FCNP Exam 3
fluid volume deficit
cardiovascular manifestations of _____ ______ _______ include: - tachycardia - flat neck veins - decreased pulse pressure - decreased capillary refill - moderate orthostatic hypotension - severe falling of diastolic/systolic BP
hypermagnesemia
causes of _______________ include: - adrenal insufficiency - increased Mg intake - diabetic ketoacidosis
hypomagnesemia
causes of _______________ include: - fluid loss - chronic alcoholism - prolonged malnutrition - malabsorption - poorly controlled diabetes - hyperaldosteronism
hyperphosphatemia
causes of ________________ include: - chronic/acute renal failure - large intake of milk and vitamin D - excessive P laxative intake - hypoparathyroidism - sickle cell anemia - chemotherapy
hypophosphatemia
causes of ________________ include: - malnourishment/malabsorption - alcohol withdraw- chronic alcoholism - TPN - P-binding antacids containing Mg or aluminum - recovery syndrome - glucose or insulin therapy - recovery from diabetic ketoacidosis
A, C, E
.What are some adverse effects of opioids? (select all that apply) A. Respiratory depression B. Diarrhea C. Sedation D. Polyuria E. Pruritus
A, C, E
5-10% of HTN cases have a known cause that can be corrected. Which of these are modifiable risk factors? (select all that apply) A. cirrhosis B. age C. drug related D. sex E. endocrine disorders
A
5-10% of HTN cases have a known cause that can be corrected. Which of these is not a modifiable risk factor? A. ethnic background B. neurologic disorders C. renal disease D. sleep apnea E. pregnancy induced
hypernatremia
Causes of _____________ include: - excessive water loss from skin losses, diarrhea, vomiting, fever, osmotic diuretics, etc. - sodium gain (can occur with hypertonic IV solutions) - clinical dehydration - inadequate water intake
hypercalcemia
Causes of _____________ include: - malignancy (most common) - hyperparathyroidism (most common) - vitamin D overdose - long term immobility - thiazide diuretics - phosphorous is likely decreased if this is increased
neuropathic
Centrally and peripherally generated pain are types of __________ pain.
C
Choose the lab value that is out of range. A. Sodium, 145 mEq/L B. Calcium, 9.9 mg/dL C. Urine output, 25 ml/hr D. Potassium, 3.6 mEq/L E. Urine specific gravity, 1.020
A
Postural drainage is an intervention that is often performed with chest physiotherapy. The purpose of postural drainage is to: A. Allow lung secretions to drain by gravity. B. Hyperventilate the patient's lungs. C. Provide inhaled medications to promote drainage of secretions. D. Break up secretions by clapping rhythmically on the chest
hypertonic
What type of solution is this? Raises osmolality of ECF and expands volume. Treatment of hyponatremia and trauma pts with head injuries. These solutions require frequent monitoring of BP, lung sounds, and serum sodium levels bc of risk for intravascular fluid loss. - Na >145 mEq/L - osmolality >295 mOm/kg
aspiration
Define: Inflammation of the lungs/bronchi from inhalation of foreign material
hypovolemia
Define: Isotonic loss (water and sodium loss in equal amounts). Osmolality is normal.
clinical dehydration
Define: Loss of extracellular water + hypernatremia. Osmolality is increased- ECF is concentrated
iron deficiency anemia
Define: Most common nutritional deficiency in the world. Etiology- inadequate dietary intake, malabsorption, blood loss, hemolysis Most susceptible- very young, poor diet, women in reproductive years
mean arterial pressure (MAP)
Define: Pressure necessary to perfuse organs.
diastole
Define: Relaxation of the myocardium
diastole
Define: Relaxation of the myocardium. Allows for filling of the ventricles (repolarization).
cardiac output
Define: The amount of blood being ejected by the left ventricle each minute
stroke volume (SV)
Define: The amount of blood ejected from the ventricle with each heartbeat.
cardiac output (CO)
Define: The amount of blood pumped by the ventricle in 1 minute.
mean arterial pressure (MAP)
Define: The average arterial pressure over a cardiac cycle (SBP + 2DBP / 3)
pulse pressure
Define: The difference between Systolic BP and Diastolic BP.
afterload
Define: The resistance the left ventricle must overcome to circulate blood
preload
Define: Volume of blood in the ventricles at the end of diastole (end diastolic pressure).
3rd spacing
Define: When fluid accumulates where it is not easily exchanged with the rest of the ECF (unavailable for use)
B
During assessment of the client's vital signs, the nurse would be concerned about a MAP of: A. 90 B. 50 C. 70 D. 100
elevated
What category of HTN is this: Systolic between 120-129 and diastolic less than 80
stage 1
What category of HTN is this: Systolic between 130-139 or diastolic between 80-89
dietary approaches to stop hypertension
What does "DASH" stand for?
face, legs, activity, cry, consolability
What does FLACC stand for? (pain assessment tool)
tissue perfusion
Possible nursing interventions for ineffective ______ ________: - monitor LOC and mental status - monitor labs for serum electrolytes - turn every 2 hours
transcutaneous electrical nerve stimulation
What does the dependent nursing intervention (that is a nonpharmacological pain strategy) abbreviated as "TENS" stand for?
A
What is a SMART, patient-centered goal for fluid volume deficit? A. The patient will maintain urine output greater than 30 mL/hr within 24 hours. B. The nurse will monitor intake and output every shift. C. Consult the dietitian for foods high in water content by the end of the shift. D. The patient will comply with fluid restrictions.
100 mL
What is the average amount of fluid output from feces? (mL)
900 mL
What is the average amount of fluid output from insensible loss? (mL)
1500 mL
What is the average amount of fluid output from urine? (mL)
300 mL
What is the average intake of water from oxidation in an adult? (mL)
daily weighs
What is the greatest indicator of fluid shifts over time?
age
What is the greatest risk factor for cardiovascular disease?
4 grams
What is the max amount of acetaminophen that can be given a day?
60
What is the minimum MAP needed to adequately perfuse organs?
22-26 mEq/L
What is the normal HCO3 range? (mEq/L) Increased- alkalosis Decreased- acidosis
95-100%
What is the normal SaO2 range? (%) Decreased- hypoxemia
11.5-15.5 g/dL
What is the normal hemoglobin range for females? (g/dL)
13.2-17.3 g/dL
What is the normal hemoglobin range for males? (g/dL)
35-45 mmHg
What is the normal pCO2 range? (mmHg) Increased- acidosis Decreased- alkalosis
7.35-7.45
What is the normal pH range for arterial blood gases? Increased- alkalosis Decreased- acidosis
80-100 mmHg
What is the normal pO2 range? (mmHg) Increased- O2 therapy Decreased- hypoxemia
9.0-10.5 mg/dL
What is the normal range for calcium? (mg/dL)
1.3-2.1 mEq/L
What is the normal range for magnesium? (mEq/L)
70-100
What is the normal range for mean arterial pressure (MAP)?
3.0-4.5 mg/dL
What is the normal range for phosphate? (mg/dL)
150,000-400,000
What is the normal range for platelet count?
3.5-5.0 mEq/L
What is the normal range for potassium? (mEq/L)
135-145 mEq/L
What is the normal range for sodium? (mEq/L)
1.005-1.030
What is the normal range for specific gravity of urine?
A
What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused? A. risk of dehydration B. risk of kidney damage C. risk of stroke D. risk of bleeding
4-8 L/min
What is the range for normal cardiac output? (L/min)
1000 mL
What is the recommended fluid intake from solid food for an adult? (mL)
1200 mL
What is the recommended intake for fluids from drinking water, tea, juice, etc. for an adult? (mL)
2500 mL
What is the recommended total fluid intake for an adult? (mL)
application of cold
What nonpharmacological pain strategy does this describe: Decreases blood flow to the area which in turn decreases inflammation and swelling Generally applied for 15-30 minutes at a time and assessed every 5-10 minutes
application of heat
What nonpharmacological pain strategy does this describe: Increases blood flow to the area which in turn relaxes the muscles and decreases pain and stiffness in the joints Generally applied for 15-30 minutes at a time and assessed every 5-10 minutes
21%
What percent oxygen is room air?
24%
What percentage of oxygen is delivered by a nasal cannula at 1 L/min?
