
respiratory disorder
SITUATION I
Question 1:
3-A
4-B
2-C
1-D
SITUATION II
Question 1:
Nurse: 234
LPN: 5
PAB: 1
SITUATION III
Question 1:
Age (89-year-old)
SITUATION IV
Question 1:
Sputum culture
SITUATION V
Question 1:
1. Placenta previa
2. Abruptio placenta
3. Premature birth
4. Intrauterine fetal death
5. Fetal growth restriction
SITUATION VI
Question 1:
1. Humidify the oxygen
2. Apply a water-soluble jelly
SITUATION VII
Question 1:
1. Audible adventitious breath sounds
2. Substernal or sub-clavicular retractions
3. Inability to complete a sentence
4. Peripheral cyanosis
5. LOC and alertness changes
6. Obstruction of the nasal passage caused by the presence of nasal secretions or discharge from the nasal passage
Question 2:
Take bronchodilator (Salbutamol) Ventolin first in order to dilate the airway by preventing bronchospasm which allows better absorption of fluticasone the corticosteroid that will diminish the inflammation in the airways.
Wait 3-5 minutes in between medications.
Question 3:
1. Administer oxygen 2L via nasal prong
2. Stay and reassure the patient
3. Administer Albuterol 2 puffs as prescribed
4. Put the patient in sitting position or Fowler's position
5. Take the patient’s vital signs
6. Perform lung assessment
Question 4:
1. Take meds before activity (15mins)
2. No strenuous exercises
3. Avoid extreme weather
4. Activity with rest periods
SITUATION VIII
Question 1:
48-72 hours
Question 2:
Liver function test (ALT or AST)
SITUATION IX
Question 1:
1. 69-year-old (low immune system)
2. She lives in a long-term facility care (higher risk)
Question 2:
1. Pain or swelling at the injection site – cold compress
2. Fever – Tylenol
3. Malaise – rest.
Question 3:
Occulorespiratory syndrome
Question 4:
1. Encourage bed rest
2. Increase fluid intake
3. Monitor vital signs
4. Give analgesics or Tylenol as per protocol or if any fever
5. Notify MD if symptoms get worse
Question 5:
Pneumonia
SITUATION X
Question 1:
Temporary side effects of the bronchodilator
Question 2:
1. Inhalers have little systemic absorption
2. With low dose prescribed; there is little risk of disturbing growth
SITUATION XI
Question 1:
1. Let it bleed
2. Wash it with soap and water
3. Have a blood test
4. Extra: Incident report, notify the head nurse or MD
SITUATION XII
Question 1:
Acute adrenocortical insufficiency
SITUATION XIII
Question 1:
Two hours after a meal
SITUATION XIV
Question 1:
Before weaning a client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure.
SITUATION XV
Question 1:
Growth rate
SITUATION XVI
Question 1:
Crackles
SITUATION XVII
Question 1:
4-AAA (Pulsating mass may rupture, emergency).
5-Ectopic pregnancy (Left lower quadrant pain, life-threatening condition, emergency).
2-Appendicitis (Needs evaluation to rule out appendicitis, possible surgery).
3-Gallbladder problem (Vomiting, which appears to be worsening).
1-Food poisoning (Usually self-limiting).
6-Ulcer (Needs a follow-up and teaching about lifestyle changes).