ATI Med Surg Pt I

A nurse is reinforcing discharge teaching w a client who has a new prescription for aluminum hydroxide (Amphojel). The nurse should advise the client to... Take the medication with food Monitor for diarrhea Wait 1-2 hr before taking other oral meds Maintain a low fiber diet

Amphojel is an antacid that protects the mucosa by increases gastric pH and neutralizing pepsin. It should be taken on an empty stomach and wait at least 1 hr before/after taking other medications orally. The nurse should monitor for constipation and maintain a high fiber diet.

A nurse is collecting data from a client who is scheduled for a scheduled cardiac catheterization. Which of the following client reported allergies has the highest priority? Shrimp Peanuts Bananas Soy

Cardiac catheterization involves contrast dye and a nurse should monitor for any shellfish/iodine allergies. The highest priority would be an allergy to shrimp.

A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect? SATA Elevated temperatures JVD Skin tenting DIzziness Orthopnea

Dehydration is a result of hypovolemia; the nurse should expect to see manifestions of low water volume in the blood such as elevated temps, flat neck veins, dry mucous membranes and poor skin turgor (skin tenting), dizziness and hypotension. Orthopnea and JVD are manifestations of hypervolemia.

Red Blood Cells

Females: 4.2 mil - 5.4 mil Males: 4.7 to 6.1 mil Decrease can be evidence of anemia or hemorrhage

Hypernatremia Causes

Water deprivation (NPO) Excessive sodium intake Excessive sodium retention (Kidney failure, Cushings disease, aldosteronism, glucocorticosteroids) Fluid losses (fever, diaphoresis, burns, respiratory infection, DI, hyperglycemia, watery diarrhea) Age related changes Increased thirst and ADH production

S/S of Hypokalemia

Weak, irregular pulse; hypotension; RD. Weakness to point of respiratory collapse and paralysis, muscle cramping, decreased muscle tone and hypoactive reflexes, paresthesias, mental confusion. Decreased GI motility, abd distention, constipation, ileus, n/v, anorexia and polyuria (diluted urine) Encourage foods high in potassium (bananas, potatoes, advocados, broccoli, dairy products, dried fruits, canteloupe), oral potassium supplementation, IV potassium should never be given as bolus (high risk of cardiac arrest) and check for phlebitis. Monitor for client receiving digoxin (hypokalemia increases risk of digoxin toxicity) Observe for shallow, ineffective respirations and diminished breath sounds Metabolic alkalosis (pH >7.45) Premature ventricular contractions (PVCs), bradycardia, blocks, ventricular tachycardia, inverted T waves, ST depression

A nurse is reinforcing teaching w a client who has a new diagnosis of dumping syndrome following gastric surgery. Which of the following should be included in the teaching? Eat three moderate sized meals/day Drink at lease one glass of water w each meal Eat at a bedtime snack that contains milk product Increase protein in diet

With dumping syndrome, the client should eat several small meals a day, avoid drinking fluids with meals and 1 hr prior and following meals, avoid eating milk products, sweets or sugars. And increase their diet high in protein and fat, low to mod carb, and low fiber diet.

Radiography (KUB) "Flat plate"

X ray of kidneys, ureters, and blabber; allows visualization of structures and detection of renal calculi, strictures, calcium deposits, or obstructions. Ask female client if she's pregnant. Clothes over the area will need to be removed including jewlery and metal objects. No known complications.

Complications of Angiography: Restenosis of Treated vessel (clot reformation after procedure)

can occur immediately post procedure or several weeks later, monitor ECG patterns and occurrences of chest pain, notify provider immediately, prepare the client for return to the cardiac catheterization laboratory.

A nurse is caring for a client following peripheral bypass graft surgery of the LLE. Which of the following client findings pose an immediate concern? SATA trace of bloody drainage on the drsg capillary refill of affected limb >6 secs mottled appearance of the limb throbbing pain of affected limb that is decreased following IV bolus analgesic Pulse of 2+ in affected limb

capillary refill greater than 2-4 seconds is abnormal and a mottled appearance of the limb poses a concern. All the other answers are expected or normal.

Human B-type natriuretic peptides

confirms a diagnosis of heart failure; hBNP levels direct the aggressiveness of tx interventions Level below 100- no HF 100-300- HF present >300- mild HF >600- moderate HF >900- severe HF

Excretory Urography

detect obstruction, assess for parenchymal mass, and assess size of kidney. IV contrast dye (iodine based) is used to enhance imaging. Pre procedure- encourage increased fluids during the day before procedure, bowel cleanse w laxatives and enemas to remove fecal contents, fluid and gas from colon for clear visualization. NPO after midnight, determine allergy to seafood, eggs, milk, chocolate; or if client has asthma. Check creatinine and BUN, Hold metformin 48 before and after procedure (risk for lactic acidosis from contrast dye) Post-procedure- Admin parenteral fluids or encourage oral fluids to excrete contrast and prevent complications, diuretics may be admin, follow up creatinine and BUN levels before metformin presumed, contrast dye can cause acute renal injury

Peptic Ulcer Disease (PUD)

erosion of mucosal lining of the stomach or duodenum; erosion can occur to the point of epithelial exposure to gastric acid and pepsin that can precipitate bleeding and perforation. C/B H Pylori infection, NSAIDs/ corticostroid use, Excess alcohol use, Hypersecretory states (Zollinger-Ellison syndrome) Client has dyspepsia, heartburn, bloating, N/V, epigastric pain upon palpitation (may radiate to back) hematemesis or melena, and weight loss. Ammonia breath test (C13-urea)- client NPO prior to test, drinks carbon enriched urea solution and breathe into collection container. If H Pylori present- solution will break down and CO2 be released. Two collections are compared. Avoid taking bismuth, misoprostol, sucralfate, H2 receptors blockers- may intefere w false negatives.

Urinalysis

evaluates waste products from the kidney and detects urologic disorders; early morning collection provides more concentrated sample. Analyzed for color, clarity, concentration/dilution, specific gravity, acidity/alkalinity, and presence of drug metabolites, glucose, ketone bodies, and protein. Leukotrase and nitrites are not normally found in urine (along w glucose, protein, and ketone bodies) and indicates DM, fat metabolism, infection, or cancer. Culture and sensitivity collected when bacteria present to determine the type of antibiotic most sensitive. Urine collectd for 24 hr measures levels of creatinine or urea nitrogen, sodium, chloride, calcium, catecholamines, and protein. Urine creatinine clearance 24 hr collection measuresGFR for clients suspected of renal dysfunction.

Hemoglobin (Hgb)

females: 12-16 males: 14-18 decreased levels evidence of anemia

Cardiac dysryhtmia

heart beat disturbances that can be benign or life threatening. Classified by: site of origin (SA node, atria, AV node, ventricular) and effect on the rate and rhythm of the heartbeat (bradycardia, tachycardia, heart block, premature beat, flutter, fibrillation, or asystole) Bradycardia- <60 bpm may need pacemaker AFib, Supraventricular tachycardia, or ventricular tachycardia w pulse- Synchronized cardioversion Ventricular tachycardia w/o pulse or VFib- Defibrillation, epinephrine, lidocaine, amiodarone

A nurse is reviewing nutrition information w a client who has cholecystitis.Which of the following food choices can trigger cholecystitis? Brownie w nuts Bowl of mixed fruit Grilled turkey Baked potato

high fat foods like a brownie can trigger cholecystitis.

A nurse is collecting data for a client who has HF. Which of the following findings is a clinical manifestation of right sided HF? JVD Daytime oliguria S3 heart sounds Orthopnea

right sided HF manifestations includes peripheral edema like JVD, ankles, sacrum, and legs. Nocturnal polyuria would be another manifestation.

Sigmoid Colostomy

small to moderate amount of mucus w semi formed stool 4-5 days after surgery. After several days to weeks, output become more semi formed stool.

Platelets

150,000- 400,000 mm3 Increased level can be evidence of malignancy or polycythemia vera; decreased can be evidence of autoimmune disease, bone marrow suppression, or enlarged spleen

Maintenance of Acid- Base balance

1st line of defense- chemical and protein buffers; either bind or release hydrogen ions as needed and responds quickly to pH changes 2nd line of defense- Respiratory buffers; control level of hydrogen ions in the blood through control of CO2 levels (Hyperventilation= decrease in H+ Hypoventilation= increase in H+) 3rd line of defense- Renal buffers; much slower to respond but most effective buffer system w longest duration. The kidneys control movement of bicarbonate in the urine; high H+= bicarbonate reabsorption and production low H+= bicarbonate excretion

White Blood Cells

5000-10000 elevation can indicate an infection decrease can be evidence of immunosuppression

A nurse is collecting data from a client who has suspected stomach perforation dt a peptic ulcer. Which of the following are expected findings? SATA Rigid abd Tachycardia Elevated B/P Circumoral cyanosis Rebound tenderness

A board-like, rigid abdomen, rebound tenderness, and S/S of hemorrhage (tachycardia, hypotension) are manifestations of a perforation.

A nurse is contributing to the POC of a client who has acute gastritis. Which of the following nursing interventions should the nurse include in the POC? SATA Evaluate I/O Monitor electrolytes lab reports Provide 3 large meals/day Admin ibuprofen dor pain Observe stool characteristics

A client w acute gastritis is experiencing inflammation of the stomach mucosal lining. The nurse should evaluate I/O and electrolyte lab reports to prevent fluid loss/dehydration. The nurse would also observe the stool characteristics for gastric bleeding. The client should avoid NSAIDs like Ibuprofen (Motrin) and large meals.

A nurse is reinforcing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should be included in the teaching? SATA You will need a monthly injection of Vit B12 for the rest of your life Using the nasal spray form of Vit B12 on a daily basis can be an option An oral supplement of Vit B12 on a daily basis can be an option You should increase your intake of animal proteins, legumes, and dairy products to increase Vit B12 in diet Add soy milk fortified w Vit B 12 to your diet to decrease risk of pernicious anemia

A client who had a gastrectomy will require a monthly injection of vitamin B12 for the rest of their life and the nasal spray form on a daily basis may be an option for the client. Oral supplementation and dietary intake will not be absorbed dt the lack of the intrinsic factor rt gastrectomy (removal of the stomach).

A nurse is collecting data from a client who has pancreatitis. Which of the following is an expected finding? Pain in the RUQ radiating to the right shoulder Report pain being worse when sitting upright Pain relieved by defecation Epigastric pain radiating to left shoulder

A client who has pancreatitis will report severe, boring epigastric pain that radiates to the back, left flank, and left shoulder.

A nurse is observing an assessment of a client who has GERD. Which of the following is an expected finding? Absence of saliva Loss of tooth enamel Client report sweet taste in mouth Client reports absence of eructation

A client with GERD will experience loss of tooth enamel dt corrosive gastric contents rising in the mouth. Hypersalivation, bitter taste in mouth and increased flatus and burping are also manifestations of GERD.

A nurse is reinforcing teaching to a client who is to have a bone marrow biopsy of the iliac crest. Which of the following statements by the client indicates a need for further teaching? Cancer can be detected in the fluid being tested I will feel a heavy pressure sensation in my hip bone The type of antibiotic I need can be determined by this test I will be awake during the procedure

A culture and sensitivity test determines what type of antibiotic will be needed. not for a bone marrow biopsy.

A nurse is caring for a client who has suspected anemia.The nurse should anticipate a prescription for which of the following tests? INR Platelet count WBC count Hgb

A decrease in Hgb or hct can diagnose anemia. INR indicates the effectiveness of Warfarin. Platelet count indicates immune response. and WBC can indicate infection or immunosuppression.

A nurse is monitoring a client receiving a blood transfusion. Which of the following medications should the nurse anticipate giving if the client experience a mild allergic reaction to the transfusion? Acetaminophen (Tylenol) Diphenhydramine Epinephrine Heparin

A mild allergic reaction to a blood transfusion includes pruritis, urticaria and flushing. The client should be given an antihistamine such as diphenhydramine. Acetaminophen (Tylenol) may be given to a client experiencing a febrile reaction and epineprhine may be given if the client experiences an anaphylactic reaction to the blood transfusion. Heparin is given to client who has DIC resulting from septic shock.