28%
What percentage of oxygen is delivered by a nasal cannula at 2 L/min?
32%
What percentage of oxygen is delivered by a nasal cannula at 3 L/min?
thiazide diuretics
What type of diuretic is this? - monitor calcium - hydrochlorothiazide (microzide)
K sparing diuretics
What type of diuretic is this? - spironolactone (aldactone)
loop diuretics
What type of diuretics are these? - monitor potassium - furosemide (lasix) - bumetanide (bumex)
non-rebreather
What type of oxygen apparatus does this describe? 10-15 L/min 60-100% Has a bag. Uncomfy- can't eat or drink Delivers highest oxygen concentration
Venturi mask
What type of oxygen apparatus does this describe? 4-12 L/min 24-60% Uncomfy- can't eat or drink Most precise
simple face mask
What type of oxygen apparatus does this describe? 5-8 L/min 40-60% Only used for a short period of time. Skin breakdown from straps Uncomfy- can't eat or drink
nasal cannula
What type of oxygen apparatus does this describe? Used for low flow rates 1-6 L/min (usually 1-4) 22-44% Usually worn when eating. Comfy, low cost Easily dislodged Skin breakdown Humidify at 4L/min+
peripherally generated pain
What type of pain is this? Diabetic neuropathy, Guillan-Barre syndrome
chronic episodic pain
What type of pain is this? Pain that occurs sporadically over an extended period of time. Pain episodes can last for hours, days, or weeks.
cancer pain
What type of pain is this? Patients with cancer can experience acute and/or chronic pain.
centrally generated pain
What type of pain is this? Phantom pain.
C
When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except: A. Crackles auscultated in lungs. B. A bounding pulse. C. An elevated hematocrit level. D. Full neck veins when upright.
pain scale
When assessing pain, use appropriate ____ _____ based on age, cognition, and learning style.
misconceptions
common ______________ about pain include: - pts who abuse substances exaggerate their pain - pts with minor ailments have less pain - administering analgesics>> drug addiction - amount of injury accurately indicates pain intensity - healthcare personnel are the best authorities on the nature of a pts pain
imbalances
common fluid and electrolyte __________ include: - extracellular volume (ECV) deficit or excess - fluid volume deficit (FVD) or excess (FVE) - electrolyte imbalances
hypotonic
_________ IV solutions: Na <135 mEq/L osmolality <275 mOm/kg - 0.45% NaCl - 0.35% NaCl *anything less than 0.9% NaCl - dextrose 5% (D5W)- isotonic in bag, once in body its...
hypertonic
__________ IV solutions include: 3% NaCl *anything above 0.9% NaCl 10% dextrose (D10W) 50% dextrose (D50W)
educational
___________ nursing interventions for hypertension include: - lifestyle modification - diet - exercise - weight control - stress reduction - limiting alcohol consumption - avoiding tobacco - BP measurement - explain medication therapy
disadvantages
_____________ of non-opioid analgesics: - analgesic ceiling - gastrointestinal upset - prolonged bleeding time - renal dysfunction
equianalgesic
_____________ tables are used when converting to another drug or another route. This chart lists equivalent doses of the same medication in a different route, or of different medications that would offer an equal amount of analgesia.
opioids
adverse effects of _______ include: - respiratory depression - constipation - sedation - urinary retention - nausea/vomiting - pruritus
systole
Define: Contraction of the myocardium. Results in blood ejected from the ventricles (depolarization).
hypoventilation
Define: Decreased rate and depth of respiration
A, C, E
A 12-year-old has just been diagnosed with anemia. You know this can be caused by? (select all that apply) A. Decreased number of RBCs B. Hematocrit increase C. Decrease in quantity or quality of Hemoglobin D. Increase in hemoglobin E. Hematocrit decrease
D
A 35-year-old, male patient with testicular cancer is joking and playing cards with his roommate. When assessed by the pain management nurse, the patient rates his pain as a 7 on a Numeric Rating Scale of 0 to 10. The nurse concludes that the patient's behavior: A. is an emotional reaction to having cancer. B. is in anticipation of future pain. C. is more indicative of the need for pain medication than the pain rating. D. may be in conflict with the pain rating, and accepts the report of pain.
D
A 45-year-old patient who reports pain in the foot that moves up along the calf says: "My right foot feels like it is on fire." The patient reports that the pain started yesterday, and he or she has no prior history of injury or falls. Which components of pain assessment has the patient reported? A. Aggravating and alleviating factors. B. Exacerbation, with associated signs and symptoms. C. Intensity, temporal characteristics, and functional impact. D. Location, quality, and onset.
A
A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea? A: Fever increases metabolic demands, requiring increased oxygen need. B: Blood glucose stores are depleted, and the cells do not have energy to use oxygen. C: Carbon dioxide production increases as result of hyperventilation. D: Carbon dioxide production decreases as a result of hypoventilation.
hypocalcemia
A calcium level of <9.0 indicates ____________.
hypercalcemia
A calcium level of >10.5 indicates _____________.
A, B, E
A charge nurse is teaching a newly graduated nurse about common misconceptions of pain. Which statement by the new nurse indicates a need for further teaching? (select all that apply) A. "Health care personnel are the best authorities on the nature of a patient's pain." B. "The amount of tissue damage in an injury accurately indicates pain intensity." C. "Pain best diagnosed based on the patient's description and history." D. "Pain is whatever the patient says it is." E. "Patients who abuse substances (drugs or alcohol) overreact to discomforts.
A
A client is admitted with shortness of breath and a history of liver disease. The nurse's abdominal assessment reveals ascites. This is an example of: A. Third-spacing B. Second-spacing C. First-spacing D. Atelectasis
D
A fluid solution with the same tonicity as normal blood is called: A. Hypertonic. B. Hypotonic. C. Osmotic. D. Isotonic.
Hypomagnesemia
A magnesium level <1.3 indicates _______________.
Hypermagnesemia
A magnesium level >2.1 indicates _______________.
ischemic
A mean arterial pressure of above 60 is needed to perfuse organs. Below that vital organs are under perfused and will become ________.
A
A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors
D, E
A nurse is assessing a patient experiencing acute pain. Which characteristic is more common with acute pain than with chronic pain? (select all that apply) A. Self-focusing B. Sleep disturbances C. Lasting longer than 6 months D. Protective (guarding) behaviors E. Variations in vital signs
B
A nurse is assessing a patient who has hypoxia. Which of the following early findings should the nurse expect? A. Bradypnea and bradycardia. B. Tachycardia, tachypnea, and increased BP. C. Decreased level of consciousness and decreased BP. D. Increased SaO2, bradypnea, decreased level of consciousness
C
A nurse is caring for a client who is receiving morphine via a patient‑controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button too much so I don't get an overdose." C."I should tell the nurse if the pain doesn't stop while I am using this device." D."I will ask my adult child to push the dose button when I am sleeping."
D
A nurse is caring for a patient who has a reduced fluid intake. The nurse assesses the patient for which response to this reduced fluid intake? A. Urinary retention B. Frequent urination C. Incontinence of urine D. Decreased urine output
A
A nurse is caring for a patient who has pneumonia. The doctor has ordered supplemental oxygen at 5L/min via nasal cannula. Which of the following actions should the nurse take? A. Attach a humidifier bottle to the base of the flow meter. B. Remove the nasal cannula while the patient eats. C. Avoid coughing and deep breathing exercises. D. Apply petroleum jelly to the nares as needed to soothe mucous membranes.
B
A nurse is caring for a patient who is receiving oxygen at 2L/min via a nasal cannula. The nurse recognizes that the patient is receiving which of the following FiO2 (inspired oxygen concentration)? A. 36% B. 28% C. 50% D. 70%
C
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain. B. Question the client about the location of the pain. C. Offer the client a pain scale to measure his pain. D. Use open‑ended questions to identify the client's pain sensations.
D
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain. B. A client who has incisional pain 72 hr following pacemaker insertion. C. A client who has food poisoning and reports abdominal cramping. D. A client who has episodic back pain following a fall 2 years ago.
