hey everyone it's nurse Sarah and in this video I'm going to go over some practice Med surge respiratory questions to help you prepare for the inlex exam our first question says you're caring for a patient with pneumonia the patient has just started treatment for pneumonia and is still experiencing hypoxemia you know that respiratory acidosis is common with pneumonia which arterial blood gas reading below represents uncompensated respiratory acidosis so in our multiple choice options we are given a bunch of arterial blood gas results and we've got to determine which results or which option represents respiratory acidosis uncompensated so you could do this question a number of ways you could go through and solve each of those options to determine which one's respiratory acidos is uncompensated you could use either the tic-tac-toe method or the Rome method I have an ABG workbook up here if you need extra help with doing these type of problems or you can do it this way which is a whole lot faster because you know these tests are timed and we've got to keep up the pace so how you can easily do this question is you got to go back and think back to normal results for pH P CO2 our carbon dioxide and our bicarb CO3 so let's quickly review that a normal blood pH is about 7.35 to 7.45 a normal P2 is 35 to 45 and then a normal B carb is about 22 to 26 so we're looking for something that is acidic let's concentrate on that pH first so we want to go ahead and just eliminate the options where the pH is either alkalic or it's normal meaning we probably have full compensation so we're going to go ahead and eliminate option b because our pH is 7.48 that is on the alkalic side because it's greater than 7.45 and then we're going to eliminate option D because the pH is 7.55 and that is definitely alkalic as well so we're going to mark that off so we're left with options A and C so option a pH is 7.29 we know that is acidic so we're somewhere in the acid realm so let's go over and look at the P2 it's 55 a normal is 35 to 45 anything greater than 45 is going to be acid so I'm seeing that my pH and my P CO2 are both acidic so let's look at our bicarb let's see where it's at is it normal cuz if it was it would be uncompensated or is it abnormal what is it so it's 23 a normal is about 22 to 26 so that is normal so right there that value is respiratory acidosis uncompensated but let's go make sure we're okay with C before we just answer Okay C pH is 7.20 that's acidic definitely what's our P2 it's 50 that is acidic as well because anything greater than 45 is acidic so that's looking very similar as number one as a but let's look at that bicarb what is it it's 22 to 26 that is abnormal so that right there is respiratory acidosis with some partial compensation our bicarb system is trying to um increase that blood pH by making itself more alkalic but it hasn't achieved it completely yet because our pH is still on the acid side so we don't have full compensation so our answer is a this question says while helping a patient with a chest tube repositioned in the bed the chest tube becomes dislodged what is your immediate nursing intervention here are patient has a chest tube and unfortunately we had an accident that chest tube has came out which you know sometimes unfortunately happens in the clinical setting so you need to know what you got to do for this patient because this is an emergency situation let's look at our options a stay with the patient and monitor their vital signs while nurse notifies the healthc care provider okay that sounds okay um I feel like we need to do a little bit more besides just staying there and just monitoring their Vital Signs we need some more action going on and of course we need to get help to not notify the healthcare provider but let's look at our other options B place a sterile occlusive dressing over the side and tape it on three sides and notify the healthc care provider that looks a little bit better because we're actually doing something and um I like that then option A but let's just look at the other options and then we'll go back and see which ones are better C attempt to reinsert the tube no you can eliminate this one right off the bat because that is out of the scope of practice of an nurse we do not insert chest tubes so mark that off and then D keep the Sigh open to Air and notify the healthc care provider well for a second you might think okay well maybe but let's think back to chest tubes chest tubes we're dealing with the lungs and they're very sensitive to pressure and so we don't want to keep this like hole open on the chest and just allow air to come in and mess with the pressures in our chest because number one that could cause further damage and then number two we're introducing infection possibly into that normal sterile space so D no so option b is looking like our best answer compared to the other option we're sort of thinking about option A and let's talk about why option b I think is the correct answer well it's telling us that we're going to put a sterile occlusive dressing and tape it on three sides where our chest tube has came out and we want to do that because that's going to prevent more air from from getting in that space which we don't want it's like going to be a temporary fix until we can get the healthc care provider there so they can reinsert another chest tube or do whatever they want to do now as a side note anytime you have a patient who has a chest tube you want to plan for the future or those unfortunate dislodgments or break in the system or anything that can happen because if it can go wrong it's definitely going to go wrong and it's going to go wrong when you're having a crazy day so always keep uh these emergency things close by you like for instance the sterile clusive dressing and the tape in case