A nurse is checking the stoma of a client with a new colostomy and notes that the stoma appears pale. Which of the following actions should the nurse take? Check the clients temp Wash the area w warm water Gently massage around the stoma Prepare the client for surgery

A pale pink or bluish/purple stoma indicates compromised circulation and requires immediate attention. The nurse should prepare the client for surgery

A nurse is collecting data from a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. Which of the following findings are a priority? Client reports difficulty sleeping Blood glucose at 0800 is 140 Client reports having a sore throat Client reports gaining 4 lb in last 6 mo

A sore throat is a priority finding because prednisone is a corticosteroid that suppresses inflammation response. The client should monitor for manifestations of infection (sore throat, fever)

A nurse is caring for a client who has chronic gastritis and is scheduled for a selective vagotomy. The purpose of this is to... Increase duodenal gastric emptying Reduce gastric acid secretions Increase gastric mucus secretion Reduce histamine secretion

A vagotomy severs only the fiber nerves that controls gastric secretion (Reducing gastric acid secretions) and often done laparascopically to reduce post operative complications. A pyloroplasty is usually done at the same time to widen the opening of the stomach to the duodenum to increase gastric emptying

Blood types

A- antigen =A, Antibodies against= B, compatible w A&O B- antigen= B, antibodies against A, compatible w B&O AB- antigen AB, antibodies against none, compatible w A, B, AB, O O- no antigen, antibodies against A, B; compatible w O

Hypokalemia risk factors

Abn GI losses- vomiting, nasogastric suctioning, diarrhea, laxative use Kidney losses- excessive diuretic use, corticosteroids Skin losses- wound losses diaphoresis Inadequate dietary intake Prolonged admin of nonelectrolyte containing IV solutions ( 5% dextrose in water) Intracellular shift ( metabolic alkalosis after acidosis correction (burns, trauma, starvation), TPN

Hyponatremia Causes

Abn GI losses- vomiting, nasogastric suctioning, diarrhea, tap water enemas, GI obstructions. Kidney losses-diuretics, kidney disease, adrenal insufficiency Skin losses- diaphoresis, burns, wound drainage, ascites rt cirrhosis Increased ECF volume - excessive oral water intake, SIADH (excessiv excretion of ADH, Edematous states (HF, cirrhosis, nephrotic syn) Excessive hypotonic fluids, inadequate salt intake (NPO, OA)

Transfusions reactions

Acute Hemolytic- immediate reaction that can be mild or life threatening. Includes chills, fever, low back pain, tachycardia flushing hypotension chest tightening or pain tachypnea nausea anxiety and hemoglobinuria. Can cause cardiovascular collapse kidney failure DIC shock and death Febrile- reaction occurs 30 min - 6 hrs after transfusion. Includes chills, fever ( increase of more than 1 degree c or 1.8 degree f) flushing headache and anxiety. Prevent by using a WBC filter and admin antipyretics Mild Allergic- occurs during or up to 24 hrs after transfusion includes itching urticaria and flushing Admin antihistamines like diphenhydramine Anaphylactic- immediate reaction that includes wheezing dyspnea chest tightness cyanosis and hypotension; maintain patent airway Admin o2 IV fluids antihistamine corticosteroids and vasopressors Immediately stop transfusion, ensure infusion of 0.9 sodium chloride initiated w separate line and save blood bag w remaining blood and blood tubing for testing at lab.

A nurse is caring for a client who has a new diagnosis of HTN and a new prescription for spironolactone (Aldactone) 25 mg/day. Which of the following statements by the client indicates a need to reinforce teaching? I should eat alot of fruits/veggies, esp bananas and potatoes I will report any changes in HR or rhythm I should use salt substitutes that are low in potassium I will continue to take this medication even if I am feeling better

Aldactone is a potassium sparing diuretic that prevent the reabsorption of sodium in exchange for potassium that can cause hyperkalemia. This client should be taught to avoid foods high in potassium such as bananas and potatoes.

Medications for Irritable Bowel Syndrome

Alosetron (Lotronex)- specific med for women w IBS-D (diarrhea) lasting more than 6 mo and resistant to conventional management. Nurse should expect increased firmness in stools, decreased urgency and frequency of defecation. Contraindicated for clients w chronic constipation, history of bowel obstruction, Crohn's disease, Ulcerative colitis, impaired intestinal circulation, or thrombophlebitis. Manifestations should resolve in 1-4 weeks but return 1 week after med d/c. Client should report constipation, malaise, fever, darkened urine, or bleeding from rectum or stool immediately. Lubiprostone (Amitiza)- specific for IBS-C (constipation); it increases fluid secretion in the intestines to promote intestinal motility. Contraindicated for clients who have known or possible bowel obstruction and should be taken w food to decrease nausea. Not effective for men w IBS.

Pancreatitis

An auto digestion of the pancreas by pancreatic digestive enzyme; enzymes activate prematurely before reaching the intestines. Classic manifestations include severe constant knife-like pain in LUQ, mild epigastric and/or radiating to the back,left flank or shoulder. unrelieved by N/V. Avoid excessive alcohol consumption and eat a low fat diet. Pain some what relieved by fetal position, worse after consumption of alcohol or high fat foods, weight loss. Ecchymoses of the flanks (Turner's sign), bluish grey periumbilical discoloration (Cullen's sign), Jaundice, Warm moist skin w fruity breath, ascites, tetany (Chvosteks and Trousseaus sign), and paralytic ileus. Lab test- Amylase considered positive when 2-3 X greater, lipase 3-5 X greater than expected value; Increased WBC, and decreased platelets. Calcium and magnesium decreased, liver enzymes and bilirubin increased, glucose increased dt decreased insulin production. No food until pain free, when diet resumed- bland, low fat w no stimulants, small freq meals, no smoking/alcohol, limit stress.

A nurse is assisting w the admission of a client who has a suspected MI and history of angina. Which of the following findings will help the nurse distinguish angina from an MI? Angina can be relieved w rest and NTG The pain of an MI resolves in less than 15 mins The type of activity that causes an MI can be identified angina can occur for longer than 30 min

Angina is relieved w rest and NTG whereas MI is relieved only by opioids. An MI occurs more than 30 mins whereas angina occurs less than 15 mins. Causes of an MI are unknown whereas angina is caused by stress or exercise.

Symptoms of pulmonary edema

Anxiety Inability to sleep Persistent cough w pink frothy sputum tachypnea, dyspnea, orthopnea hypoxemia cyanosis crackles tachycardia s3 heart sounds reduced urinary output confusion, stupor

A client asks a nurse why the provider prescribed 81 mg/day of aspirin. Which of the following is an appropriate response by the nurse? Aspirin reduces the formation of blood clots that cause a heart attack Aspirin relieves the pain dt myocardial ischemia Aspirin dissolves clots that are forming in your coronary arteries Aspirin relieves headaches that are c/b other meds

Aspirin acts as an antiplatelet that reduces the formation of blood clots that can cause a heart attack. NTG relieves pain d/t ischemia by dilating the coronary arteries. Aspirin doesn't dissolve clots or relieve headaches

A nurse is collecting data from a client who has type II DM and a recent diagnosis of HTN. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following data collected should be reported to the provider? takes psyllium hydrophilic mucilloid (Metamucil) daily Drinks skim milk daily Takes metoprolol (Lopressor) daily Drinks grapefruit juice daily

Beta blockers such as metoprolol or atenolol (Tenormin) are given to help treat HTN by decreasing cardiac output and blocking the release of renin which causes vasoconstriction thus raising the BP. Beta blockers can mask symptoms of hypoglycemia (tachycardia) because it suppresses the SNS (epinephrine and norepinephrine). Skim milk increases blood sugar and lowers cholesterol- does not need to be reported Grapefruit juice raise the blood sugar levels and doesn't need to be reported.

S/S of anemia

Can be asymptomatic in mild cases pallor, fatigue irritability paresthesias of the extremities dyspnea on exertion sensitivity to cold pain and hypoxia w sickle cell crisis SOB tachycardia/ palpitations nail bed deformities dizziness/syncope upon rising smooth sore bright red tongue (Vit B12 deficiency) palloe w pale nails and mucous membranes

a nurse is caring for a client who has been taking captopril (Capoten). The nurse should monitor the client for which of the electrolyte disorders? Hyperkalemia Hypokalemia Hypernatremia Hyponatremia

Captopril is an ace inhibitor that can cause hyperkalemia. Loop diuretics like furosemide causes hypokalemia. Ace inhibitors don't affect sodium levels

A nurse is caring for a client who has a prescription for captopril (Capoten). Which of the following instructions should the nurse reinforce to the client to monitor and report to the provider? Dry cough Urinary retention Headache Diarrhea

Captopril is an ace inhibitor that prevents the conversion of angiotensin I into Angiotensin II, thus preventing vasoconstriction (increasing the B/P). the client should monitor for hypotension, evidence of HF such as edema, and should report cough which is a sign the medication should be D/C. It can also cause hyperkalemia

A nurse is discussing cardioversion w a newly licensed nurse. Which of the following statements by the new nurse indicates an understanding of this procedure? The client should take an anticoagulant prior to the procedure The client will receive an unsynchronized countershock during the procedure The client who has VFib should receive this procedure The client will be placed on a mechanical ventilator during this procedure

Cardioversion is a direct countershock to the hearts QRS complex when the client is experiencing atrial dysrhythmias, supraventricular tachycardia, and ventricular tachycardia w pulse. a client w/ VFib should receive immediate defibrillation to stop the hearts electrical activity to allow the SA node to take over. The client will receive oxygen during this procedure.

Cardio-version and Defibrillation

Cardioversion is delivery of a direct countershock to the heart synchronized to the QRS complex Defibrillation is an unsynchronized, direct countershock to the heart, stopping the heart to allow the SA node to take over and reestablish a perfusing rhythm. Preprocedure- clients w AFib must recieve adequate anticoagulation therapy for 4-6 wks prior to cardioversion to prevent dislodgement of thrombi into bloodstream, must verify consent and an anesthetic is given for sedation Intraprocedure- All staff must stand clear of the client, equipment connected and bed when delivering shock. CPR is performed for cardiac asystole and other pulseless rhythms. Immediate defibrillation for clients in VFIB (the ventricles are quivering, not delivering blood) Postprocedure- Document # of defibrillation or cardioversion attempts, energy settings, time, and response. The clients condition and LOC following the procedure, and skin conditions under the electrodes. Report palpitations or irregularities.

