therapy.