A
A nurse is helping a patient who is experiencing mild pain to get ready for bed. Which nursing action is most effective to help limit pain? A. Assisting with relaxing imagery or meditation B. Obtaining a prescription for an opioid C. Encouraging the patient to take a warm shower D. Recommending that the patient be more active during the day
C
A nurse is monitoring a patient who is receiving IV fluid. Which clinical findings indicate that the patient has a fluid overload? A. Chills, fever, generalized discomfort B. Blood in the tubing close to the insertion site C. Dyspnea, headache, increased blood pressure D. Pallor, swelling, discomfort at insertion site
D
A nurse on the post-surgical unit believes that all patients who have the same surgery have the same type and amount of pain. This belief A. Will contribute to good pain management for the patients B. Reflects accurate knowledge about pain assessment and relief measures C. Will have no effect on their overall control of pain D. Shows a lack of knowledge that may contribute to poor pain management
B
A patient has a prn order for 650 mg Acetaminophen, q 6hr, PO. It has been 8 hours since his last dose, and the patient is complaining of pain level 6 on a scale from 0 to 10. Which statements by the nurse would show appropriate patient education, before administering the tylenol? A. Because of its toxic effects on the liver, no more than 6 grams of Acetaminophen may be given each day. B. Please alert me immediately if you begin to experience ringing in your ear, decreased hearing acuity, or dizziness. C. You should take this medication on an empty stomach for maximum efficacy. D. You should start to experience pain relief 5-10 minutes after taking this medication.
C
A patient has anemia related to inadequate intake of essential nutrients. Which intervention would be appropriate for the nurse to include in the plan of care for this patient? A. instruct the patient to select soft, bland, and nonacidic foods B. Give the patient a list of medications that inhibit iron absorption C. Encourage foods high in protein, iron, vitamin C, and folate D. Plan for 30 minutes of rest before and after very meal
A
A patient has been admitted with a sodium level of 152 mEq/L. Which of the following would the nurse expect to see ordered? A. Hypotonic IV fluids B. Hypertonic IV fluids C. Unrestricted diet with magnesium and phosphorus supplementation D. Fluid restriction
B
A patient has been admitted with a sodium level of 152 mEq/L. Which of the following would the nurse expect to see ordered? A. Hypotonic IV fluids B. Hypertonic IV fluids C. Unrestricted diet with magnesium and phosphorus supplementation D. Fluid restriction
D
A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation? A. Increased breathlessness but increased activity tolerance B. Decreased breathlessness and decreased activity tolerance C. Increased activity tolerance and decreased breathlessness D. Decreased activity tolerance and increased breathlessness
C
A patient has just come in with the following symptoms: Pallor, glottis, cheilitis, and frequent headaches. What do you suspect? A. cardiopulmonary disease B. Anaphylactic shock C. Iron deficiency anemia D. GI bleed
C
A patient is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis, dry, sticky mucous membranes, weakness, disorientation, and a decreasing LOC (level of consciousness). Which electrolyte imbalance does this data support? A. Hyperkalemia B. Hypercalcemia C. Hypernatremia D. Hypokalemia
C
A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A: Coughing up thick sputum only occasionally B: Coughing up thin, watery sputum easily after nebulization C: Decreased independent ability to cough D: Lung sounds clear only after coughing
C
A patient is experiencing thirst, weight loss, increased hematocrit, orthostatic hypotension (OH), fatigue, dry mucous membranes, oliguria, and decreased pulse pressure. The nurse recognizes these as manifestations of: A. FVE (Fluid Volume Excess) B. Hypercalcemia C. FVD (Fluid Volume Deficit) D. Hypocalcemia
A
A patient is postoperative and the operation was a success. However he is on an opioid for the pain, what should we be assessing for? A. Decreasing respiratory rate and chest wall expansion B. Signs of addiction C. Tolerance D. Urinary retention
A
A patient is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication? A. fluid volume excess B. fluid volume deficit C. seizure activity D. liver failure
A
A patient prescribed spironolactone is demonstrating a peaked T wave on the ECG & complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which of the following? A. Hyperkalemia B. Hypokalemia C. Hypercalcemia D. Hypocalcemia
C
A patient presents to the clinic for their yearly physical exam. After taking vitals, you discover they have a blood pressure reading of 120/86. What stage of Hypertension does your patient have? A. Normal B. Elevated C. Stage 1 D. Stage 2
D
A patient receiving an enteral feeding develops diarrhea. Which characteristic of the tube feeding formula does the nurse conclude precipitated the diarrhea? A. Icteric B. Isotonic C. Hypotonic D. Hypertonic
A
A patient recovering from surgery has an indwelling urinary catheter. The nurse would contact the patient primary healthcare provider with which of the following 24-hour urine output volumes? A. 600 mL B. 750 mL C. 1000 mL D. 1200 mL
D
A patient requests pain medication for severe pain. Which should the nurse do first when responding to this patient's request? A. Use distraction to minimize the patient's perception of pain B. Place the patient in the most comfortable position possible C. Administer pain medication to the patient quickly D. Assess the various aspects of the patient's pain
D
A patient who had a total abdominal hysterectomy two day ago reports abdominal pain at level 7 on a 0-10 pain scale. After assessing the pain further, which should the nurse do first? A. Reposition the patient B. Offer a relaxing back rub C. Use distraction techniques D. Administer the prescribed analgesic
D
A patient who had a total abdominal hysterectomy two days ago reports abdominal pain at level 5 on a 0-to-10 pain scale. After assessing the pain further, which should the nurse do first? A. Reposition the patient B. Offer a relaxing back rub C. Use distraction techniques D. Administer the prescribed analgesics
A
A patient with Increased cardiac contractility, increased risk for fractures, and depressed reflexes is most likely to have A. hypercalcemia B. hypernatremia C. hypocalcemia D. hyponatremia
hyperventilation
Define: Increased rate and depth of respiration
C
A patient with a tracheostomy has just had surgery for a fractured leg. He is unable to speak and unable to follow commands. What is the best way to assess the patient's pain? A. Ask him to point a number on the pain scale to rate his pain. B. Wait for a family member who knows him well to help assess his pain. C. Use facial expressions, blood pressure, pulse and respiratory rate as assessment tools. D. Wait for the physician to assess his pain.
C
A patient with kidney failure should be educated about A. Eating large amounts of nuts and bananas B. Drinking as much water as possible C. Avoiding large amounts of phosphorus and magnesium in the diet D. Increasing intake of antacids that contain magnesium
B
A patient with parasthesias, Chovstek sign, and hyperphosphatemia is most likely to have: A. hypermagnesemia B. hypocalcemia C. hypokalemia D. hypernatremia
C
A postoperative patient is diagnosed with fluid volume overload. Which of the following should the nurse assess in this patient? A. poor skin turgor B. decreased urine output C. distended neck veins D. concentrated hemoglobin & hematocrit levels
B
A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented? A. Infection B. Seizure C. Neutropenic D. High-risk fall
isotonic
ALWAYS use ________ solutions first before labs come back. - Na 135-145 mEq/L - osmolality 275-295 mOm/kg
C
Abscess, amputation, cuts, and heavy lifting are: A. biological injury agents B. Chemical injury agents C. physical injury agents
analgesics
Acetaminophen (Tylenol) and NSAIDS (aspirin, ibuprofen, naproxen, ketorolac) are non-opioid __________. - monitor for tinnitus, vertigo, and decreased hearing acuity - prevent gastric upset by admin with food or antacids - monitor for bleeding with long-term NSAID use
D
After assessing each of his patients during his morning rounds, which of the following clients does the nurse recognize is most at risk for electrolyte imbalance? A. 88-year-old with a fractured femur scheduled for surgery. B. 20-year-old client with a 5-year history of Type One Diabetes Mellitus. C. 50-year-old client with second degree burns to the ankles and feet. D. 65-year-old client with a nasogastric (NG) tube to low continuous suction
A
All of the following are factors that affect stroke volume (SV) except: A. Heart rate. B. Preload. C. Afterload. D. Contractility
C
An elderly pt does not complain of thirst. What should the nurse do to assess that this pt is not dehydrated? A. Ask the physician for an order to begin intravenous fluid replacement. B. Ask the physician to order a chest x-ray. C. Assess the urine for osmolality. D. Ask the physician for an order for a brain scan.