this does happen so you don't have to be scrambling and having to call Supply and get your supplies for this situation so we're going to do that and also you're going to incorporate option A into it of course but here the answer is B but you're going to get help from another nurse and get them to call the healthcare provider while you're staying there with the patient monitoring their Vital Signs and looking for any respiratory distress here we have a patient with severe COPD and they are having an episode of extreme shortness of breath and requests their inhaler which type of inhaler ordered by The Physician would provide the fastest relief for the patient based on this particular situation here we have a patient who has severe COPD so let's quickly recap about what this is COPD stands for chronic obstructive pulmonary disease and in a nutshell what happens is that we have this chronic inflammation that has affected the lungs over time and it's led to the Airways being damaged like the bronchial tubes and the Alvi sacs and because of this it's going to obstruct airf flow and patients can have various cases where they have just a mild case or they have an extreme case and you're going to see like chronic coughing with this wheezing and difficulty breathing like with exertion or I've even seen some cases where the patient have had COPD so bad that even just talking they can only talk a couple words and then they have to stop and take breaths and then they can talk a little bit more so just even talking is really hard on some of these patients so in this scenario we're told that our patient is having an episode of extreme shortness of breath so we have some emergency situation going on where we need to get airf flow moving because this patient is not breathing really well so we're giving these medications and we need to pick the medication that's going to provide the fastest relief therefore whenever you are studying like in Pharmacology these types of medications that are Ed for pulmonary diseases you need to be paying attention to if they're like a long acting or short acting Bronco dilator like how fast does it work when do they take this because treatment is going to be based on what's going on with your patient and what type of inhaler they need so our first option A it says tiotropium bromide the brand name for for this is Spa which is a lot easier to say than that generic name um and this medication is a long term preventative Bronco dilator so this is used to prevent Bronco spasms right now our patient is probably having one so we need something that's going to work immediately so we can rule that one out and then B somm Medrol solm Medrol is a bronco dilator but you got to determine is a short or long acting and this is one of those long acting ones it's also used as preventative and maintenance of lung diseases it's not used for a rescue situation so we can eliminate that one then we have option C which is beeside with fotol this is an inhaler that has two different types of drugs in it the budesonide is the corticosteroid and the fol is the Bronco dilator and this is part of that long acting class so again that's going to be for the maintenance of our signs and symptoms but that corticosteroid is also going to help maintain our signs and symptoms keep those decreased because it's going to decrease inflammation in our lungs however it's not really good for what's going on in this current situation so we're going to mark that off therefore we're just left with option D which must be our answer but why is it our answer so albuterol is a short acting Bronco dilator it works as a beta 2 Agonist so in your lungs you have beta 2 receptors and what this handy little medication does once you inhale it it goes and binds to those receptors in the lungs because those receptors are on the smooth muscles which control the opening and closing of your Airways which in this situation our patient is Bronco constricting and we need to Bronco dilate them so we need to go in there get on those beta 2 receptors so we can get on that smooth muscle and open it up so we can get some air flow going in and that's what AOL is going to do and it's going to do it pretty fast so this is our best option for a patient here we have a patient that we educating on how to use a peak flow meter to help monitor the status of their asthma which statement by the patient demonstrates they understand how to use this device so to answer this question we need to select the option or the patient statement that tells us that the patient truly understands what a peak flow meter is so in other words we are eliminating options that are incorrectly said by the patient so a this device will make my lung stronger so I don't have another asthma okay whenever I read that it makes me think that the patient thinks that by using this device they are going to be improving their lung function it's going to make their lungs stronger so they're sort of confusing the peak flow meter with an incentive spreter and those are two handheld devices they're both really handy but they both have different goals a peak flow meter is used to really monitor a patient asthma because it's going to tell us how well air is Flowing out of their lungs because this device helps the patient measure the highest amount of air that they can exhale out of the lung so it's looking at that Peak expiratory flow so by measuring that that tells us if the patient might have narrowing in their lung so they have their goal where they're at with you know their highest reading they've got on this peak flow meter so if they're using this regularly throughout the day like they should and they notice that that percentage is going down well that tells us that there's less air being able to come out of the lungs which tells us that we have