A nurse is caring for a client who has advanced cirrhosis w worsening hepatic encephalopathy. Which of the following is an expected assessment finding? SATA Anorexia Change in orientation Asterixis Ascites Fector hepaticus

Change i orientation, Asterixis, and Fector hpaticus are signs of worsening hepatic encephalopathy. Anorexia and ascites are just signs of a client w liver dysfunction

Complications of Angiography: Hematoma Formation near insertion site

Check groin at prescribed interval times and PRN, hold pressure for uncontrolled oozing/bleeding, monitor peripheral circulation (6 Ps) Notify provider

Cholecystitis/Cholelithiasis

Cholecystitis is inflammation of gallbladder often caused by obstruction (cholelithiasis =gallstones). Can cause pancreatitis if pancreas is obstructed. Consume low fat diet rich in HDL sources (safood, nuts, olive oil), dont smoke, regular exercise program. Risk factors- High fat diet, type I DM; low calorie, liquid protein diets, Rapid weight loss, Obesity. S/S- sharp pain in RUQ radiating to right shoulder, pain w deep inspiration during right subcostal palpation (Murphy's sign), rebound tendrness (Blumberg's sign), intense pain (increased HR, pallor, diaphoreis) w N/V after ingestion of high fat foods caused by biliary colic, dyspepsia, eructation, flatulence, and fever. Jaundice, clay colored stools, steatorrhea, dark urine, and pruritis. Morphine and dilaudid > demerol (causes sz), Bile acids (chenodiol, ursodiol), lithotripsy (lay on fluid filled bag for shock delivery, multiple procedures required)

Percutaneous Coronary Intervention (PCI)- non surgical procedure that requires a consent form performed to open coronary arteries by atherectomy, stent placement, or angioplasty (inflating a balloon to dilate arterial lumen and adhering the plaque, thus widening the lumen). Indicated if CAD greater than 50% occlusion, the area of occlusion is confined, not scattered, and easy to access; can reduce ischemia during acute MI and most effective if done w/t 90 min of chest pain; as alternative to CABG, can be used w stent placement to dilate main coronary artery which supplies blood flow to large area of the heart

Client Presentation- Chest pain w or w/o exertion, pain radiates the the jaw, left arm, back or shoulder. manifestations may increase in cold weather or w exercise, dyspnea, nausea, fatigue, and diaphoresis. ECG ST chnages, bradycardia, tachycardia, hypotension, HTN, vomiting, and mental disorientation. Must remain NPO for at least 8 hrs, ask for allergy to iodine/shellfish, monitor renal function to excrete dye post procedure, admin antiplatelet meds to decrease dvt risk.client will be awake and sedated, a small incision made in the groin to insert catheter. the client may feel flushed or warmth when dye inserted. must maintain bed rest in supine position w leg straight a sandbag may be given to prevent bleeding.

A nurse is reviewing the medical record of a client with pancreatitis. The physical exam reports indicates the presence of Cullen's sign. Which of the following is an appropriate action by the nurse to identify this finding? Tap lightly at the costovertebral margin on the clients back Palpate the clients right lower quadrant Inspect the skin around the umbilicus Auscultate the area below the clients scapula

Cullen's sign is a bluish-grey discoloration around the periumbilicus.

Cystography/Cystourethrography

Cystography- detects urethral or bladder injury when contrast dye is instilled through the urinary catheter to provide a image of the bladder Cystourethrography- imaging of ureters. Used to discover abnormalities of the bladder wall and/or occlusions of ureter or urethra. Given anesthesia for the procedure, check for signs of bleeding and infection (first 72 hrs), NPO after midnight, admin laxative or enema for bowel prep night before procedure, placed in litotomy position, urine may be pink tinged, irrigate urinary catheter w 0.9 NS if blood clots are present or UO is decreased or absent. Increase fluids to reduce burning sensation w voiding

Cystography/Cystourethrography/ VCUG

Detects urethral or bladder injury when contrast dye is instilled through a urinary catheter to provide image of the bladder and ureters. VCUG detects whether urine refluxes into the ureters as an x ray is taken while the client is voiding. Monitor for infection first 72 hrs after procedure, increase fluid intake to dilute urine and minimize burning. Less than 30 mL urine a hr is suspected pelvic or urethral trauma. Contrast dye does not reach kidneys and are not nephrotoxic. UTI can occur dt catheter placement (cloudy foul smelling urine, urgency, urine positive for leukoesterase and nitrites, sediment, and RBCs.

A nurse is caring for a client who has cirrhosis. Which of the following meds can the nurse expect to administer to this client? SATA Diuretics Beta blocking agent opioid analgesic lactulose (Cepulac) sedative

Diuretics- decrease excessive fluids in the body Beta blocking agents- prevent varices from bleeding Lactulose (Cephulac)- promotote excretion of ammonia from the body through stool Nonabsorbable antibiotic- can be used in placed of lactulose Depending on functioning of liver: Opioids, Sedatives, and Barbiturates are admin sapringly.

Gastrointestinal Series

Done w or w/o contrast to help define an anatomical functional abnormalities. Radiopaque liquid (barium) can be drank to trace through the small intestine or a barium enema may be done. Interpretations of findings include altered bowel shape and size increased motility or obstruction. Inform client of clear liquid and or low residue diet, NPO after midnight avoid smoking and chewing gum as it promotes peristalsis report constipaion as it can retain contrast. Stool will be white for 24-72 hrs until barium clears. Report abdominal fullness pain or delay of return of brown stool.

A student nurse is observing a cardioversion procedure and hears the the team leader call out " Stand clear". The student should recognize the purpose of this action is to alert personnel that... the cardioverter is being charged to the appropriate setting they should initiate CPR due to pulseless activity they cannot be in contact w equipment connected to client a time out is being called to verify correct protocols

During cardioversion a direct shock is delivered so when the team leader calls out stand clear it is to alert the personnel to step away from the client, the equipment the client is connected to, and the bed to prevent the personnel from also receiving a shock.

A nurse is monitoring a client who began receiving a unit of blood 10 mins ago. Which of the following pose an immediate concern for the nurse? SATA temperature change from 98.6 f to 99 Dyspnea Hr increase from 74 bpm to 81 bpm PT Client reports itching Client appears flushed

Dyspnea, flushed and itching is a concern for the nurse

Ulcerative Colitis

Edema and inflammation of the rectum and sigmoid colon; Bowel obstruction can occur. mucosal cell changes can cause colon cancer or insufficient production of intrinsic factor (pernicious anemia). Risk factors include genetics, Caucasian and Jewish heritage, diet low in fiber, smoking, stress and infection. S/S: Abd cramping pain, LLQ, anorexia, and weight loss. Fever, Diarrhea (mucus, blood , pus present, up to 15-20 liquid stools/day), rectal bleeding,abd distention, tenderness, and/or firmness upon palpation, high pitched BS. Barium enema ( monitor for bowel perforation-rectal bleeding, firm abd, tachycardia, hypotension) Remain NPO after midnight, possible abd discomfort and cramping during barium enema. TPN promotes bowel rest, eat foods high in protein calories and low in fiber. Avoid caffeine and alcohol, take multi V containing iron. small frequent meals. Watch for dehydration. May need monthly B12 shots.

A nurse is caring for a client who has a small bowel obstruction from adhesions. Which of the following findings are consistent with this diagnosis? SATA Emesis >500 w a fecal odor Report of spasmodic abd pain Pain relieved by vomiting Abd flat w rebound tenderness to palpitation Lab findings indicating metabolic acidosis

Expected findings of obstruction dt adhesions include emesis greater than 500 w fecal odor, spasmodic abd pain, and pain relieved by vomiting. Also, Abd distention and metabolic alkalosis.

A nurse is reinforcing teaching w a client who has a new prescription for famotidine (Pepcid). Which of the following statements by the client indicates understanding of this teaching? This medicine coats the lining of my stomach This should stop the pain right away I will take my pill at meal time I will monitor for bleeding from my nose

Famotidine (Pepcid) is a H2 receptor blocker that decreases gastric acid output. It takes several days to work and should be taken at meal times or w fluid. The client should monitor for GI bleeding such as melena and hematemesis.

Iron

Females: 60 -160 mcg/dL Males: 80-180 mcg/dL elevated level can be evidence of hemochromotosis, iron excess, liver disorder, or megaloblastic anemia ; decreased can be evidence of iron deficiency anemia or hemorrhage

a nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? I will be glad to get back to my exercise routine right away I will have my prothrombin time checked on the regular basis I will talk to my dentist about no longer needing antibiotics before dental exams I will continue to limit my intake of foods containing potassium

Following a heart valve placement, the client is encouraged to limit activity for 6 weeks, PT is checked on the regular basis dt anticoagulation therapy, the client will need prophylactic antibiotics before dental exams and dietary requirements encourage a low sodium diet, not a restriction on potassium

A nurse is caring for a client who has HF and reports increased SOB. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take next? Measure the client's weight Assist client into high fowlers auscultate breath sounds check oxygen saturation w pulse ox

Following priority actions and ABCs, the nurse should assist the client into high fowlers to maximize ventilation and improve oxygenation by opening the airways

a nurse is assisting w the admission of a client who has a possible dissecting AAA. Which of the following is the priority nursing intervention? Admin pain meds ensure a warm environment Admin Iv fluids Initiate a 12 lead ECG

Following the ABCs, the nurses priority is to administer IV fluids to raise the BP. With a dissecting AAA the initial symptom is hypovolemia AEB hypotension and tachycardia.

A nurse is reinforcing teaching w a client who has a new prescription for ferrous sulfate (Feosol). Which of the following should be included in the teaching? Stools will be dark red in color take w a glass of milk if GI distress occur Food high in vitamin C promote absorption Take ferrous sulfate for 14 days

Foods high in vitamin c promote absorption of iron supplements. It should not be taken w dairy products because it decreases the iron absorption. While taking iron the clients stool may be dark green or black and tarry. and ferrous sulfate therapy lasts 4-6 weeks.

a nurse is caring for a client who has pericarditis. Which of the following expected findings should the nurse anticipate? Petechiae murmur rash friction rub

Friction rub, SOB, and pain relieved when sitting and leaning forward

a nurse is reinforcing discharge teaching for a client who has a prescription for furosemide (Lasix) 40 mg PO daily. What time of day should the nurse encourage the client to take the medication? Morning Immediately after lunch Immediately before dinner Bedtime

Furosemide is a diuretic given to increase urinary output in order to lower the clients BP. The client should monitor for any signs of hypokalemia (muscle weakness, irregular HR, and dehydration) and encouraged to increase intake of potassium rich foods such as bananas. Since lasix increases the UO, the client is also encouraged to take the medication in the early morning to avoid nocturia. It should be avoided at bedtime because the client risk of injury/falls is higher if they have to constantly get up in the middle of the night.

Gastric/Duodenal Ulcers

Gastric ulcer- occurs 30-60 min after a meal, rarely occurs at night, and pain exacerbated by ingestion of food Duodenal ulcer- 1.5-3 hr after a meal, often occurs at night, pain may be relieved by food ingestion or antacids.

A nurse is reinforcing discharge teaching w a client who has an infection dt Heliocobacter pylori. Which of the following statements by the client indicates understanding of the teaching? I will continue my prescriptions for corticosteroids I will schedule a CT scan to monitor for improvement I will take a combination of meds for tx I will have my throat swabbed to recheck for this bacteria

H pylori testing is done by testing the clients breath. The client exhale into a collection container after ingesting a carbon enriched urea solution. A esophagogastroduodenospy is performed to evaluate for presence of H pylori and effectiveness of treatment. Corticosteroid use is a contributing factor to an infection caused by H pylori.

Medications for Gastritis

H2 receptor blockers- decrease gastric acid output by blocking histamine 2 receptors; Ends in "dine". Allow 1 hr before/after antacid admin, monitor for neutropenia and hypotension, and admin IV slowly; too fast can cause bradycardia and hypotension. Do not smoke/drink, take w meals and monitor for GI bleeding Antacids- increases gastric pH and neutralizes pepsin; improves mucosal protection. Do not give to clients who have kidney failure or renal dysfunction. Monitor for aluminum antacid toxicity and constipation; magnesium antacids for diarrhea or hypermagnesemia. Take on empty stomach and wait 1 hr to take other medications. PPI- Reduces gastric acid by stopping acid producing proton pump; ends in "zole".Can cause N/V and abd pain. Use filter for IV admin, do not crush or chew capsules, allow 30 mins before eating and take on an empty stomach. Prostaglandins- Reduces gastric acid secretion (misoprostol- Cytotec) may be given w NSAIDs to prevent gastric mucosal damage; may cause abd pain and diarrhea. Use contraceptives. Taken w food to decrease gastric effects. Do not take if pregnant Anti Ulcer/ Mucosal barriers- inhibits acid and forms a protective coating over mucosa; Sucralfate (Carafate). Allow 30 min before/after to give antacid. Take on an empty stomach, do not drink/smoke, continue to take even if symptoms subsides.Notify provider of tinnitus. Antibiotics

A nurse is assisting w the admission of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider? History of cholelithiasis Amylase levels 3X greater than expected Client report severe pain of 8/10 radiating to back Hand spasms present when BP checked

Hand spasms indicate a positive Trousseau's sign meaning the client has hypocalcemia that can lead to cardiac dysrrhythmias.