B
An older patient comes into the clinic complaining of watery diarrhea for several days with abdominal and muscle cramping. The nurse realizes that this patient is demonstrating which imbalance? A. Hypernatremia B. Hyponatremia C. Fluid volume excess D. Hyperkalemia
extracellular volume excess
Causes of ____________ ______ ______ include: - retention of H2O and Na - excessive intake of Na- containing substances - iatrogenic factors
hyperkalemia
Causes of ____________ include: - K-sparing diuretics and other meds - acidosis - renal disease, decreased kidney function - excess admin of KCl - K-containing salt substitutes, increased K intake
hyponatremia
Causes of ____________ include: - Na excretion via vomiting, diarrhea, GI suction, etc. - fluid overload - increased/oversecreted ADH: SIADH, polydipsia (DI)
hypocalcemia
Causes of ____________ include: - thyroid surgery - hypoparathyroidism - vitamin D or Mg deficiency - acute pancreatitis - multiple blood transfusions - chronic renal disease - chronic alcoholism - elevated Phosphorous
extracellular volume deficit
Causes of _____________ ______ _______ include: - excessive loss of GI fluids - renal losses - H2O and Na losses - hemorrhage - chronic laxative and enema use - 3rd spacing
FVE (fluid volume excess)
Are ascites (accumulation of fluid in the abdomen) indicative of FVE or FVD?
FVD (fluid volume deficit)
Are these GI S&S indicative of FVE or FVD? Constipation Dry mucous membranes
FVE (fluid volume excess)
Are these nervous/musculoskeletal S&S indicative of FVE or FVD? Cerebral edema Heart failure Vein distention
FVD (fluid volume deficit)
Are these nervous/musculoskeletal S&S indicative of FVE or FVD? Weakness Cramping Altered mental status Fatigue Possible coma
FVD (fluid volume deficit)
Are these vital signs indicative of FVD or FVE? Decreased BP Tachypnea Tachycardia Weak Pulse
FVE (fluid volume excess)
Are these vital signs indicative of FVD or FVE? Increased BP Coughing Crackles in lungs Bounding pulse Tachypnea Tachycardia Bradycardia
murmurs
As we age our cardiac valves thicken/stiffen which causes regurgitation and stenosis. This results in heart _______.
myocardium
As we age our collagen increases and our elastin decreases, this affects the __________'s ability to stretch and contract.
B, C, E
At-risk patients for iron deficiency anemia include: (select all that apply) A. teenagers B. premenopausal and pregnant women C. older adults D. caucasians E. individuals experiencing blood loss
repolarization
Blood filling the ventricles is (depolarization/repolarization).
B
Burns are: A. biological injury agents B. Chemical injury agents C. physical injury agents
Phosphourus
Calcium has an inverse relationship with ___________.
mild
Cardiopulmonary manifestations of ____ ______ include: - palpitations - exertional dyspnea
severe anemia
Cardiopulmonary manifestations of ______ ______ include: - tachycardia and tachypnea - increased pulse pressure - systolic murmurs - angina - heart failure - myocardial infarction
moderate anemia
Cardiopulmonary manifestations of ________ ______ include: - increased palpitations (bounding pulse) - dyspnea - hypoxia
Fluid Volume Deficit (FVD)
Causes of _____ ______ _______ include: - hypovolemia - clinical dehydration
anemia
Causes of ______ include: - blood loss - impaired production or increased destruction of RBCs - renal disease
hypokalemia
Causes of ___________ include: - losses through GI, renal (diuretics), or skin (diaphoresis) - alkalosis - correction/repair of tissue damage - K missing in diet or IV fluids
systole
Define: Contraction of the myocardium
D
Clinical assessment of dehydration would be confirmed if the nurse identified: A. Engorged neck veins. B. Bounding radial pulse. C. Bradycardia. D. Dry mucous membranes.
fluid volume excess
Clinical manifestations of _____ ______ ______ include: - weight gain -ascites - anasarca - heart failure - htn - bounding pulse - distended veins - cough, dyspnea, orthopnea, crackles - polyuria - cerebral edema
hypernatremia
Clinical manifestations of _____________ include: - flushed skin, fever, dry/swollen tongue - restlessness, agitation, twitching - intense thirst - edema - decreased urine output
hypercalcemia
Clinical manifestations of _____________ include: - lethargy/weakness - depressed reflexes - decreased memory - stupor, coma - confusion/personality changes - anorexia, nausea, vomiting - bone pain/fractures - increased cardiac contractility - shortened QT interval because time to depolarize is shorter - prolonged PR interval because slower conduction through AV node
hyponatremia
Clinical manifestations of _____________ include: - seizures - abdominal cramping - lethargy/confusion - tendon reflexes decreased - loss of urine - orthostatic hypotension - skeletal muscle weakness - spasms (muscle)
hypokalemia
Clinical manifestations of _____________ include: - weakness and fatigue - ECG changes- flat T-wave - confusion - reflexes decreased - anorexia, n/v - muscle cramping - paralytic ileus, constipation
hyperkalemia
Clinical manifestations of _____________ include: - weakness and fatigue - irritability - cramping in the abdomen, diarrhea - ECG changes- peaked T-wave - irregular pulse - cardiac standstill if sudden or severe - decreased reflexes
hypomagnesemia
Clinical manifestations of ______________ include: ◦ confusion ◦ tremors, seizures ◦ muscle cramps ◦ hyperactive deep tendon reflexes ◦ insomnia ◦ tachycardia, hypertension
hypermagnesemia
Clinical manifestations of _______________ include: ◦ lethargy, drowsiness ◦ diminished deep tendon reflexes ◦ muscle weakness ◦ flushed, warm skin ◦ nausea and vomiting ◦ bradycardia, hypotension
hypophosphatemia
Clinical manifestations of ________________ include: - cardiopulmonary manifestations: tachypnea, malaise, decreased myocardial apprehension, delirium - neurological s/s: confusion, irritability, apprehension, delirium - may progress to seizures or coma
hyperphosphatemia
Clinical manifestations of ________________ include: - numbness and tingling in extremities and around mouth - hyperreflexia, muscle cramps - tetany, seizures - deposition of calcium-phosphate precipitates in the skin, cornea, soft tissue, viscera, and blood vessels
hypocalcemia
Clinical manifestations of mild to moderate _____________ include: - easily fatigued - paresthesias: extremities and perioral - hyperreflexia, muscle cramps - chvostek's sign- facial spasm - trousseau's sign- carpal spasm
hypocalcemia
Clinical manifestations of severe _____________ include: - tetany/seizures - laryngeal spasm - decreased cardiac contractility: prolonged QT interval bc repolarization takes longer
iron deficiency
Clinical manifestations specific to ____ _________ include: - pallor: most common - glossitis - cheilitis: lip inflammation - headache - paresthesias - burning sensation of tongue
C
Common manifestations of moderate anemia (Hemoglobin 6-10 g/dL) include all the following except: A. Palpitations. B. Dyspnea. C. Jaundice. D. Bounding pulse
C
Compulsive use of a drug that results in craving if stopped. A. drug dependence B. drug tolerance C. drug addiction
plasma oncotic
Decrease in ______ ________ pressure: Low plasma protein count. Causes: - renal disorders resulting in excessive protein loss - deficient protein synthesis (liver disease) - deficient protein intake
anemia
Define: A condition where there is a decreased number of RBCs in the blood. Not a specific disease- results from pathological processes.
oxygen toxicity
Define: Caused by over-administration of oxygen. Suppression of breathing. Symptoms: - tunnel vision - tinnitus - nausea - confusion - convulsions
edema
Define: Caused from changes in fluid movement including: - increased venous hydrostatic pressure - decreased plasma oncotic pressure - increase in interstitial oncotic pressure - obstruction of lymphatic outflow causing decreased removal of interstitial fluid
atelectasis
Define: Collapse of alveoli, prevents normal exchange of O2 and CO2, can cause hypoventilation.
venous
Elevated ______ pressure: Pressure at the venous end of the capillary inhibits fluid movement back into the capillary. Causes: - fluid overload - heart failure - tourniquets - tight clothing - venous insufficiency
interstitial oncotic
Elevation of ___________ _______ pressure: Damage of capillary walls allowing plasma protein to accumulate in interstitial space. Causes: - trauma - burns - inflammation
pulse oximetry
Factors affecting _____ ________ readings: ‣ nail polish and nail coverings ‣ irregular heart rhythms ‣ hyperemia ‣ motion artifact ‣ pressure on the sensor ‣ electrical interference ‣ dyshemoglobinemias ‣ bright overhead lights ‣ venous congestion
C
Manifestations of moderate anemia (Hemoglobin 6-10 g/dL) include all the following except: A. Palpitations. B. Dyspnea. C. Jaundice. D. Fatigue.
fluid volume excess
Medications for _____ ______ ______ include: Loop diuretics- monitor potassium! • furosemide (lasix) • bumetanide (bumex) Thiazides diuretics- monitor calcium! • hydrochlorothiazide (microzide) K+ sparing diuretics- spironolactone (aldactone)
hyperkalemia
Fill in the blank: A peaked T-wave on an EKG is an indicator of ____________.