narrowing and the asthma is worsening so the patient can adjust their medication regimen based on this treatment plan that they've created with their healthc care provider depending on the numbers that they're getting with their Peak flow meter so option A we're going to eliminate that one B I will exhale as hard as I can while using this device okay well whenever you're using the peak flow meter that's what you do you don't inhale on the device you're breathing out because we're measuring the air flow out of the lungs so option b is looking good C I will lie down when I use this device no that's not right whenever you use the peak flow meter you're not going to be lying down while you're doing it you're going to be standing up and blowing on this device so we can eliminate that one and then D I will notify the doctor if my Peak flow rating is 90% or more than my personal best Peak flow so with this you've got to be familiar where the patient should be in these readings so here on your screen you can see where we want the patients there's different color zones and based on what zone the patients in will depend on what they're going to do so for instance the green zone we have an 80 to 100% of their readings that they've got if they get this this is great and we know that green means go it's good so they're going to continue with their normal medications they have good lung function and control at the moment now let's say it's less than 80% they're in that yellow zone so we're a little cautious here that tells us that hey not much air you know it's decreased about how much is Flowing out so your asthma is getting a little worse so you want to follow the medication treatment plan that you've made with your health care provider to prevent an attack from coming on and then the absolute worst they can get is less than 50% that means they are in the red red is bad so they're in the red zone and if that's the case they need to go and get medical care so we can give them some treat treatments to prevent a asthma attack from coming on so our best answer is B next question says you're educating a patient with COPD on how to deep breathe by using an incentive spirometer which of the following is the correct way to use this device so now we're dealing with an incentive spirometer instead of our Peak flow meter so the incentive spirometer we like to give patients who are going to be having surgery with this because it can help prevent pneumonia also it's a great device for patients who have breathing disorders like COPD because it helps keep their lung function stronger and it helps clear the airway so option A encourage the patient to use it twice a day so twice a day that's not a lot you need to be using this device at least 10 times every 1 to two hours while awake so you know if they're sleeping they don't need to get up and do it but while they're awake they need to be using it at least 10 times every 1 to two hours so we can be popping those lungs open moving those secretions making sure we're not decreasing our lung function so we're going to eliminate that one B the patient exhales into the device rapidly and then coughs okay so I know with the peak flow meter we talked about you're exhaling in the device so with an inum perometer you're doing the opposite instead we are inhaling on the device here on your screen I want you to look at these steps on how to use an incentive spirometer so first depending on what kind of device you have you're going to attach that flexible tubing to the port and then you want to set the goal for the patient with a marker of any kind that's on the device because that lets the patient know where they've got to go and um then you know you have the patient set up and exhale completely and then they want to seal their lips around that mouthpiece tightly and then have the patient inhale deep and slowly so we're inhaling we're not EX exhaling and making sure to keep the yellow indicator within normal range you don't want them doing this too fast or too slow and this piston is going to rise now the patient needs to keep inhaling as deep as possible until unable to hold their breath any longer and then hold breath for 6 seconds then after that exhale slowly and allow the Piston to fall and then repeat again so we can eliminate B and then C says patient inhale slowly from the device until no longer able and then holds breath for 6 seconds and exhales and that looks pretty good pretty promising that's like what the steps were that we went over but let's take a look at D the patient rapidly inhales 10 times from the device and then exhales six for 6 seconds this is not correct because we need to make sure that the patient is using this device slowly until they're no longer able they just don't rapidly pull or suck on this device and what's interesting is that a lot of times you really whenever you give patients these in Sim promets you have to take time to educate them because I've had patients whenever they're about to use it I've seen them rapidly inhale on the device it's almost like that's what you naturally think you need to do and then I've also seen where patients will try to blow in the device of course it's not going to work whenever they do that and then another problem I've seen is that they just don't use it as often as they need to or they're not using the device in sets of 10 so they're not using it really long enough so our best answer for this question is C next we have a patient who is recovering from a pneumothorax and has a chest tube present which of the following is an appropriate finding when assessing the chest tube drainage system so our options say the following we have a intermittent bubbling may be noted in the Water Seal chamber so let's think about this for a moment it tells us that there's intermittent bubbling