A nurse is monitoring for post operative complications in a client who had a kidney biopsy. Which of the following complications causes the most immediate risk to the client? Infection Hemorrhage Hematuria Kidney failure

Hemorrhage is the most immediate risk to the client. Hematuria is most common forst 48-72 hrs post biopsy

a nurse is reinforcing teaching on prevention of transmission of hepatitis A w a recently infected client. Which of the following should the nurse include? Don't share razors w other individuals Wash your hands after toileting Cough and sneeze into a tissue Use spermicide during intercourse

Hepatitis A is an infection that is usually transmitted fecal-oral route through undercooked or raw food and not improper hand hygiene. The client should wash their hands after toileting.

A nurse is reviewing the health record of a client who is being evaluated for a possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? SATA surgical repair of an atrial septal defect at age 2 Measles infection during childhood HTN for 5 years Wt gain of 10 lbs in past year Diastolic murmur

History of congenital malformations, streptococcal infection or rheumatic fever, and a murmur indicates turbulent blood flow. HTN places client at risk.

Blood transfusions

Homologous transfusions- blood from donor's are used Autologous transfusions- client's blood is collected in anticipation of future transfusions (elective surgery); the blood is designated for and can only be used by the client. Excessive blood loss (hgb 6-10 g/dL)- whole blood Anemia (6-10 g/dL)- packed RBCs Kidney failure- packed RBCs Coagulation factor deficiencies- fresh frozen plasma Thrombocytopenia/platelet dysfunction- platelets less than 20,000 or less than 80,000 and actively bleeding- platelets PRBCs are usually for hgb <8 g/dL Verify the prescription for specific blood order, obtain type and crossmatch, ensure a 20 gauge or larger IV access, inspect blood for discolorations, excessive bubbles, or cloudiness; confirm clients identity, blood compatibility, and expiration time of blood product w another nurse. 0.9 sodium chloride are only infused w blood products and never added w other medications. Remain w the client the first 15-30 min and monitor VS, rate of infusion, respiratory status, sudden increase in anxiety, breath sounds, neck vein distention. Complete the transfusion w/t 2-4 hr to avoid bacterial growth. Hgb should rise 1g/dl w each unit infused.

A nurse is instructing a new graduate nurse on age related changes that can cause electrolyte imbalances among older adults. Which of the following should the nurse include as a risk factor for hypernatremia? SATA Decreased total body water content Inadequate water intake inadequate calcium intake Altered thirst mechanism Muscle weakness

Hypernatremia causes dehydration. D/T age related changes, the older adult have decreased total body water content, inadequate water intake, and altered thirst mechanism.

Respiratory Alkalosis (Hyperventilation)

Hyperventilation d/t fear, anxiety, intracerebral trauma, salicylate toxicity, or excessive mechanical ventilation; hypoxemia from asphyxiation, high altitudes, shock, early stage asthma, or pneumonia S/S= tachypnea, anxiety, tetany, convulsions, tingling, numbness, palpitations, chest pain, rapid deep respirations (kussmaul), dysrrhythmia.

Hyperkalemia risk factors

Increased total body potassium (salt subs, supplements) Extracellular shift (decreased insulin, DKA, tissue catabolism; trauma, sepsis, surgery, fever, MI. Hypertonic states- uncontrolled DM Decreased excretion of K+ -KF, severe dehydration, K+ sparing diuretics, ACE-I, NSAIDs, adrenal insufficiency

Diverticulitis

Inflammation of the diverticula (hernia in the intestinal walls) that frequently occurs in the colon. Caused by bacteria or fecal matter trapped in one or more diverticula. Frequent episodes lead to bleeding and infection. Can cause peritonitis. Occurs more often in older adults and more frequently in men than women. Abd pain in LLQ, N/V, Fever, Chills, and Tachycardia. Client hospitalized when clinical findings are more severe (severe pain, high fever), NPO, NG suctioning, IV fluids/antibiotics, and TPN. Consume clear liquid diet until manifestations subside progress to low fiber diet. Add fiber once solid foods tolerated w/o other manifestations. Avoid seeds, nuts, popcorn that may block diverticulum. Avoid enema use, drink adequate fluids, and take bulk forming laxatives only. High protein, calories (3000/day) and low fiber.

Coronary Artery Bypass Graft (CABG)- invasive surgical procedure used to restore vascularization of the myocardium. Performed to improve quality of life by bypassing an obstruction in one or more of the coronary arteries. Most effective when a client has sufficient ventricular function (EF greater than 40%). Can be elective or emergency and requires an informed consent form. Anxiolytics (lorazepam {Ativan} and diazepam {Valium}) is given to reduce anxiety, prophylactic antibiotics, and anticholingerics (scopolamine) given to reduce secretions and risk for aspiration.

Inform client of importance of coughing an deep breathing post procedure to prevent atelectasis, pulmonary edema, or pneumonia. Client should splint the incision when coughing and deep breathing to decrease pain, inform client to expect endotacheal tube or mechanical ventilator for airway management for several hrs post procedure. Diuretics are stopped 2-3 days before surgery, aspirin and other anticoagulants 1 week before sugery. Potassium supplements, scheduled antidysrhytmics , insulin, and scheduled antihypertensives are continued. Encourage client to consume heart healthy diet (low fat, low cholesterol, high fiber, low salt) stop smoking Remain home first week after surgery and resume normal activities slowly.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Insertion of endoscope through the mouth into the biliary tree via the duodenum Allows visualization of the biliary ducts, gallbladder, liver and pancreas. Conscious sedation- topical anesthetic. Initially semi prone w repositioning throughout procedure. NPO 6-8 hr. Remove dentures and any tongue or mouth jewelry. Explain the need to change positions throughout the procedure. Notify provider of bleeding abdominal or chest pain and any evidence of infection. Withhold fluids until gag reflex returns.

Esophagogastroduodenoscopy (EGD)

Insertion of endoscope through the mouth into the esophagus stomach and duodenum. Moderate sedation- topical anesthetic. Client placed in the left side lying position. NPO 6-8 hrs prior Remove dentures and any tongue or mouth jewelry. Notify provider of bleeding abdominal or chest pain. And any evidence of infection. Withhold fluids until gag reflex returns.

Right sided HF (systemic edema)

JVD dependent edema (legs, ankles, sacrum) abd distention, ascites fatigue, weakness nausea and anorexia nocturnal polyuria hepatomegaly and tenderness weight gain Expected EF 45-60%

Surgical interventions for cholecystitis

Laparascopy/NOTES- discharged w/t 24 hours; ambulate frequently to minimize free air pain, monitor for dishisence and infection, report indication of bile leakage (pain, vomiting, abd distention) Activities often resumed in 1 week Open approach- hospitalized 2-3 days; drainage initially 400 ml then decreased gradually. Initially bloody then green brown bile. Report absence of drainage w nausea and pain, report sudden increases in drainage (up to 1000/day), Maintain flow by gravity (below gallbladder),Empty bag Q 8 hr, Clamp tube 1-2 hr before/after meals to test food tolerance. Resume activity gradually avoid heavy lifting 4-6 weeks, report sudden increased drainage, foul odor, pain, fever, or jaundice. Usually left in 1-2 weeks, take showers instead of baths until t tube removed, color of stool should return to brown in about a week and diarrhea is common. Encourage low fat diet, reduce dairy products and fatty fried foods, chocolate, nuts, gravies. avoid gas forming foods, and take fat soluble vit or bath salts.

Potassium imbalances

Major cation in ICF; plays a vital role in cell metabolism; transmission of nerve impulses; functioning of cardiac, lung, and muscle tissues, and acid-base balances. Has reciprocal action w sodium (if sodium is in, potassium is out and vice versa) Hypokalemia = increased loss of potassium from body or movement <3.5 Hyperkalemia= increased intake of potassium , movement of potassium out of cells, or inadequate renal excretion >5.0

Intestinal Obstruction

Mechanical- milder, colicky, intermittent pain Non mechanical- vague, diffuse, constant pain w significant abd distention. Bowel sounds are hyperactive above the obstruction and hypoactive below the obstruction. Volvlus (twisting) or intussusception (telescoping) of bowel segments. Increased hgb, hct, creatinine, and BUN= dehydration Increased amylase and WBC= strangulating obstruction ABGs= metabolic imbalance Decreased sodium, chloride, and potassium Encourage ambulation, Withhold intake until peristalsis returns, Ng tube to decompress obstruction; Irriagte Q 4 hrs to check NG tube patency, oral hygiene Q 2hrs, Clamp NG tube during ambulation, intermittent suctioning. Clamp NG tube 1-2 hrs after eating and prior to removal to test clients tolerance (report any intolerance)

A nurse is instructing a client who has angina about a new prescription for metoprolol (Lopressor). Which of the following statements by the client indicates understanding of the teaching? I should place the tablet under the tongue I should have my clotting time checked weekly I will expect this medication to cause ringing in my ears I will call my doctor if my pulse rate is less than 60

Metoprolol is a beta blocker that act as an antidysrhythmic agent and antihypertensive by slowing the HR and lowering the BP (afterload). Beta blockers should be avoided in clients w asthma and held if HR is less than 60. NTG is given SL, beta blockers doesn't affect clotting time or bleeding, ringing in the ears is an adverse sign of aspirin not b blockers. Clients taking beta blockers should monitor for hypotension , bradycardia and any manifestations of HF (SOB, weight gain, edema, or cough)

A nurse is reinforcing discharge teaching w a client who is 3 days postoperative for transverse colostomy. Which of the following should be included in the instruction? Mucus will be present in stool 5-7 days after surgery Expect 500-1000 mL of semi liquid stools after two weeks Stoma should be moist and pink Change the ostomy bag when 3/4 full

Mucus will be present 2-3 days after surgery, after two weeks stools should be more stool like; semi formed. The stoma should always be pink and moist and the ostomy bag should be changed when 1/4-1/2 full.

Peripheral Bypass Grafts restores adequate blood flow to the areas affected by the peripheral artery disease. it involves suturing graft material to an occluded area of an artery. If the bypass fails to restore circulation the client can need to undergo amputation of the limb. The client may experience intermittent claudication (numbness/ burning pain to lower extremity w exercise and can stop w rest) or burning/numbness pain to LE at rest and can awaken the client at night relieved by lowering the extremity below the level of the heart. Objective data include: decreased or absent pedal pulses, dry hairless shiny skin of legs, cold and dark colored skin, mottled dusky feet/toes, thick toenails, rubor when extremity is dropped to a dependent postion and pallor when elevated, arterial or venous ulcers.

Must remain NPO for at least 8 hrs prior to surgery, teach deep breathing and incentive spirometer exercises. Decrease risk of DVT by not crossing legs, pedal pulses must be checked frequently, know that hypotension can reduce blood flow to graft and HTN causes bleeding. Throbbing pain dt increased blood flow to extremity and ischemic pain is difficult to relieve with opioids. Turn, cough and deep breathing Q2 hrs, maintain bedrest for 18-24 hrs legs kept straight during this time. Encourage the client to get out of bed and ambulate using a walker initially. discourage sitting for long periods of time to reduce dvt risk. Graft occlusions usually occur first 24 hrs postoperative- notify the provider immediately for changes in pedal pulses, extremity color, or temp. Compartment syndrome is when pressure from tissue swelling or bleeding in restricted space causes reduced blood flow to the area. if left untreated can cause tissue to become necrotic and die- monitor for worsening pain swelling and tense or taut skin.

A nurse is completing a integumentary assessment of a client who has anemia. Which of the following is an expected finding? Absent turgor spoon shaped nails Yellow mucous membranes shiny hairless leg

Nail deformities such as spoon shaped nails, pallor of nail beds and mucous membranes is a sign of anemia. Absent turgor is rt dehydration and shiny hairless legs are rt PVD.