T wave
Fill in the blank: Hypokalemia can cause dysrhythmias, and can be indicated on an EKG as a flattened ___ ____.
cardiac output
Fill in the blank: Stroke volume X HR = _______ ______
deficit
Fluid management for fluid volume _______ includes: - oral rehydration - IV therapy - 0.9% NS - D5W or 0.45% NS if CD - for severe cases, blood products or lactated ringers - fluid challenge
reassessment
For ____________ of pain: - not analgesic received and effectiveness - note non-medication therapies provided and effectiveness - discomfort heard, acknowledged, and addressed
B
For a client with the nursing diagnosis of excess fluid volume, the nurse is alert to which of the following signs and symptoms? A. Flushed skin. B. Hypertension. C. Weak, thready pulse. D. Dry mucous membranes.
A
Hgb 10-12 g/dL: A. mild anemia B. moderate anemia C. severe anemia
B
Hgb 6-10 g/dL: A. mild anemia B. moderate anemia C. severe anemia
C
Hgb <6 g/dL: A. mild anemia B. moderate anemia C. severe anemia
B, C, E, F, G
How do you assess pain? (select all that apply) A. Age B. Location C. Intensity D. Gender E. Duration F. Quality G. Aggravating/alleviating factors
preload
Hypovolemia, aortic stenosis, and myocardial infarctions (MI) can cause an increased volume of blood left in the ventricles at the end of diastole, which is also known as _______.
edema
If intake>output, assess for signs of _____.
dehydration
If output>intake, assess for signs of ___________.
P wave
In the P-QRS-T sequence, which wave represents atrial depolarization?
QRS wave
In the P-QRS-T sequence, which wave represents ventricular depolarization?
T wave
In the P-QRS-T sequence, which wave represents ventricular repolarization?
A
Infection, ischemia, and neoplasm are: A. biological injury agents B. Chemical injury agents C. physical injury agents
severe anemia
Integumentary changes in ______ ______ include: - pallor - jaundice - pruritis
gas exchange
Interventions for risk for impaired ___ ________ include: - auscultate lung sounds - fowler's position - pulse oximetry and ABGs
skin integrity
Interventions for risk for impaired ____ _________ include: - frequent skin assessment - reposition pt Q2 hours - devices to reduce pressure
contraction
Is depolarization contraction or resting?
sodium
Kidneys are the primary regulator of which electrolyte?
fluid volume excess
Management for _____ ______ ______ includes: ‣ fluid restrictions ‣ intake and output ‣ dietary management ‣ health promotion- teaching preventative measures to clients who have risk for fluid overload
fluid volume deficit
Manifestations of _____ ______ _______ include: - dry/sticky mucous membranes - decreased tongue size - decreased urine output, increased urine SG, severe oliguria - fatigue - altered mental status, anxiety, possibly coma - fatigue - dry skin, increased turgor - pale, cool extremities - cardiovascular alterations - increased hematocrit - thirst and weight loss
hypocalcemia
Mild to moderate ____________ is a level of 7.5-8.5 mg/dL.
fluid volume deficit
Nursing assessments for _____ ______ _______: Health history Physical assessment: - intake/output - oliguria? - daily weighs - CV changes: BP, HR, pulse force, JVD - skin assessment: turgor Diagnostic tests: - serum electrolytes - serum osmolality (decreases in clinicald ehydration) - Hgb and Hct- % higher - urine specific gravity- increases - central venous pressure- decreases
iron deficiency anemia
Nursing interventions for ____ __________ ______ include: - Assessment: identify at risk patients - treat underlying condition or absorption - educate about diet/supplementation
fluid volume excess
Nursing interventions for _____ ______ ______ include: - assess VS, heart sounds, CVP, volume of peripheral pulses - assess presence and extend of edema - daily weighs - admin of oral fluid with fluid restriction - oral hygiene Q2 hours - diuretics - review diagnostics - client teaching
isoelectric
On an EKG, the baseline is known as the ___________ line.
mild
On the pain scale, 1-3 is ____ pain.
moderate
On the pain scale, 4-6 is _________ pain.
severe
On the pain scale, 7-10 is _______ pain.
B
Over time, patient experiences decreased effect with same dosage. A. drug dependence B. drug tolerance C. drug addiction
alkalosis
PaCO2 <40 and pH <7.4 indicates respiratory _________.
acidosis
PaCO2 >40 with a pH <7.4 indicates respiratory ________.
incentive spirometry
Patient teaching for the use of _________ _________: 1. put mouth around mouthpiece and make a seal 2. inhale slowly and deeply 3. when you can't inhale anymore, remove the mouthpiece and hold breath for 3 seconds 4. slowly exhale 5. repeat 6. clean mouthpiece with soap and water after each use 7. keep a log
4%
Percentage of oxygen delivered by nasal cannula is 24-44%. 1 L/min delivers 24%, from there the oxygen percentage increases by _% for each additional L/min.
stage 2
What category of HTN is this: Systolic at least 139 or up or diastolic at least 90 mm Hg
A
Persistent use of a drug that leads to withdrawal if drug is stopped. A. drug dependence B. drug tolerance C. drug addiction
chronic
Persistent, non-cancer pain is also known as _______ pain.
Hypophosphatemia
Phosphate levels <3.0 indicate ________________.
hyperphosphatemia
Phosphate levels >4.5 indicate ________________.
decreased
Pick one: (Increased/Decreased) pulse pressure (<40) may be caused by: - heart failure - hypovolemia
increased
Pick one: (Increased/Decreased) pulse pressure (>60) may be caused by: - exercise - atherosclerosis of larger arteries
females
Pick one: After age 64, hypertension is more prevalent in (males/females).
systolic
Pick one: As we age arteries stiffen, which causes increased (diastolic/systolic) BP.
depolarization
Pick one: Blood ejecting from the ventricles is (depolarization/repolarization).
increased
Pick one: Fluid volume deficit causes (increased/decreased) lab values.
decreased
Pick one: Fluid volume deficit causes (increased/decreased) urine output.
decreased
Pick one: Fluid volume excess causes (increased/decreased) lab values.
increased
Pick one: Fluid volume excess causes (increased/decreased) urine output.
males
Pick one: In younger adults, hypertension is more prevalent in (males/females).
subjective
Pick one: Pain is always (subjective/objective).
excess
Pick one: Retention of Na/H2O and excessive intake of sodium containing substances are causes of fluid volume (excess/deficit).
deficit
Pick one: These are causes of fluid volume (excess/deficit). H2O and Na losses via excessive sweating Excessive urination Renal losses through diuretic therapy Renal and endocrine disorders
deficit
Pick one: Tired, pale, cool clammy skin, thirst, dry mucous membranes, decrease in skin turgor, decreased capillary refill, and weight loss are all S&S of fluid volume (excess/deficit).
nursing diagnoses
Possible _______ ________ for fluid and electrolyte imbalances include: ◦ deficient fluid volume ◦ excess fluid volume ◦ risk for electrolyte imbalance ◦ acute confusion ◦ risk for injury ◦ constipation ◦ diarrhea
nursing interventions
Possible _______ _____________ for fluid and electrolyte imbalances include: ◦ monitor intake and output ◦ monitor serum electrolytes ◦ monitor vital signs ◦ monitory daily weigh, mucous membranes, and skin turgor ◦ focused assessments
fluid volume deficit
Possible nursing diagnoses for _____ ______ _______: - deficient fluid volume - decreased cardiac output -risk for deficient fluid volume - risk for injury - ineffective tissue perfusion
hypokalemia
Potassium levels <3.5 (severe <2.5) indicate ___________.
hyperkalemia
Potassium levels >5.0 indicate ____________.