what does intermittent mean that means it's happening occasionally here and there it doesn't say it's continuously happening which means it's happening constantly that if it did that would be Troublesome because we may have a leak and we need to investigate that but it's intermittent so whenever you're seeing this bubbling you want to ask yourself okay why does my patient have a chest tube again and we're told that the reason they have one is because they have a numa thorax and remember anuma thorax is where air has got inside that plur space and shouldn't have been there and it's caused our lung to to collapse so in a nutshell what's going to happen is that they get this chest tube that's going to help relieve or take out that air that is there and hopefully help our lung re-expand so in our chest tube what is going to be coming out of that tube if they have auma thorax mainly air so it's just going to be natural that you're going to see this intermittent bubbling here in this water seal chamber so that option looks possibly like an appro apprpriate finding but let's look at our other ones B 200 mls of drainage per hour is expected during recovery of auma thorax well that's quite a bit and the fact that our patient has auma thorax they really shouldn't have that much drainage and if they're having 200 mls per hour that tells me that something else may be going on maybe they have some more damage in there and we need to investigate that so that wouldn't be inappropriate we'll mark that off see the chest tube drainage system is positioned at the patient's chest level to facilitate drainage with this you want to remember how you should position the drainage system of the chest tube it's going to be assisted with gravity and draining out what it needs to drain out so we do that with gravity so it's best to place that drainage system below the patient's chest so that's not an appropriate finding so we'll mark that off and then D that makes our job easy all these options are appropriate findings and we just very F out that B and C weren't so D is not the answer so a is our answer here we're told we have a patient who has exercise induce asthma which of the following actions can the patient perform to prevent an attack during exercise select all that apply so we're going to have multiple answers option A says avoid warming up before exercise so is this something that a person who has a history of exercise induce asthma would want to do would they want to avoid you know warming up before the exercise the answer to that would be no because they need to get their body acclimated or prepared for what is about to happen especially prepping those Airways so doing some little short warm-ups will help prepare the lungs for their exercise instead of shocking them so we are just going to X that one out option b says administer a short acting beta Agonist before exercise so is this something they would want to do well let's think about this short acting beta Agonist is going to work really fast they can use it right before the exercise anywhere between 10 minutes 30 minutes and what it's going to do is it's going to go ahead and prep those Airways and get those nice and dilated so whenever they go to exercise which could you know cause some Bronco constriction we've already have that Bronco dilator in there to prevent those signs and symptoms from coming on because depending on what medication they're using these uh Bronco dilators can last up to 4 hours which gives them plenty of time to their exercise regimen so yes this can definitely be something that a patient with exercise induced asthma can do now as a side note you know short acting beta Agonist you know the rapid acting inhalers can be used but patients could also use one of those ones that we talked about earlier like simor where we have the combination of beeside and fotol where they take that beforehand to prevent that so just keep that as a side note as well and then option C says administer a short acting beta Agonist after exercise no it's best to do it beforehand so we have that dilation before we exercise because exercise hence exercise induc asthma that's what's causing our asthma so we want that on board before we actually do it so it wouldn't be after and then D avoiding exercise when experiencing a respiratory illness yes we want to educate and tell them about this because whenever you have something going on with your lungs they're compromised they're definitely at risk for experiencing Bronco constriction so we want them to just fully recover before they go and exercise our next question says a 52-year-old female patient is receiving medical treatment for a possible tuberculosis infection the patient is a US resident but grew up in a foreign country she reports that as a child she received the BCG vaccine which is the bacil colat Gan vaccine which order by the healthcare provider below would require the nurse to ask for clarification so whenever we're looking at these options we're looking for an option that really jumps out at us that wouldn't be something that would be good to be ordered on this patient so we see that the patient has had the BCG vaccine that's one thing that should be jumping out at you and we're testing them for possible a tuberculosis infection so option A is a PPD test which is a Man 2 test that is the skin test for tuberculosis PPD stands for purified protein derivative that's where you get the little injections on your skin and we're looking for a positive result b a chest x-ray C an interferon gamma release essay which is an IG which is a blood test that test for tuberculosis or D as sputum culture so which one makes our nursing Bells go off and says hey this probably isn't the best test for this patient to help us look for tuberculosis okay so let's talk about this BCG