Large Intestine Obstruction

Obstipation Abd distention Borborygmi Hypoactive BS below obstruction minor fluid/electrolyte imbalances Metabolic acidosis Intermittent abd cramping Infrequent vomiting Diarrhea or "ribbon like" stools around impaction (Intussusception)

Small Bowel Obstructions

Obstipation (inability to pass stool/flatus more than 8 hr despite feeling urge Abd distention High pitched sounds above obstruction (borborygmi) Hypoactive BS below obstruction Severe fluid/electrolyte imbalance Metabolic Alkalosis Visible peristalic waves Profuse, sudden projectile vomiting w fecal odor Vomiting relieves pain Abd pain, discomfort

A nurse is reinforcing teaching w a client who has a new dx of pernicious anemia dt chronic gastritis. Which of the following should be included in the teaching? Cells producing salivary amylase have been damaged A monthly injection of medication is required Vitamin K supplements will be admin Increased production of intrinsic factor is occurring

Pernicious anemia involves decreased production of intrinsic factor dt damage to parietal cells in the stomach lining. Dt the damage, the client is not able yto produce vitamin B12 found in the stomach. The client will need to have a monthly injection of vitamin B12.

a nurse is reinforcing teaching to a client who has a new prescription for clopridogrel (Plavix). Which of the following should be included in the teaching? SATA Effects may not be present for several wks Monitor the presence of black tarry stools Use an electric razor schedule a weekly PT test Advise the client about food sources containing Vitamin K

Plavix is an antiplatelet that reduces blood viscosity by decreasing blood fibrinogen levels, enhancing erythocyte flexibility, and increasing blood flow to the extremities. It is specifically given to treat intermittent claudication. Effects of the drug may not be apparent for several weeks, monitor for evidence of bleeding such as black tarry stools, abd pain or coffee ground emesis. Bleeding precautions, weekly PT testing, and vitamin K are for anticoagulation therapy such as warfarin not antiplatelets like Plavix.

A nurse is caring for a client who has a lab finding of serum K+ levels 5.4 mEq/L. The nurse should monitor the client for which of the following clinical manifestations? ECG changes Constipation Polyuria Hypotension

Potassium affects the heart and too much potassium can cause cardiac arrest and dysrrhythmias. Hypokalemia can cause constipation, polyuria, and hypotension

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following are expected findings? SATA Tachypnea Persistent cough Increased Urinary Output Thick yellow sputum Orthopnea

Pulmonary edema expected findings include tachypnea, orthopnea, dyspnea, persistent cough, decreased urinary output, and pink frothy sputum

A nurse is reinforcing teaching w a client who has a new prescription for metoclopramide (Reglan). Which of the following should the nurse instruct the client to avoid taking while using this medication? Antacids Alcohol Antihypertensives Anticoagulants

Reglan is a CNS depressant that causes sedation. Alcohol is contraindicated and the nurse should monitor for extrapyramidal side effects (abn and involuntary movements)

Kidney biopsy

Removal of sample of tissue by excision or needle aspiration for cytological (histological) examination. Client recieves sedation and monitored during procedure. Pre-procedure- review coagulation studies and NPO for 4-6 hrs Post procedure- Monitor VS post sedation, monitor dressing and UO (hematuria) review hgb and hct values Admin PRN meds Hemorrhage and infection can occur.

A nurse is collecting data on a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected finding? Rubor of the affected leg when elevated 3+ dorsal pulses in the left foot thin, peeling toenails of the foot Report of intermittent claudication in the affected leg

Report of intermittent claudication is normal and the client experience pain w exercise and it stops at rest. Rubor should occur when the feet are dependent, pedal pulses are decreased or absent, and toenails are thickened.

Metabolic Alkalosis

Results from base excess (antacids intake, blood transfusions, TPN, or sodium bicarbonate) or acid deficit (gastric secretions loss, potassium depletion dt diuretics, laxative abuse, cushings syndrome) S/S- tachycardia, normotensive or hypotensive, dysrrhythmias, numbness, tingling, tetany, muscle weakness, hyperreflexia, confusion, convulsions, depressed skeletal muscles (resulting in ineffective breathing)

Metabolic Acidosis

Results from excessive production of H+ (DKA, Lactic acidosis, starvation, heavy exercise, seizure activity, fever, hypoxia, intoxication of ethanol or salicylates), inadequate elimination of H+ (KF), Inadequate production of bicarbonate (KF, Pancreatitis, Liver failure, dehydration), excess elimination of bicarbonate (diarrhea, ileostomy) S/S- bradycardia, weak peripheral pulses, hypotension, tachypnea, dysrrhythmias, muscle weakness, hyporeflexia, flaccid paralysis, fatigue, confusion, Kussmaul respirations, warm dry flushed skin

Respiratory Acidosis (Hypoventilation)

Results from respiratory depression ( poisons, anesthetics, trauma, neurological diseases such as myasthenia gravis and Guillain Barre.), inadequate chest expansion, Airway obstruction, alveolar capillary blockage, inadequate ventilation and opioid use. S/S: tachycardia, tachypnea, dysrrhythmias, anxiety, irritability, confusion, coma, pallor, cyanosis, shallow rapid breathing)

A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following lab tests to assist in confirmation of this diagnosis? ABG serum albumin Liver enzymes Throat culture

Rheumatic endocarditis is usually caused by streptococcal bacteria and a throat culture will confirm the diagnosis

A nurse is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for developing a dysrhtmia? SATA a client w/ metabolic acidosis client w 4.3 potassium level client who SaO2 is 96% a client w COPD client who underwent stent placement in coronary artery

Risk factors for Dysrhytmias: Cardiovascular disease MI Hypoxia Acid base imbalances electrolyte disturbances Kidney failure, liver, or lung disease Pericarditis Drug or alcohol use Hypovolemia/Shock

A nurse is reviewing lab findings for a client who is suspected to have OD on aspirin. Which of the following ABG findings should the nurse expect? pH <7.35 PaCO2 <35 HCO3 > 26 HCO3 <22

Salicylate toxicity usually causes respiratory alkalosis; Respiratory mechanisms are opposite of pH levels so if CO2 levels are low that increased the Ph (more H+ the more acidic, less H+ the more alkaline)

Sigmoidoscopy

Scope is shorter than a colonoscope, allowing visualization of the anus rectum and sigmoid colon. Requires no anesthesia and client placed on left side. Bowel prep may include laxatives and GoLYTELY (polyethylene glycol). Clear liquid diet NPO after midnight and avoid medications indicated by provider. Monitor for rectal bleeding Allow client to resume regular diet encourage increased fluids and instruct client on increased flatulent dt air instillation

Transverse Colostomy

Small, semi liquid w some mucus 2-3 days after surgery; blood may be present first few days after surgery. After several days to weeks, output become more stool like and semi formed.

S/S of Hyponatremia

Tachycardia, rapid thready pulse, hypotension, headache, confusion, lethargy, muscle weakness, fatigue, decreased DTR, and seizures. increased GI motility, hyperactive BS, abd cramping, nausea

A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/ L and K+ 3.4 mEq/L. Which of the following treatments can result in these lab findings? Tap water enema Lactose intolerance Hypoparathyroidism Water deprivation

Tap water enemas can cause excretion of potassium and sodium. Lactose intolerance and hypoparathyroidism is a risk factor for hypocalemia. Water deprivation will cause electrolytes above the expected range, not below.

A nurse is reviewing the lab findings of a client who has an acute exacerbation of Crohn's disease. Which of the following lab findings should the nurse expect to be increased? SATA hematocrit erythrocyte sedimentation rate wbc folic acid serum albumin

The ESR and WBC will be increased; decreased folic acid, hgb,hct, and serum albumin.

a nurse is caring for a client who has severe PAD. The nurse should expect that the client will sleep most comfortably in which of the following positions? Affected limb hanging off bed Affected limb elevated on pillows HOB raised side lying, recumbent position

The affected limb should hang off the bed to promote circulation to the lower extremities. elevation is for PVD.

A nurse is caring for a client following angiography. The nurse informs the client he should lie still for 6 hours because he is at risk for which of the following? Urinary retention Infection Bleeding Respiratory Depression

The client is at risk for bleeding

A nurse is assisting w the care of a client who is on telemetry. The clients HR is 46 bpm. The nurse should anticipate that which of the following management strategies will be used for this client? Defibrillation Pacemaker insertion Synchronized cardioversion Admin of lidocaine

The client is experiencing bradycardia and should receive a pacemaker. Defibrillation is for VFib or pulseless ventricuolar tachycardia Cardioversion is for AFib, SVT, Ventricular tachycardia w pulse

A nurse is assisting w the POC for a client who is postoperative following a PCI w a stent placement. Which of the following should the nurse include? SATA Elevate the HOB 45 degree Restrict oral fluids maintain the leg in extended position Place a sandbag over the access site monitor for dysrhythmias

The client should be in a supine position and encouraged to increase oral intake to get rid of the contrast dye. The client should keep the affected extremity straight to reduce risk of bleeding and a sandbag may be placed over the site to prevent bleeding. DT reperfusions following the treatment the nurse should monitor for dysrhytmias.

A nurse is reinforcing nutrition teaching w a client who has pancreatitis. Which of the following statements by the client requires further teaching? I plan to eat small, freq meals I will eat easy to digest foods I will use skim milk when cooking I plan to drink diet colas

The client should consume caffeine free beverages.

A nurse is reinforcing preoperative teaching w a client who will undergo an elective surgery that will include a blood transfusion. Which of the following statements by the nurse should be included in the teaching? You will make an appt to donate blood 8 wks prior to surgery If you need an autologous transfusion, the blood your brother donates can be used We will have you come donate your blood the day before surgery You will receive the blood you donated 4 wks prior to surgery

The client should donate blood for an autologous transfusion (clients own blood used) no sooner than 5 weeks in advance, up to 72 hrs prior to surgery. A homologous transfusion involves receiving blood from a donor.

A nurse is reinforcing teaching w a client who is scheduled for a stress test. Which of the following should be included in the teaching? You should not have anything to eat/drink for 8 hrs prior to test You will exercise your heart by walking on a treadmill IV contrast will be given during the test A chest x ray will be obtained following the test

The client should fast 2-4 hrs prior to the stress test avoiding tobacco, alcohol, and caffeine consumption and there is no x ray or IV contrast involved. the client will exercise the heart by walking on a treadmill to determine the cardiac workload.

A nurse is reinforcing teaching to a client who has GERD. Which of the following should the client be instructed to limit in his diet? SATA Coffee Tomatoes Bananas Chocolate Pasta

The client should limit coffee, tomatoes, chocolate, peppermint, spicy foods, fatty/fried foods, caffeinated beverages, citrus fruits, and alcohol.

A nurse is caring for a client w GERD. Which of the following instructions should the nurse reinforce teaching? Limit caffeine intake to 2 cups of coffee/ day Remain upright for 2 hrs after eating Follow a low protein diet Take medications w milk to decrease irritation

The client should remain upright for 2 hrs after eating to decrease heartburn and risk of aspiration. The client should avoid caffeinated beverages, follow a high protein diet, and avoid dairy products with medications dt increased gastric irritation.

A nurse id reviewing medications of a client who is scheduled for an elective coronary artery bypass graft. The nurse should anticipate that the provider will instruct the client to discontinue taking which of the following medications prior to surgery? aspirin amiodarone (Cordarone) Potassium supplement Diltiazem (Cardizem)

The client should stop taking any diuretics 2-4 days before surgery and antiplatelet meds 1 week before surgery to reduce risk of bleeding and low BP. All other medications are continued.

A nurse is reviewing clinical manifestations of a thoracic AA w a newlt hired nurse. Which of the following should the nurse include in the discussion? SATA Cough SOB Upper chest pain diaphoresis altered swallowing

The client would experience severe back pain, hoarseness cough SOB and dysphagia and a decrease in UO

A nurse is caring for a client who has the following ABG results: pH= 7.25, PaO2=94, PaCO2= 38, HCO3= 18. Which of the following does the nurse expect the provider to order? Serum sodium bicarbonate level Oxygen therapy Anxiolytic medication Chest X ray

The clients' pH is abnormal (acidic) and the bicarbonate level is too low ( HCO3 22-26). The nurse should expect the provider to order sodium bicarbonate to rise it to expected ranges. Oxygen therapy will be for respiratory dysfunction, anxiolytic therapy for hyperventilation (respiratory alkalosis), and chest x ray for hypoventilation (respiratory acidosis)

A nurse is is reviewing the lab reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? Serum albumin 4.1 WBC 9511 Direct bilurubin 2.1 Serum cholesterol 171

The direct bilirubin is increased and outside of the expected range.

A nurse is contributing to the POC for a client who has a small bowel obstruction and a NG tube in place. Which of following nursing interventions should be included in the POC? SATA Subtract the drainage from the NG output Irrigate the NG tube Q 8 hrs Auscultate BS Provide oral hygiene Q 2hrs Clamp the NG tube during ambulation

The nurse should auscultate BS, provide oral care Q 2 hrs, and clamp the NG tube during ambulation. Any output (besides stool) including NG drainage is considered output and the nurse should irrigate the NG tube Q 4 hrs

A nurse is assisting in the care of a client who experienced defibrillation. Which of the following should be included in the documentation of the procedure? SATA Follow up ECG Energy setting used IV fluid intake Urinary Output Skin conditions under the electrodes

The nurse should document the follow up ECG, Energy setting used, and skin conditions under the electrodes.

a nurse is caring for a client following an angioplasty that was inserted into the femoral artery. While turning the client, the nurse discovers blood underneath the clients lower back. The nurse should suspect... Retroperitoneal bleeding cardiac tamponade bleeding from the incisional site heart failure

The nurse should expect bleeding from the incisional site. Retroperitoneal bleeding and cardiac tamponade are internal bleeding.

A nurse is reinforcing discharge teaching w a client who is postoperative following open cholecystectomy w t tube placement. Which of the following instruction should the nurse include in teaching? SATA Take baths rather than showers Clamp t tube for 1-2 hrs before/after meals keep drainage system above gallbladder level Expect constipation Empty drainage bag Q 8 hrs

The nurse should include: clamp the t tube for 1-2 hrs before and after meals to test food tolerance, and empty drainage bag Q 8 hrs. The nurse should also include to take showers rather than baths, keep drainage bag below gallbladder level to maintain flow by gravity, and expect diarrhea.

a nurse is reinforcing teaching w a client who had hepatitis B about home care. Which of the following should the nurse include in the teaching? SATA Limit physical activity Avoid alcohol consumption Take acetaminophen for comfort Wear a mask in public places eat small frequent meals

The nurse should include: limit activity to promote liver regeneration and hepatic healing, avoid alcohol consumption (prevents further scarring, prevents irritation of stomach/esophagus lining, helps decrease risk of bleeding, helps prevent other life threatening complications), and eat small frequent meals. Acetaminophen (OTC med) should be avoided because it is metabolized in the liver and wearing a mask isnt appropriate because hepatitis B is a blood bourne disease.

A nurse should remain with a client during the first 15 mins of blood transfusion to...? Verify the blood being transfused Monitor for an adverse reaction Explain the procedure to the client Obtain blood specimens

The nurse should remain w the client for the first 15-30 mins to monitor for an adverse reaction of the transfusion

A nurse is reviewing the medical record of a client who has a small bowel obstruction. Which of the following findings should the nurse report to the provider? SATA Profuse emesis prior to insertion of NG tube Urine specific gravity 1.040 Hematocrit 30% Serum potassium 3.0 WBC 10,000/mm3

The nurse should report any signs of dehydration such as increased urine specific gravity, hematocrit, hgb, BUN, and creatinine. And any electrolyte imbalances especially potassium (3.5-5.0). Profuse emesis prior to NG tube insertion is expected and WBC is between 4-1000/mm3

A nurse is caring for a client who had T2DM and is to undergo excretory urograpghy. Which of the following are appropriate nursing actions prior to the procedure? SATA Identify client allergy to seafood Hold metformin (Glucophage) for 24 hr Administeran enema Obtain serum coagulation profile Check client for history of asthma

The nurse will identify any allergy to seafood, eggs, milk, chocolate or have asthma (contrast dye iodine based) Hold metformin 24 hr before and after procedure (lactic acidosis) and Administer and enema or laxatives for bowel prep

A nurse is helping a client who has hepatitis B w ascites. Which of the following actions should the nurse include in the POC? Follow contact precautions Weigh client weekly Measure abd girth 7.5 cm (3 in) above the umbilicus Provide high calorie, high carb diet

The nurse will include a high carb, high calorie diet in the POC. She would also include standard precautions for blood and bodily fluids, measure abd girth at largest part of the abd, and the client will be weighed daily to measure accurate I/O.

A nurse is caring for a client who has hypervolemia s/t CHF. Which of the following should the nurse expect to include in the POC? SATA Monitor for edema have client lie supine admin Kayexalate Reduce IV fluid rate Encourage intake of sodium rich foods

The nurse would monitor for evidence of excess fluid such as edema, JVD, the client should be placed in semi fowlers position, and reduce IV rate. The admin for Kkayexalate is for Hyperkalemia and the client would discouraged to intake sodium rich foods because it can cause fluid retention.

A nurse is assisting in the POC for a client who had a surgical placement of a synthetic graft to repair an aneurysm. Which of the following interventions should the nurse include in the POC? SATA Assess pedal pulses Monitor for increase in pain below the graft site Maintain client in high fowlers Admin antiplatelet agents Report hrly UO of 60 mL

The nurse would monitor pulses distal to the graft, maintain the HOB below 45 degree to prevent flexion of the graft, report any evidence of occlusion (changes in pulse, coolness of extremity below the graft, white or blue extremities or flanks, severe pain, abd distention, decreased UO. antiplatelet agents prevent a thrombus formation. prolonged hypotension can cause thrombi to form and hypertension can cause leakage or rupture at the suture line. The client should report UO less than 50, weight gain, elevated BUN or creatinine. enocurage coughing and deep breathing q 2hrs and splinting when coughing.

A nurse is reviewing a client lab finding for urinalysis. The findings indicate the urine is positive for leukoesterase and nitrites. Which of the following is an appropriate nursing action? Repeat the test early the next morning Start a 24 hr urine collection for creatinine clearance Obtain a clean catch urine specimen for culture and sensitivity Insert an urinary catheter to collct a urine specimen

The presence of leukoesterase and nitrites indicates the client may have a UTI. The nurse will obtain a clean catch urine specimen for culture and sensitivity to determine which antibiotic is less sensitive to the bacteria

A nurse is reinforcing teaching to a client who is to have an x ray of the kidneys ureters, and bladder (KUB). Which of the following statements should the nurse include in the teaching? Contrast dye is given during the procedures An enema is necessary before the procedure You will need to be in prone position during the procedure The procedure determines whether a kidney stone is present

The procedure will determine whether a kidney stone is present, strictures, calcium deposits, and obstructions. Doesnt involve enemas or contrast dye instillation.

A nurse is reviewing the medical record of a newly admitted client. The laboratory results for the client are sodium 136 and magnesium 1.0. Which of the following is most likely to cause these results? Recent alcohol ingestion Having been NPO for 4 hrs Iv admin of dextrose 5% in water at 75ml/hr Admin of potassium sparing diuretic

The sodium is within expected range. The magnesium level is low and can be caused by recent alcohol ingestion.

A nurse is instructing a client who is scheduled for an echocardiogram. which of the following should the nurse include in the teaching? "You may experience some discomfort during the test" "This test will require 2 hrs to complete" "You will need to lie flat during the test" "This test allows us to see a picture inside the heart"

The test is noninvasive so it shouldn't be uncomfortable, it only requires up to 1 hour, the client will have to remain still on the left side, and it allows to see structural defects of the heart, valves, and cardiomyopathies.

a client in a provider's office tells the nurse, "My cholesterol is 198 mg/dL but my doctor says my bad cholesterol is too high. which of the following responses should the nurse give? This means your LDL is too high This means your HDL is too high This means your triglycerides is too high this means your total cholesterol is too high

This means the LDL cholesterol is too high.

A nurse is reviewing laboratory findings of a client who has a MI and reports that his dyspnea began two weeks ago. Which of the following cardiac enzymes would confirm the infarction occurring 14 days ago? CK-MB Troponin I Troponin T Myoglobin

Troponin T will be evident up to 14-21 days. CK MB is evident up to 3 days, Troponin I up to 7 days, and myoglobin up to 24 hrs.

A nurse is reviewing a new prescription for ursodiol (ursodeoxycholic acid) with a client who has cholelithiasis. Which of the following should be included in the teaching? This medication reduces biliary spasms This medication reduces inflammation in the biliary tract This medication dilates the bile duct to promote bile passage This medication dissolves gall stones

Ursodiol is a bile acid that is used to gradually dissolve cholesterol based gall stones

Colonoscopy

Use of a flexible fiber optic colonoscope, entering through the anus, to visualize the rectum and the sigmoid descending transverse and ascending colon. The client will have moderate sedation- midozolam (Versed) usually w an opiate analgesic and placed on the left side w knees to chest. Bowel prep may include laxatives and GoLYTELY. Clear liquid diet avoiding red purple and orange fluids NPO after midnight. Notify the provider of severe pain (possible perforation) or signs of hemorrhage. Monitor rectal bleeding, vs, RR, encourage increased fluids intake, there can be an increased flactulence dt air instillation during the procedure.

Ultrasound of Kidneys

Used to assess size of kidney, image of ureters, bladder, masses, cysts, calculi and obstructions of the lower urinary tract; provide skin care by removing gel on completion of procedure, good option if not able to do excretory urography, minimal risk of client

A nurse is preparing to administer pancrelipase (Vioske) to a client who has pancreatitis. Which of the following is an appropriate nursing action? Admin 30 min after a snack Offer a glass of water following admin Admin 30 min before meals Sprinkle contents on peanut butter

Vioske aid in the digestion of fats and proteins when taken w meals and snacks. Client may sprinkles capsules on non protein foods, should drink a full glass of watr following admin of pancrelipase, and should wipe lips and rinse mouth after taking to prevent skin breakdown and irritation.

Pernicious anemia

Vitamin B12 deficiency dt decreased vitamin B12 absorption in the stomach. A schilling test measures Vitamin B12 absorption to differentiate between malabsorption and pernicious anemia. Vitamin B12 supplementation (cyanocobalamin) is necessary to convert folic acid for DNA production. Can be given orally if the deficient is dt inadequate dietary intake. If dt impaired absorption , it must be admin parenterally or intranasally to be absorbed. Parenteral forms of Vitamin B12 must be admin IM or deep SQ to decrease irritation and must not be mixed w other meds in the syringe. Clients who lack intrinsic factor or have irreversible malabsorption syndrome should be informed that this therapy must be continued for the rest of their life on a monthly basis. S/S- pallor, glossitis, fatigue, and paresthesias

A nurse is reinforcing preoperative teaching w a client who will undergo a laparoscopic cholecystectomy. Which of the following should be included? Scope will pass through the rectum You will have shoulder pain after surgery T tube will remain in place for 1-2 weeks you should limit how often you walk 1-2 weeks

W/ a laparascopy, free air is instilled in the abdomen causing gas and referred pain to the right shoulder. NOTES (Natural Orifice Transluminal endoscopic surgery) involves the scope passing the mouth, rectum or anus. A t tube is placed when the common bile duct is explored Th client is encouraged to ambulate frequently to minimize free air

a nurse is caring for a client who has a DVT and has been taking unfractioned heparin for a week. The provider prescribed Warfarin 2 days ago. The client questions the nurse about receiving both medications at the same time. Which of the following is an appropriate response by the nurse? I will remind your provider that you are already taking heparin Laboratory findings indicated that two anticoagulants are needed It takes 3-4 days before the effects of Warfarin are received and heparin can be D/C Only one of these medications is being given to treat your DVT

Warfarin is an anticoagulant that inhibits the synthesis of the four vitamin K dependent clotting factors. The therapeutic effects takes 3-4 days to develop, so its administration may begin while still on heparin and once therapeutic levels are reached, heparin is D/C. A PT/INR is monitored to make sure its levels are maintained between 2-3.