7.5
Severe hypocalcemia is less than ___ mg/dL.
hyponatremia
Sodium levels of <135 (<125 is severe) indicates ____________.
hypernatremia
Sodium levels of >145 mEq/L indicate ______________.
nociceptive
Somatic and visceral pain are types of ___________ pain.
excess
Some nursing diagnoses for fluid volume _______ include: - risk for impaired skin integrity - risk for impaired gas exchange
COPD
Special considerations regarding O2 use and patient's with ____: - body has adapted to high CO2 level>> chemoreceptors are no longer sensitive to changes in CO2 - stimulus to breathe becomes low O2 level - over-administration of O2 can lead to oxygen toxicity
A
The nurse is caring for a patient who will be requiring oxygen therapy at an inspired oxygen concentration level of 50%. Which one of the oxygen masks provides the most precise oxygen concentration? A. Venturi mask. B. Simple mask. C. Non-rebreather mask. D. Partial rebreather mask.
D
What are some manifestations of hypertension? A. Migraines B. Nosebleeds C. Dyspnea D. Hypertension rarely has manifestations-Silent killer
erythropoietin
The hormone that promotes formation of RBCs (erythrocytes) is called ______________. It is produced in the kidneys, so those with renal disease are at increased risk for anemia.
C
The interprofessional team is collaborating to teach a client with hypertension about controlling the condition. The team recognizes that A. All patients with elevated blood pressure require medications. B. Obese clients must achieve a normal weight to lower blood pressure. C. Lifestyle modifications are indicated for all clients with elevated blood pressure. D. It is not necessary for the patient to limit sodium in the diet if taking a diuretic.
hypercalcemia
The most common cause of ______________ is malignancy and hyperparathyroidism.
A
The most significant effect of aging that contributes to the development of hypertension is related to: A. Loss of elasticity in the arterial walls. B. Decreased serum lipid levels. C. Loosening of the capillary walls. D. Environmental factors.
B
The nurse administering potassium to the patient carefully monitors the infusion because of the risk for which condition? A. Pulmonary edema B. Cardiac dysrhythmia C. Postural hypotension D. Renal failure
D
The nurse anticipates that the physician will initially order which intravenous (IV) solution for a client with dehydration and extracellular fluid volume (ECV) deficit? A. 3% Sodium Choloride. B. Dextrose 10% in water. C. Dextrose 5% in 0.45% Sodium Chloride. D. 0.9% Sodium Chloride.
A
The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? A: Raise the head of the bed to 45 degrees. B: Take his oxygen saturation with a pulse oximeter. C: Take his blood pressure and respiratory rate. D: Notify the health care provider of his shortness of breath
A
The nurse goes to assess a new patient and finds him short of breath with a rate of 32 and lying supine in bed. What is the priority nursing action? A. Raise the head of the bed to 60 degrees or higher. B. Get his oxygen saturation with a pulse oximeter. C. Take his blood pressure and respiratory rate. D. Notify the health care provider of his shortness of breath.
C
The nurse has reviewed information about the cardiovascular system before caring for a client with heart disease. The nurse knows that which of the following statements is true concerning the physiology of the cardiovascular system? A. Stimulating the parasympathetic system would cause the heart rate to go up B. When a person has heart muscle disease, the heart muscles stretch as far as is necessary to maintain function C. The QRS interval on the ECG represents the electrical impulses passing through the ventricles D. When stroke volume decreases there is a resultant decrease in heart rate
C
The nurse has reviewed information about the cardiovascular system before caring for a client with heart disease. The nurse knows that which of the following statements is true concerning the physiology of the cardiovascular system? A. The P wave on the electrocardiogram (ECG) represents the electrical impulses passing through the ventricles. B. The nurse should be able to see the repolarization of the atria on the electrocardiogram (ECG). C. The QRS complex on the electrocardiogram (ECG) represents the electrical impulses passing through the ventricles. D. The T wave generally decreases in size with hyperkalemia.
D
The nurse is admitting a patient who is diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most affected with this disorder? A. calcium B. magnesium C. phosphorus D. potassium
A
The nurse is assessing a patient who reports anxiety and whose breathing is very deep and rapid. What term will the nurse use to describe the patient's breathing? A. Hyperventilation B. Atelectasis C. Activity intolerance D. Hypoventilation
B
The nurse is assessing four clients. Which client is at the greatest risk for hypomagnesemia? A. A 41-year-old with hypernatremia. B. A 72-year-old with chronic alcoholism. C. A 46-year-old with respiratory acidosis. D. A 75-year-old with bone cancer.
B
The nurse is caring for a patient who has an order for furosemide 60 mg PO twice daily. The available dosage form of furosemide is a 40 mg tablet. How many tablets will the nurse administer for each dose? A. 1 tablet B. .5 tablets C. 2 tablets D. 0.5 tablets
B
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? A: Antibiotics B: Frequent change of position C: Oxygen humidification D: Chest physiotherapy
true
True or false? The first thing you should do when a patient is experiencing dyspnea is to elevate the head of the bed because it is the best position for lung expansion.
B, D, E
The nurse is completing a physical examination for a dark-skinned client who has severe iron-deficiency anemia. The signs/symptoms of iron-deficiency anemia that the nurse is most likely to assess are: (Select all that apply). A. Pallor in the extremities. B. Glossitis. C. Cyanosis in the extremities D. Jaundice of the eyes. E. Pruritis.
C
The nurse is evaluating a client with a history of cardiac disease who takes a potassium-wasting diuretic (furosemide). The client complains of muscle weakness. In evaluating the client's lab values, the nurse might expect which electrolyte abnormality? A. Hypocalemia. B. Hypernatremia. C. Hypokalemia. D. Hypomagnesemia.
A
The nurse is preparing to administer albuterol as ordered: Albuterol syrup 1.5 mg po TID. The label on the albuterol states that it contains albuterol 2 mg/5mL. Using DA, how many mL will the nurse administer? A. 3.8 mL B. 0.3 mL C. 0.8 mL D. 11.3 mL
C
The nurse is teaching the client with hypertension about controlling the condition. The nurse recognizes that: A. All patients with elevated blood pressure require medications. B. Obese clients must achieve a normal weight to lower blood pressure. C. Lifestyle modifications are indicated for all clients with elevated blood pressure. D. It is not necessary to limit salt in the diet if taking a diuretic.
A
The nurse walks into the room and notices that the patient is experiencing shortness of breath. The patient is lying in bed and is receiving oxygen 2L via nasal cannula. Which of the following interventions is the nurse's priority? A. Assist the patient to Fowler's position. B. Change the oxygen delivery device to a simple face mask. C. Suction with a Yankauer to remove pulmonary secretions. D. Prepare to obtain arterial blood gases.
pain management
The nurse's role in _____ __________ includes: - direct clinical care - pt/family teaching - education of colleagues - identification of system barriers
A
The nursing care for a patient with fluid volume excess and hyponatremia includes: A. Fluid restriction B. Administration of hypotonic IV fluids C. Administration of 0.45% NaCl D. Encouraging PO fluids
A
The pain management nurse notices a male patient grimacing as he moves from the bed to a chair. The patient tells the nurse that he is not experiencing any pain. The nurse's response is to: A. clarify the patient's report by reviewing the patient's nonverbal behavior. B. confronting the patient's denial of pain. C. obtaining an order for pain medication. D. supporting the patient's stoic behavior.
C
The physician has ordered a thiazide diuretic for a client with hypertension. The nurse knows to closely monitor the client for: A. Hypokalemia. B. Hyponatremia. C. Hypercalcemia. D. Hypermagnesemia.
2300
The recommended dietary allowance for sodium is ____ mg/day or less (1 tsp salt).
1500
The recommended dietary allowance for sodium is ____ mg/day or less for African Americans, older adults, HTN, diabetes, and chronic kidney disease.
nursing diagnoses
These are common _______ _________ for oxygenation issues: ∗ Ineffective Airway Clearance ∗ Ineffective Breathing Pattern ∗ Impaired Gas Exchange ∗ Risk for Aspiration ∗ Activity Intolerance ∗ Fatigue
colloids
These are examples of ________: - plasma expanders - albumin - hetastarch - dextran
diagnostic tests
These are examples of __________ _____ that could be performed during the assessment of the respiratory system: ‣ SpO2 ‣ arterial blood gases (ABG) ‣ chest x-ray (CXR) ‣ sputum studies ‣ pulmonary function tests ‣ bronchoscopy
subjective
These are examples of __________ data that you would ask about during a focused assessment of the respiratory system: ‣ dyspnea/orthopnea ‣ wheezing ‣ cough ‣ sputum production ‣ hemoptysis ‣ pain with breathing
atelectasis
These are nursing interventions for what respiratory issue? ◦ auscultate- crackles, diminished breath sounds ◦ monitor vital signs, SpO2, observe cough ◦ reposition/ambulate ◦ encourage fluids ◦ cough and deep breath/incentive spirometer ◦ perform chest physiotherapy
aspiration
These are nursing interventions for what respiratory issue? ◦ prevention- aspiration precautions ◦ auscultate- rhonchi, wheezes, diminished breath sounds ◦ monitor vital signs, SpO2 ◦ suction
hyperventilation
These are nursing interventions for which respiratory alteration? Monitor RR, depth, breath sounds Monitor LOC Assessment- possible anxiety and cause Monitor SpO2, ABG Assess need for and provide supplemental O2 as ordered
hypoventilation
These are nursing interventions for which respiratory alteration? Monitor RR, depth, breath sounds Monitor LOC Monitor SpO2, ABG Assess need for and provide supplemental O2 as ordered
nursing interventions
These are some _______ ____________ for oxygenation issues: - Ensure adequate diet, including fluid intake - May provide postural drainage, percussion, vibration - Provide good oral hygiene - Provide emotional support - Administer meds as ordered - Provide education
hyperventilation
These are some causes of ________________: ‣ metabolic acidosis (low pH, low HCO3)- severe infection, some drug overdoses, starvation, diabetic ketoacidosis ‣ pain, fear, anxiety>> respirations fast and deep
oxygen therapy
These are the principles of ______ ______: - should be treated as a drug - verify 6 rights of med admin - expensive - side effects - safety issues
true
True or false? Those of lower socioeconomic status and/or who are less educated are more likely to develop HTN.
True
True or false? You should use a flexible catheter for suctioning the nasopharynx/ nasotracheal area.
true
True or false? For fluid volume deficit you should hydrate the pt with isotonic liquids.
oropharynx
Use Yankaeur/tonsil-tipped suction for which part of the pharynx?
excess
Weight gain, edema, and distended neck veinsare all S&S of fluid volume (excess/deficit).
acute
Transient pain is also known as ____ pain.
hyponatremia
Treatment and nursing interventions for _____________ includes: ‣ Serum electrolyte levels- monitor labs ‣ Assess daily weights ‣ Limit fluids- fluid restriction, monitor intake and output ‣ Treatment with IV fluid • NS • hypertonic saline- slowly on a pump in a monitored/critical care setting
hypercalcemia
Treatment and nursing interventions for _____________ includes: ‣ correct underlying causes ‣ promote calcium excretion: • IV of 0.9% NaCl (dilute serum Ca) • diuretics (not thiazides bc they cause this) ‣ calcitonin • increase renal calcium excretion • decrease bone resorption
hypocalcemia
Treatment and nursing interventions for _____________ includes: ‣ dietary intake of calcium- foods, calcium carbonate/vitamin D ‣ IV administration of calcium • calcium gluconate: preferred- less damaging of extravasation • calcium chloride ‣ hypomagnesia often occurs with this- may also need magnesium supplementation
hypokalemia
Treatment and nursing interventions for _____________ includes: ‣ increase dietary intake ‣ oral or IV potassium replacement- oral preferred when feasible ‣ IV potassium • never exceed 10-20 mEq/hr • must be given with an IV infusion pump • must be diluted in solution- can cause pain at IV site • if given peripherally, max 10 mEq ‣ monitor K levels closely ‣ monitor vital signs closely
hypernatremia
Treatment and nursing interventions for _____________ includes: ‣ labs- monitor serum electrolyte levels ‣ IV D5W after initial treatment change to 0.45% NaCl ‣ monitor neuro and mental status closely and frequently to avoid cerebral edema ‣ intake and output
hyperkalemia
Treatment and nursing interventions for _____________ includes: ‣ withhold potassium ‣ increase elimination of K • diuretics • sodium polystyrene sulfonate (kayexalate) • closely monitor vital signs • K level- monitor labs • ECG monitoring for rhythm changes • deliver K+ from ECF to ICF- IV insulin and dextrose, NaHCO3
hyperphosphatemia
Treatment and nursing interventions for ________________ includes: ◦ identify underlying cause ◦ restriction of phosphate containing product ingestion ◦ renal failure- reduce serum phosphate
hypophosphatemia
Treatment and nursing interventions for ________________ includes: ◦ mild- oral supplementation and ingestion of foods high in phosphorous (dairy) ◦ symptomatic- IV sodium phosphate or potassium phosphate
hypermagnesemia
Treatment and nursing interventions for ________________ includes: ◦ prevention ‣ teaching renal failure patients to avoid Mg containing foods (green veggies, nuts, bananas, oranges) ‣ avoid Mg containing antacids ◦ in emergency- IV calcium chloride or gluconate (opposes effect in cardiac muscle)
hypomagnesemia
Treatment and nursing interventions for ________________ includes: ◦ primary goal is treating underlying cause ◦ dietary treatment- foods high in Mg ◦ oral supplements ◦ severe- IV magnesium
false
True or False? Administering analgesics regularly leads to drug addiction
false
True or False? Chronic pain is psychological
false
True or False? For endotracheal suctioning, you should not suction through the patient's tracheostomy tube.
false
True or False? If the patient does not report pain then he/she does not have pain.
true
True or False? Nurses spend more time with patient than other members of the healthcare team
true
True or False? Nurses usually are the first one to assess pain
true
True or False? Oxygen should be treated as a medication- meaning there must be a provider's order and you must verify the 6 rights of med admin.
false
True or False? Pain perception, or sensitivity decrease with age
true
True or False? Severe bradycardia or tachycardia, or other dysrhythmia can affect the accuracy of a pulse oximeter.
true
True or False? The skill of performing artificial airway care (i.e. oropharyngeal and permanent tracheostomy tube suction) cannot be delegated to a NAP.
true
True or false? 90-95% of all hypertension cases have no known cause.
false
True or false? All patients who are hospitalized are in pain.
True
True or false? If a patient is on a ventilator, you should suction through the endotracheal tube.
true
True or false? Massage, distraction, relaxation, and acupuncture/acupressure are all examples of nonpharmacological pain strategies.
true
True or false? Patients with musculoskeletal changes, mental status changes, and older adults are at increased risk for extracellular volume deficit.
false
True or false? Psychogenic pain is not real.
true
True or false? Risk for HTN is 2x higher for African Americans than Caucasians.
preload, contractility, afterload
What are the 3 factors that affect stroke volume?
medical asepsis
When performing oropharyngeal/nasopharyngeal suctioning, would you use medical or surgical asepsis?
surgical
When performing tracheal suctioning, would you use medical or surgical asepsis?
A
When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate? A. Restrict sodium intake B. Restrict all caffeine C. Use calcium supplements D. Increase protein intake
aortic, mitral
Which 2 heart valves are most commonly affected by thickening/stiffening caused by aging?
lactated ringers
Which IV solution is this? Ideal fluid in certain situations such as surgery, burns, or GI fluid loss. Has additional electrolytes which makes it better than NS in some situations.
dextrose 5% (D5W)
Which IV solution is this? Isotonic in the bag, but becomes hypotonic once in the body.
0.9% sodium chloride (normal saline)
Which IV solution is this? Used when a pt has experienced both fluid and sodium losses (diarrhea, vomiting). It is the fluid of choice for replacement.
A, B, C, D, E
Which are factors that influence the experience of pain? (select all that apply) A. Age B. Culture C. Gender D. Spirituality E. Cognitive level
DASH
Which diet does this describe? - more fruit, veggies, whole grains, fish, poultry, beans - less red meat, salt, added sugar - avoid high Na foods such as canned food, frozen meals, salty snacks
C
Which fluid would be administered to a patient with fluid volume deficit? A. 0.45% NS B. D5 1/2NS C. Lactated Ringer's D. A colloid
B
Which is one of the greatest risk factors for cardiovascular disease. A. Smoking B. Age C. Being overweight D. Gender
C
Which of following electrolyte imbalances include the following signs and symptoms: abdominal distention, flattened T wave, and muscle weakness? A. hypercalcemia B. hypermagnesemia C. hypokalemia D. hypophosphatemia
D
Which of the following are symptoms of hypocalcemia? A. Positive Chvostek's and Trousseau signs and seizures B. Prolonged QT interval C. Numbness and tingling of the hands and muscle cramps D. All of the above
C
Which of the following best describes drug dependence? A. The patient needs increasing doses to produce the same effect. B. The patient refuses to stop using the medication. C. The patient develops withdrawal symptoms if the medication is discontinued. D. The patient is using the medication for a reason other than pain management.
B
Which of the following interventions would be the best choice to monitor fluid and electrolyte balance? A. assess if client is voiding B. assess daily weight C. evaluate daily urine specimens D. check daily sodium levels
B
Which of the following is a barrier to patients receiving adequate pain relief? A. The nurse chooses an appropriate pain scale, based on the patient's age and cognitive state. B. The nurse believes that the patient is asking for pain medicine because they have an addiction. C. The nurse reassesses pain level after administering pain medication. D. The nurse is careful not to put words in the patient's mouth when asking about pain level
A
Which of the following is a true statement regarding hypertension signs and symptoms? A. There are often no signs and symptoms of hypertension. B. Most people with hypertension experience dizziness. C. Palpitations and headaches are frequently early signs of hypertension. D. Dyspnea and chest pain are frequently the first signs of hypertension.
C
Which of the following is not a modifiable risk factor for hypertension? A. Obesity. B. Dietary sodium intake. C. Age. D. Tobacco use.
B, C, D
Which of the following statements are misconceptions about pain management? (Select all that apply) A. Not every hospitalized patient has pain. B. Prolonged use of narcotic analgesics always leads to addiction. C. Long-term opioid use should never be considered for a patient with cancer-related pain. D. Health care providers are the best authorities on rating a patient's pain from 0-10. E. Pain is subjective.
C
Which of the following supplemental oxygen devices is likely to be the most comfortable for a patient? A. Simple face mask B. Venturi mask C. Nasal cannula D. Non-rebreather mas
increase
________ in plasma oncotic or osmotic pressure: Draws fluid into the plasma from the interstitial space. Causes: - admin of colloids, dextran, mannitol, or hypertonic solutions
B, C, E, F
Which of these can a nurse delegate to a NAP in an acute care setting? (select all that apply) A. artificial airway care B. applying a nasal cannula or mask C. placing and positioning the O2 device D. chest tube management E. skin care around the ears/nose F. oropharyngeal and tracheostomy suctioning (in a stable patient)
D
Which one of these conditions is most likely caused by atelectasis? A. CVA tenderness B. Aspiration C. Hyperventilation D. Hypoventilation
A
Which statement indicates the development of opioid tolerance? A. Larger doses of opioids are needed to control pain, as compared to several weeks earlier. B. Stimulants are needed to counteract the sedating effects of opioids. C. The patient becomes anxious about knowing the exact time of the next dose of opioid. D. The patient no longer experiences constipation from the usual dose of opioid.
E
Which substance increases pain transmission? A. Substance P B. Histamine C. Prostaglandins D. Bradykinin E. All of the above
A
Which term is defined as the resistance the left ventricle must overcome to eject blood? A. Afterload B. Preload C. Myocardium D. Diastole
2nd spacing
Which type of fluid spacing is this? Abnormal accumulation of interstitial fluid (edema)
1st spacing
Which type of fluid spacing is this? Normal distribution of fluid in the ICF and ECF
idiopathic pain
Which type of pain does this describe: A form of chronic pain without a known cause.
nociceptive pain
Which type of pain does this describe: A pain sensation that results abruptly after injury. Normal stimulation of peripheral nerve endings called nociceptors.
somatic pain
Which type of pain does this describe: Pain arising from the connective tissues, skin, bones, muscles, or joints.
visceral pain
Which type of pain does this describe: Pain arising from the organs or viscera- GI tract, pancreas, etc.
neuropathic pain
Which type of pain does this describe: Pain associated with damaged or malfunctioning nerves due to illness, injury or undetermined reasons. Abnormal processing of sensory input by the peripheral or central nervous system.
referred pain
Which type of pain does this describe: Pain that arises from a different area than the source
chronic pain
Which type of pain is this? Not protective. Is ongoing or frequent and lasts 6> months. Physiological responses do not usually alter VS. Psychological responses can lead to disability. Management aims at symptomatic pain relief, but pain does not always respond to interventions. Can be malignant or nonmalignant.
acute pain
Which type of pain is this? Protective, temporary, usually self-limiting, has a direct cause, and resolves with tissue healing. Physiological responses: - increased HR & BP - anxiety - diaphoresis - muscle tension Behavioral Responses: - grimacing - moaning - flinching - guarding Interventions- treat underlying problem
P wave
Which wave on the EKG is this: - first deflection from isoelectric line - depolarization of the atria
T wave
Which wave on the EKG is this: - ventricular repolarization
QRS complex
Which wave on the EKG is this: -depolarization of the ventricles
D
While obtaining subjective assessment data from a patient with hypertension, the nurse recognizes that a modifiable risk factor for the development of hypertension is: A. Consumption of a high-protein diet. B. A low-calcium diet. C. A family history of hypertension. D. Excessive alcohol consumption.
D
While obtaining subjective assessment data from a patient with hypertension, the nurse recognizes that a modifiable risk factor for the development of hypertension is: A. Consumption of a high-protein diet. B. A low-calcium diet. C. A family history of hypertension. D. Excessive alcohol consumption.
risk factors
____ _______ for fluid and electrolyte imbalances include: - age: very young and very old - musculoskeletal changes - mental status changes - elevation of venous pressure - elevation of interstitial oncotic pressure - decrease of plasma oncotic or osmotic pressure - edema
risk factors
____ _______ for hypertension include: - alcohol and tobacco use - DM - atherosclerosis - excessive dietary sodium - gender - family history - obesity - ethnicity - sedentary lifestyle - socioeconomic status - stress
iron
____-rich foods include: - legumes, nuts, seeds - meat and fish - fruit - breads and grain - veggies
plasma expanders
______ _________ may be given for rapid expansion of the intravascular space
safety
______ while using oxygen includes: - admin by provider's order ONLY - placing an "oxygen in use" sign - securing the cylinders - ensuring adequate amount of O2 in tank and adequate tubing length when pt is mobile - using tubing safety to prevent tripping and falls
hypoxia
_______ results from any impairment in oxygen delivery or use at the cellular level. Causes include: - Decreased Hgb - Poisoning - Pneumonia - Shock - Poor tissue perfusion
isotonic
________ IV solutions include: - 0.9% sodium chloride (normal saline) - lactated ringers (LR or RL) - dextrose 5% (D5W)
nursing diagnoses
________ ________ for pain include: Acute pain r/t biological, physical, or chemical injury agents Chronic pain r/t: - older adults: alteration in sleep pattern - chronic musculoskeletal condition - emotional distress - fatigue
physical examination
________ ___________ of the respiratory system includes: ‣ respirations ‣ skin/nails ‣ neck ‣ chest wall ‣ palpate chest, back ‣ breath sounds
older adults
common misconceptions about pain in _____ ______ include: - pain is natural part of aging - pain sensitivity decreases - not reporting pain = not having pain - if pt appears to be occupied, sleeping, or otherwise distracted from pain, then they do not have any - potential side effects of opioids make them too dangerous
excess
diagnostic tests and monitoring for fluid volume ______ include: - serum electrolytes and osmolality - serum hgb and hct - renal and liver function
non-opioid analgesics
indications for administration of ___-______ __________ include: - inflammatory conditions - mild to moderate pain of peripheral origin - co-analgesic for severe pain - desire by pt to avoid opioids - conditions associated w/ excessive prostaglandin at site - postoperative pain