vaccine this is a vaccine given in foreign countries it's not given here in the US it's given to Pediatric patients to help prevent a tuberculosis infection where in areas where tuberculosis is very high now because they're getting a vaccine they're being exposed to this bacteria if we go and do a skin test on them the PPD what do you think's going to happen they're probably going to have a false positive so that's not the best test for them the Man 2 test however what would be a little bit better for them would it be a chest Xtra chess x-ray the IG or the sputum culture a better option for them would be the blood test so just testing their blood for it however this question wants to know which one will require a clarification and the answer would be a the PPD next we have a patient who's had a PPD skin test again that Man 2 test as the nurse you tell the patient to report back to the office in so we have a drop- down box and it says 24 hours to 48 Hours 12 to 24 hours 48 to 72 hours or 24 to 72 hours so the results can be interpreted so with this you just got to pull from your memory bank and you got to think back to when a patient should come back to get the reading read and the answer is 48 to 72 hours they have to come back within that time frame not before or not after because if they come before it's way too early we can't interpret it if they come after they're just going to have to redo the test because that's when the results pop up our next question says a patient is on mechanical ventilation with peep which stands for positive in expiratory pressure which finding below indicates a patient is developing a complication related to their therapy and requires immediate treatment so to answer this question we're looking for something that jumps out at us that tells us they're developing a problem related to this mechanical ventilation with peep so a a b carb of 26 normal B carb is 22 to about 26 that's within range not too concerned about it so we're good with that b a blood pressure of 70 over 45 that's concerning that is hypotensive now is that a problem and let's talk about it for a second with peep okay so peep is a setting on the ventilator and in a nutshell what it is is that we're keeping this small amount of pressure in there especially during expiration so those Alvi sacs are just staying open a little bit more so we can have better gas exchange where oxygen is going into that bloodstream and carbon dioxide is going out but the problem is is that we can overinflate these lungs and so whenever we do that we could cause a numa thorax we could cause subq inisa where air starts to actually escape from the lungs and go into to our subq tissue or um we can cause another big problem which is probably what's going on with this situation where we've increased inter thoracic pressure inside the chest so in your chest you have your lungs but what's next door your heart so we've increased the pressure on those lungs on that heart we're affecting how that heart can pump so it can't fully contract and expand and we're going to affect how it can actually fill with blood and pump that blood out so when we do that are you pumping out a lot of blood throughout your heart no you're going to drop your cardiac output when we drop cardiac output one of the things that you can see is that their blood pressure will drop so that is very concerning so going to keep B in the back of her mind C A pa2 of 80 how much Oxygen's in their arterial blood that's within range about 80 to 100 so we're okay with that um d a P2 this is our carbon dioxide in our blood blood we don't want too much or too little about 35 to 45s are normal and they're within that range so our answer is B next we're told the healthc care provider orders chest physiotherapy on your patient with cystic fibrosis this is best performed wi so just to recap cystic fibrosis is a genetic disorder that is caused by a mutated Gene the CFT Gene so we have an issue with our CFT protein and because we have an issue with this we have problems with creating this thick sticky mucus that affects not only our respiratory system but our digestive system particularly the pancreas so with this patients have to get phys chest physio therapy and this is like a combination of percussion vibration deep breathing and um expelling mucus clearing those Airways and they have to do this regularly so as the nurse you need to know when this should be best performed so we have a immediately after a meal okay so whenever you eat food your belly is full and is this a good time to have percussion and vibration and coughing and spitting up no because doing that can increase the risk of aspirating and vomiting because you have a full stomach so we would not want to do this immediately after a meal B right before a meal think about the patient they're about to eat a meal they're hungry but do they just want to have have been going through percussion coughing deep breathing getting the sticky mucus up and have that in their mouth and then go eating RTO meal it's not going to be that Pleasant so it's probably not best before a meal so we're going to ex that out see 1 to two hours after a meal okay 1 to two hours after a meal our food has been able to leave our stomach by then it's making it way through intestines so we should have relieved the pressure in there we're full we've already ate good so yes that would be probably the best time to perform this and then D only at bedtime no because this is not something that's just performed at bedtime they're going to do this multiple times throughout the day so our answer would be C okay so that wraps up this review over practice Med surge respiratory questions now I also have other reviews where I go over other types of questions so if you want to access those you can get it in the link below