A nurse is planning care for a client who has a hbg of 7.5 and hct of 21.5. Which of the following should the nurse include in the POC? SATA Provide assistance w ambulating monitor oxygen saturation weigh the client weekly obtain stool specimen for occult blood schedule daily rest periods

When a client has anemia they may experience fatigue, dizziness, and syncope and may need assistance with ambulating and need scheduled daily rest periods. The oxygen saturation may need to be monitor dt a decrease in oxygen carrying capacity dt low RBCs (major carriers of hgb). A stool specimen may be obtained for occult blood dt GI bleeding related anemia. The client will not be weighed weekly but daily.

A nurse is reviewing the bowel prep using polyethylene glycol w a client scheduled for a colonoscopy. Which of the following information should the nurse include? Check w the provider about current meds when consuming bowel prep Consume a normal diet until starting the bowel prep The bowel prep will not begin acting until the day after it is consumed The bowel prep may be discontinued once feces start to be expelled

When bowel prepping, the client should avoid medications indicated by the provider, consume a clear liquid diet avoid red purple or orange fluids. And remain NPO after midnight. The bowel prep may begin working 2-3 hr after consumption. And the client must consume the full amount prescribed.

A nurse is reinforcing discharge instructions to a client post operative following fundoplication. Which of the following statements by the client indicates understanding of the teaching? When sitting after a meal, I will lower the back of it I will to try to eat 3 large meals a day I will elevate the head of my bed with blocks When sleeping, I will lay on my left side

When sitting the client should remain upright 2hrs after a meal avoiding lying down. Eat several small meals a day to promote gastric emptying. Elevate HOB w blocks 6-8 in and sleep on the right side.

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take when there is a transfusion reaction? SATA Stop the transfusion Send the blood bag and IV to the blood bank Maintain an IV fusion of 0.9 sodium chloride Elevate the clients feet Obtain a blood culture

When there is a transfusion reaction the nurse should immediately stop the transfusion, ensure an infusion of 0.9 sodium chloride , and save the blood bag and remaining blood and the tubing to be tested at the lab. The nurse would elevate the clients feet and obtain a blood culture if sepsis is suspected.

A nurse is reviewing discharge teaching to a client who has crohn's disease. Which of the following should be included in the teaching? Decrease in calorie dense foods drink canned protein supplements Take calcium supplements daily Take a bulk forming laxative daily

With Crohn's disease, the client should increase protein and calories (at least 3000/day including canned and bottles), take a multivitamin containing iron.

A nurse is reinforcing discharge teaching with a client who has irritable bowel syndrome. Which of the following should be included in the teaching? Increase dairy product intake Consume 15-20 g of fiber daily Plan three moderate to large meals/day Drink at least 2 L of fluids a day

With IBS, the client should avoid milk products,eggs, and wheat. Consume 30-40 g of fiber/day, eat several small meals/day and increase fluids 2-3L day

A nurse is caring for an older adult client. Which of the following findings indicate the client has a stool impaction causing a large intestine obstruction? LBM was the previous day small, frequent liquid stools flatulence one episode of vomiting this morning

With a fecal impaction, the older adult client would experience small amounts of liquid stools around the impaction frequently.

A nurse is collecting data from a client who has a gastric ulcer. Which of the following are expected findings? SATA Client reports pain relieved by eating Client states that pain often occur HS Client reports sensation of bloating Client states pain occur 1/2-1 hr after meal Client experiences pain upon palpitation of epigastric region

With a gastric ulcer, the client reports sensation of bloating, pain in epigastric region upon palpitation, and occurs 30-60 mins after a meal. Duodenal ulcers are relieved by food and antacids and often occurs at night

A nurse in a clinic is reviewing self care information w a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? I will plan to limit fiber in my diet I will eat meals and plan fluid intake between meals I will drink coffee w breakfast rather than citrus juice I will try to eat 3 moderate to large meals

With ulcerative colitis, the client should increase protein and limit fiber in the diet, avoid coffee and alcohol, and eat small frequent meals.

Aneurysms

a weakened section in a dilated artery causing widening/ ballooning in the walls of a blood vessel. It can occur in two forms; saccular- one side of the artery affected or fusiform- complete circumference. A dissecting aneurysm is considered a life threatening condition where blood accumulates within the artery wall (hematoma) following a tear in the lining of the artery (usually dt HTN) Initially the client is asymptomatic Abd aortic aneurysm- constant gnawing feeling in abd, flank, or back; pulsating abd mass (do not palpate, can rupture);bruit, elevated BP Aortic dissection- sudden onset of tearing, ripping and stabbing abd or back pain; hypovolemic shock (diaphoresis, N/V, faintness, apprehension, decreased/absent pulses, neurological deficits) Thoracic aortic aneurysm- severe back pain, hoarseness, cough, SOB, and dysphagia, decrease in UO. Priority intervention is to reduce SBP between 100-120 and a long term goal =/<130-140

A nurse is caring for a client who has hemophilia. The nurse should anticipate a prescription from the provider for which of the following tests? RBC TIBC aPTT MCH

aPTT checks clotting factors

Anemias

abnormally low amount of circulating RBCs, Hgb concentration, or both. It is an indicator of an underlying disease or disorder. Results in diminished oxygen carrying capacity and delivery to tissues and organs. The goal of tx is to restore and maintain adequate tissue oxygenation. Anemias are dt: Blood loss, inadequate RBC production, increased RBC destruction, and deficiency of necessary components such as iron, erythopoetin, and/or vitamin B12.

Peripheral Arterial Disease Buerger's disease, subclavian steal syn, Raynaud's disease and popliteal entrapment are examples of PAD

affects the arteries (blood away from heart) and PVD affects veins (blood carried toward the heart); PAD results from atherosclerosis usually in the arteries of the LE. Findings include intermittent claudication, numbness or burning pain in legs primarily at rest when feet is in bed, pain relieved by placing feet in dependent position. Bruit over femoral and aortic arteries. Decreased or absent pulses , loss of hairon lower calf, ankle and foot. thick toenails, dependent rubor, pallor when elevated, dry scaly mottled skin. Promote vasodilation avoid vasoconstriction- insulated socks, warm environment, avoid stress, caffeine and nicotine.

Endoscopy

allows direct visualization of body cavities, tissues, and organs through the use of a flexible, lighted tube. They can perform biopsies, remove abn tissue, and perform minor surgery such as cauterizing a bleeding ulcer. Involves a contrast medium to allow visualization of structures beyond capabilities of the scope. Verify that the consent form is signed and any allergies (medications, food, environmental, latex), may be NPO, NSAIDs warfarin and aspirin puts client at higher risk for complications, previous radiographic exams (barium) may affect results. ensure client follow proper bowel cleanse.

angiography (coronary angiogram or cardiac catheterization)- Consent form required

an invasive diagnostic procedure used to evaluate the presence and degree of coronary artery blockage; a catheter is inserted into the femoral or brachial arteries and threaded to the right or left side of the heart. Narrowings and/or occlusions are identified by the injection of contrast media under fluoroscopy. Client should remain NPO for 8 hr dt high risk of aspiration when lying flat, identify any allergy to shellfish/ iodine, determine renal function before contrast dye, and admin diphenhydramine and methylprednisolone (Solu-Medrol). client remain awake and sedated during procedure the client may feel flushed and warmth when dye is inserted. after the procedure the client must keep affected extremity straight to minimize bleeding and in supine position. Admin antiplatelet or thrombolytic agents to prevent clot formation and restenosis. avoid strenuous activities, immediately report bleeding at insertion site, chest pain. SOB and changes in color and temp of exxtremity, restrict lifting (less than 10lb) stent placement requires anticoagulation 6-8 wks prior, avoid activities that causes bleeding

Echocardiogram transthoracic or transesophageal (posterior of heart)

an ultrasound of the heart used to diagnose valve disorders and cardiomyopathy. Procedure is noninvasive and takes up to an hr. Client is instructed to remain still and lie on left side.

Angina

angina pectoris is a sign of impending acute MI, research shows improved outcomes when treated w aspirin, b blockers, and ACE inhibitors. Anginal pain d/t ischemia. Its a tight, squeezing, heavy pressure or constricting feeling in the chest that may radiate to the jaw neck or arm. There are three types of angina: Stable angina (exertional angina) occurs w exercise or stress and relieved by rest or NTG, Unstable angina (preinfarction angina) occurs w exercise or stress but increases w occurrence, severity, and duration over time, and Variant angina (Prinzmetal angina) is dt coronary artery spasm that often occurs during rest. Symptoms lasts less than 15 mins and not associated w nausea, epigastric pain, dyspnea, anxiety or diaphoresis.

Renography (Kidney scan)

assess renal blood flow and estimates GFR after IV injection of radioactive material to produce a scanned image of the kidneys. Post procedure- check BP frequently during and after procedure if captopril is given, monitor for orthostatic hypotension, increase fluids if hypotension occurs, standard precautions when handling urine, radioactive material is not nephrotoxic.

Nursing Care for Peptic Ulcer Disease

avoid foods causing distress, encourage rest periods, avoid alcohol, smoking and NSAIDs. Take full course of antibiotics, Ranitidine may be taken w or w/o food, notify provider of coffee ground emesis. Take omeprazole once a day prior to eating in the morning. Antacids given 1-3 hrs after meals to neutralize gastric acid which occurs w food ingestion and at bedtime. Give antacids 1 hr apart from other meds to avoid reducing absorption of other meds. Take all other meds at least 1 hr before or after antacids. Sucralfate (Carafate) is a mucosal protectant given 1 hr before meals and at HS- monitor for adverse effect of constipation. Avoid milk products, caffeine, decaf coffee, spicy foods, NSAIDs. Perforation presents as severe epigastric pain spreading across the abd, rigid boardlike abd, hyperactive to diminished bowel sounds, and rebound tenderness.

Gastroesophageal Reflux Disease (GERD)

characterized by corrosive gastric content and enzyme leakage into the esophagus causing irritation. Primary tx is diet and lifestyle changes. Excessive ingestion of foods that relaxes the LES include fatty fried foods, chocolate, caffeine, peppermint, spicy foods, tomatoes, citrus fruits, and alcohol. Increased gastric acid dt NSAIDs or stress. S/S- dyspepsia (freq and prolonged substernal heartburn) after eating an offending food/fluid, and regurgitation. Wavelike pain that radiates to neck back and jaw that mimics a heart attack, pain worsens w position changes, and occurs after eating lasting 20 min -2 hr. Throat irritation, hypersalivation, bitter taste in mouth, increased flatus and eructation. Pain is relieved by drinking water, sitting up, or taking antacids. May have tooth erosion and hoarseness. Antacids given 1-3 hr after meals and HS and seperate from others meds at least 1 hr. H2 Receptor blockers (end in dine)- given w meals and HS; do not mix w nizatidine (Axid) w vegetable juices PPIs end in zole- SR caps can be opened and sprinkled on food or mixed w applesauce or juice for NG tube. Avoid offending foods, large meals, remain upright after eating 30 min-2 hr and avoid eating at bedtime. Elevate HOB w 6-8 in blocks and sleep on right side.

Valvular Heart Disease

classified as stenosis (narrowing) or insufficiency (regurgitation) and can be congenital or acquired. acquired valvular heart disease is classified as degenerative disease (mechanical stress like HTN), Rheumatic disease (fibrotic changes/ calcification of valve cusps), and Infective endocarditis (infectious organisms destroy the valves like streptococcal infections) Valves on the left side are more commonly affected dt higher pressures. Early detection and prevention of rheumatic fever helps prevent valvular disease. Clients are often asymptomatic until late in the progression of the disease. A murmur can be heard dt turbulent blood flow and graded on scale of 1 (faint) to 5 (very loud).

A nurse is providing care to a client who is 1 day postoperative paracentesis. The nurse observes clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention? Place a clean towel near the site Apply a dry, sterile dressing Attach an ostomy bag Place the client in a supine position

clear pale yellow fluid is normal; the nurse should apply a dry, sterile dressing to prevent further leakage. Cloudy drainage may indicate infection.

a nurse is caring for a client who has a chronic venous insufficiency. The provider prescribed thigh high compression stockings. The nurse should instruct the client to.. massage both legs firmly w lotion prior to applying socks apply the stockings in the morning before getting out of bed roll the socks down to the knees if they will not stay up on thighs remove the stockings while out out bed for 1 hr, QID to allow the legs to rest

compression stockings compresses the veins allowing blood return to the heart. it is more effective put them on upon awakening and before getting out of bed. The client should avoid crossing their legs or massaging the legs to prevent dislodging any blood clots. The stockings are measured to fit snugly around the clients thigh and are not suppose to be rolled down to the knee. The socks are worn all day and taken off before going to bed.

Aplastic anemia

decreased numbers of RBCs, platelets, and WBCs. Bone marrow aspiration/biopsy is used to diagnose aplastic anemia (failure of bone marrow to produce RBCs, WBCs, and platelets). Instruct the client and family about energy conservation and the risk of experiencing dizziness upon standing. Erythropoetin (epoetin alfa {Epogen, Procrit}) is a hematopoietic growth factor used to increase RBC production. The nurse should monitor for an increase in BP, monitor hgb and hct twice a week, and monitor for a cardiovascular event if hgb increases too rapidly (greater than 1 g/dL in two weeks) Folic acid supplements is necessary for the production of new RBCs. It is a water soluble, B complex vitamin given orally or parenteral. Large doses of folic acid can mask vitamin B12 deficiency and turn the clients urine dark yellow.

Irritable bowel syndrome (IBS)

disorder of the GI system that causes changes in bowel function (chronic diarrhea, constipation, or abd pain); Avoid foods containing dairy, eggs, and wheat products, alcoholic and caffeinated beverages and other fluids containing fructose and sorbitol. Consume 2-3 L of fluids/day and increase fiber intake 30-40 g /day. Client may present: cramping pain in abd, nausea w meals or passing stools, anorexia, bloating, belching, diarrhea, and constipation. Difficult to dx w specific tests but specific characteristics (abd pain w changes in bowel pattern, abd distention, feeling that defecation isnt complete, and mucus in stools). Hydrogen breath test- client exhales into a hydrogen analyzer before and after ingesting sugar; positive test indicates excess hydrogen in bloodstream from bacterial overgrowth or mal-absorption. Reduce stress, limit intake of irritating foods, high fiber diet, and keep food diary.

Hernia

displacement of the bowel through the abd muscle into other areas of the abd cavity; Hernias that cannot be moved back into place are considered irreducible and treated surgically. Protrusion or "lump" at involved site (groin area, umbilicus, healed incision). Instruct client to wear truss pad w hernia belt during wake hours and to inspect skin daily (nonsurgical client) avoid increased intra- abdominal pressure for 2-3 weeks post operatively (coughing, straining, heavy lifting)

Stress testing

during the procedure the cardiac muscle is exercised by the client walking on a treadmill providing info on workload of the heart. Clients who become too tired, disabled, or physically challenged may do a pharmacological stress test using adenosine (Adenocard) or dobutmaine (Dobutrex). Involves a consent form, recommended comfortable shoes and clothing and the client should fast 2-4 hrs prior avoiding tobacco, alcohol, caffeine before the test.

Left sided HF (pulmonary edema)

dyspnea, orthopnea, nocturnal fatigue hypertrophy s3 heart sounds (gallop) cough, crackles pink frothy sputum AMS Manifestations of organ failure (oliguria) Expected EF 55-70%

Electrocardiography (resting, holter, continuous cardiac monitoring or telemetry)

electrocardiograph records electrical activity of the heart over time; continuous cardiac monitoring requires the client to be in close proximity to the monitoring system and telemetry allows the client to ambulate while maintaining proximity to the monitoring system. Client must be placed in supine position w chest exposed , wash clients skin to remove oils, attach one electrode to clients extremities by applying electrodes to flat surfaces above the wrists and ankles and the other 6 to the chest avoiding hair. Males may need to be shaved. Client must remain still and breathe normally

A nurse receives a phone call from a client seeking info about his new prescription for erythopoetin (Epogen). Which of the following information should be reviewed w the client? The client needs an erythrocyte sedimentation rate weekly Client should have a hemoglobin checked twice a week Blood pressure can decrease Folic acid production will increase

erythropoetin is given to increase production of RBCs. The client will have their hgb and hct monitored twice a week (changes in hct evaluated for effectiveness of erythropoetin). The nurse will monitor for an increase in BP.

A nurse is reinforcing teaching w a client who has duodenal ulcer and a new prescription for esomeprazole (Nexium). Which of the following should be included in the teaching? SATA Take the medication 1 hr before a meal Limit NSAIDs when taking this med Expect skin flushing Increase fiber intake Chew thoroughly before swallowing

esomeprazole (Nexium) is a PPI that reduces gastric acid secretion by inhibiting enzymes that produce gastric acid. Tablets should not be chewed or crushed; must be taken whole. Avoid alcohol and NSAIDs when taking this medication. And take once a day 1 hr prior to eating in the morning

Bone marrow aspiration/Biopsy

extraction of a very small amt of tissue to definitely diagnose cell type and confirm or rule out malignancy. Is commonly performed to diagnose causes of blood disorders like anemia or thrombocytopenia, or to rule out diseases such as leukemia and other cancers , and infection. Involves an informed consent and the client positioned in a prone or side lying position to expose the iliac crest. The biopsy site is anesthetized w local anesthetic and the client can feel pressure and brief pain during the aspiration. Older adults need renal clearance and are at greater risk for complications associated w sedation. Apply pressure to site to control bleeding and sterile drsg. ice may be applied if prescribed, avoid aspirin and other medications that affect clotting. check biopsy site daily making sure it is clean dry and intact. If sutures are placed it will be removed after 7-10 days. Report bleeding immediately.

Hematocrit (Hct)

females 37-47% males 42-52% decreased levels evidence of anemia

Complications of Angiography: Cardiac Tamponade

fluid accumulation in the pericardial sac; manifestations include hypotension, JVD, muffled heart sounds, and paradoxical pulse (variance of 10 mm Hg or more in SBP between expiration and inspiration)

Hypovolemic Shock

fluid volume deficit; vital organ hypoxia/anoxia- decreased hgb oxygen saturation and pulse pressure. Admin O2, monitor clients receiving fluid replacement (colloids= whole blood, PRBCs, plasma, synthetic plasma expanders; crystalloids= lactated ringers and NS) client may receive vasoconstrictors (dopamine and norepinephrine {Levoped}), coronary vasodilators (sodium nitroprusside), and positive inotropic meds such as dobutamine (Dobutrex).

A nurse is caring for a client who has acute divrticulitis. The nurse notes that the NG tube is draining green liquid bile. Which of following actions should the nurse implement? Document the findings Irrigate the NG tube Determine the last BM Insert the NG tube another 2 inches

green liquid bowel indicates that the NG tube is in the stomach; the nurse should document the findings.

Dumping Syndrome

group of manifestations that occur after eating; a shift of fluid to the abd is triggered by rapid gastric emptying or high carbohydrate ingestation. Can cause decrease in circulating volume (syncope, pallor, palpitations, dizziness, headache). Avoid drinking water with meals. Early manifestations- w/t 30 min after eating (N/V, dizziness, tachycardia, plapitations Late manifestations- 1.5-3 hr after eating c/b excessive insulin release (hunger, dizziness, sweating, tachycardia, palpitations, shakiness, anxiety, confusion Lie down when vasomotor manifestations occur. Powered pectin or octreotide (Sandostatin) may be prescribed if too severe. Lying down after meal slows movement of food into intestines, eliminate liquids 1 hr prior to eating and following a meal, consume high protein, high fat, low fibr and low to moderate carb diet. Avoid sweets, milk, or sugars and consume small freq meals.

S/S of Hypernatremia

hyperthermia, tachycardia, orthostatic hypotension, restlessness, irritability, muscle twitching to muscle weakness, decreased to absent DTRs, seizures, and coma. Thirst, dry mucous membranes, increased GI motility, hyperactive BS, abd cramping, nausea, Edema, warm flushed skin, oliguria. Encourage foods high in sodium (chesse, milk, condiments), frequent mouth care, sugarless gum/candy

Fluid volume excess

hypervolemia- isotonic (water and sodium retained in abn high proportions) and overhydration osmolar (more water gained than electrolytes) Severe hypervolemia can lead to pulmonary edema and HF. Compensatory mechanisms include increased release of natriuretic peptides (increased loss of sodium and water by kidneys and decrease in aldosterone release. Restrict sodium and/or water intake. S/S of hypervolemia: tachycardia, bounding pulse, HTN, tachypnea, headache, confusion, muscle weakness, weight gain, ascites, dependent edema, distended neck veins, cool pale skin Hemodilution- decreased hct, decreased urine specific gravity, respiratory alkalosis, decreased BUN, electrolytes, and creatinine. Place client in semi fowlers, admin diuretics, limit fluid/sodium intake, reduce iv fluid rate, turn q 2 hrs, monitor for edema (sacral, pretibial, and periorbital areas.

Fluid volume deficit

hypovolemia- isotonic (loss of water and electrolytes from the ECF) and dehydration- osmolar (loss of water w no loss of electrolytes; SNS response of increased thirst, antidiuretic hormone release, and aldosterone release. Increase fluid intake when engaging in vigorous exercise, in high altitudes and dry climates, avoid beverages containing caffeine and alcohol (diuretic), thirst mechanism less sensitive in OA. S/S: hyperthermia, tachycardia, hypotension, increased RR, dizziness, syncope, confusion, weakness, fatigue, thirst, dry furrowed tongue, n/v, anorexia, acute weight loss, oliguria, concentrated urine, diminished cap refill, dry mucous membranes w cracks poor skin turgor (tenting), sunken eyballs, flattened neck veins. Hemoconcentration- increased hct, increased urine specific gravity, increased serum sodium, increased protein, BUN, electrolytes and glucose. Alert provider for UO less than 30 ml/hr, place in shock position (supine w legs elevated), Monitor LOC and maintain safety, change positions slowly, slowly rolling from side to side, or standing.

Retrograde pyelogram, cystogram, urethrogram

identifies obstructionor structural disorders of the ureters and renal pelvis of kidneys (pyelogram) by instilling contrast dye during cystocopy. Fistulas, diverticula, and tumors are identified in the bladder (Cystogram) and urethra (urethrogram) by instilling contrast dye during a cystoscopy.

Rheumatic endocarditis

infection of the endocardium dt streptococcal bacteria. Preceded by an upper respiratory infection. Produces lesions in the heart, occurs in half of clients w rheumatic fever. Findings include fever, chest pain, joint pain, tachycardia, SOB, rash on trunk and extremities, friction rub. murmur, and muscle spasms.

Infective (Bacterial) Endocarditis

infection of the endocardium dt streptococcal or staphylococcal bacteria. Most common in IV drug users or clients who have cardiac malformations. findings are flu like, murmur, petechiae (on trunk and mucous membranes), positive blood cultures, and splinter hemorrhage (red streaks under nail beds)

Crohn's disease

inflammation and ulceration of the GI tract, often at the distal ileum. Lesions are sporadic, fistulas are common; Can involve entire GI tract from from the mouth to the anus. Malabsorption and malnutrition can develop when the jejunum and ileum becomes involved (B12 shots). Abd pain/cramping, RLQ, fever, diarrhea (up to 5 loose stools/day w mucus or pus), steatorrhea, abd distention, tenderness, and/or firmness upon palpation, high pitched BS. