Final Prep U Quizlet

reason for ET intubation

-bypass upper airway obstruction -support mechanical ventilation -facilitate removal of tracheobronchial secretions

what are the phsyiologic response of all types of shock

-hyperperfusion of tissues -hypermetabolism (anerobic) -inflamm response

What is Maslow's hierarchy of needs?

1. Physiological needs- ABC, food, water 2. Safety and Security needs 3. Love and Belonging Needs 4. Self esteem 5. self actualization Pedro Sang Lullaby So Softly

A client is receiving intravenous (IV) dobutamine (Dobutrex) to help provide adequate perfusion to the brain. The order is for dobutamine 50 mg in 500 mL D5W at 2 mcg/kg/min. The client weighs 58 kg. At how many mL per hour will the nurse administer this medication? Enter the correct number ONLY.

70 58 kg X 2 = 116 mcg/min. 116 mcg X 60 minutes = 6,960 mcg per hour. 6,960 mcg/1000 = 6.96 mg, rounded to 7 mg/hour. (7 mg/50 mg) X 500 mL = 70 mL/hour.

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns? a. deep tissue cooling b. continuing inflammatory process c. protein cell coagulation d. All options are correct.

A Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? a. vasodilation b. vasoconstriction c. hypertension d. increased PaO

A Hypotension and hypoxia lead to vasodilation, which contributes to increased ICP, compressing blood vessels and leading to cerebral ischemia. As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP.

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. a. Increased paCO² levels b. Reports of chest pain c. Loss in consciousness d. Ecchymoses and petechiae e. Decreases in liver enzymes

A, B, C, D; pt in progressive stage of shock The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activites of the liver are impaired, and liver enzymes will increase.

A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply. A. The client who is in the first 15 minutes of receiving 1 unit of PRBCs B. The 55 year-old client with spina bifida C. The client who is scheduled for a repeat CT scan of the abdomen D. The client with an infection who is prescribed intravenous vancomycin E. The client who reports an allergy to peanuts that causes throat swelling

A, B, E

The statements presented here match nursing interventions with nursing diagnoses. Which statements are appropriate for a client who has suffered a head injury? Select all that apply. A. Ineffective airway clearance: Apply suction as indicated B. Deficient fluid volume: Administer 1 L of normal saline daily C. Disturbed sleep pattern: Provide back rubs to the client D. Ineffective cerebral tissue perfusion: Maintain cerebral perfusion pressure ≤50 mm Hg E. Interrupted family process: Encourage the family to join a support group

A, C, E These nursing diagnoses match the interventions correctly. The goal of hydration is to prevent dehydration or fluid overload; fluid replacement is based on the client's individual needs. Cerebral perfusion pressure should be maintained between 50 and 70 mm Hg.

A client has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A. Perform a rapid physical assessment. B. Initiate health education. C. Perform diagnostic imaging. D. Establish the circumstances of the accident.

A; Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. Health education is initiated later in the care process and diagnostic imaging would take place after a rapid physical assessment. It is not the care team's responsibility to determine the circumstances of the accident.

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? a. Sodium deficit b. Decreased prothrombin time (PT) c. Potassium deficit d. Decreased hematocrit

A; Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium deficit, potassium excess, and elevated hematocrit. PT does not typically decrease.

Nursing assessment for the patient receiving peritoneal dialysis would include which of the following to detect the most serious complication of this procedure? a. Palpate the abdominal wall for rebound tenderness. b. Inspect the catheter site for leakage of dialysate. c. Observe for evidence of bleeding. d. Measure fluid drainage to estimate incomplete recovery of fluid.

A; Peritonitis is the most serious complication of peritoneal dialysis. To detect rebound tenderness, the nurse presses one hand firmly into the abdominal wall and quickly withdraws the hand. Rebound tenderness exists when pain occurs upon removal; this pain is associated with inflammation of the peritoneal cavity.

The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury? A. It results from inadequate delivery of nutrients and oxygen to the cells B. It results from initial damage to the brain from the traumatic event. C. It refers to the permanent deficits seen after the rehabilitation process. D. It refers to the difficulties suffered by the client and family related to the changes in the client.

A; Secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually as a result of cerebral edema and increased intracranial pressure. Primary injury results from initial damage related to the traumatic event.

The nurse is discussing cardiac hemodynamics with a nursing student, who understands the the following formula: CO = HR X SV (cardiac output equals heart rate times stroke volume). The nursing student asks what determines heart rate. The correct response by the nurse is which of the following? A. The autonomic nervous system controls the heart rate. B. Preload controls the heart rate. C. Stroke volume controls the heart rate. D. Force of contractility controls the heart rate.

A; The autonomic nervous system primarily controls the heart rate. When the sympathetic branch is stimulated, heart rate increases. When the parasympathetic branch is stimulated, heart rate decreases. Stroke volume is the amount of blood pumped out of the ventricle with each contraction and depends on three factors: preload, afterload, and contractility.

Which finding would indicate a decrease in pressure with mechanical ventilation? A. Kinked tubing B. Increase in compliance C. Decrease in lung compliance D. Plugged airway tube

B

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury? a. Diarrhea b. Placing the client in a sitting position c. Placing a blanket over the client d. Voiding

C An object on the skin or skin pressure may precipitate an autonomic dysreflexic episode. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? a. Complaint of headache off and on for past month b. No bowel movement since yesterday c. Nausea d. Frequent voiding

C Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Complaint of headache for past month is significant and probably attributes to the evaluation at hand. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.

A nurse is caring for a client who's ordered continuous ambulatory peritoneal dialysis (CAPD). Which finding should lead the nurse to question the client's suitability for CAPD? a. The client is blind in his right eye. b. The client has a history of severe anemia during hemodialysis. c. The client has a history of diverticulitis. d. The client is on the kidney transplant waiting list.

C; A history of diverticulitis contraindicates CAPD because CAPD has been associated with the rupture of diverticulum.

A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid? a. Isotonic fluid b. No intravenous solution c. Hypertonic solution d. Hypotonic solution

C; There are three types (tonicity) of intravenous fluids, which are isotonic, hypotonic, and hypertonic solutions. By process of osmosis and diffusion, solutes are moved through the body. A hypertonic solution is used to pull water back in to circulation as a hypertonic solution has more particles than the body's water. An isotonic solution is the same concentration as the body's water and is used as an intravenous volume expander. A hypotonic solution has fewer particles than the body's water thus shifting water from the vascular space to the tissue

A patient is placed on hemodialysis for the first time. The patient complains of a headache with nausea and begins to vomit, and the nurse observes a decreased level of consciousness. What does the nurse determine has happened? A. The dialysis was performed too rapidly. B. The patient is having an allergic reaction to the dialysate. C. The patient is experiencing a cerebral fluid shift. D. Too much fluid was pulled off during dialysis.

C; Dialysis disequilibrium results from cerebral fluid shifts. Signs and symptoms include headache, nausea and vomiting, restlessness, decreased level of consciousness, and seizures. It is rare and more likely to occur in AKI or when BUN levels are very high (exceeding 150 mg/dL).

The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because a. the client can experience nausea and emesis when given oral medications. b. pain resulting from a burn injury requires relief by the fastest route available. c. bleeding may occur at injection sites when the intramuscular route is used. d. tissue edema may interfere with drug absorption via other routes.

D

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply. a. Hypotension b. Tachycardia c. Venous pooling d. Diaphoresis e. Tachypnea f. Hypothermia

a, c, e, f s/s: -venous pooling -bradycardia -warm skin The vital organs are affected in a spinal cord injury, causing the blood pressure and heart rate to decrease. This loss of sympathetic innervation causes a variety of other clinical manifestations, including a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the patient does not perspire on the paralyzed portions of the body because sympathetic activity is blocked; therefore, close observation is required for early detection of an abrupt onset of fever.

he duty to do good to benefit others

beneficence

most common issues facing nurses today

confidentiality restraints trust refusing care end of life concerns

refers to the duty to be faithful to one's commitments.

fidelity

Which term refers to the shifting of brain tissue form an area of high pressure to an area of low pressure?

herniation

is the duty not to inflict harm as well as to prevent and remove harm

nonmaleficence more binding than beneficence

what is a symptom of shock

shallow, rapid respirations or tachycardia

is the obligation to tell the truth

veracity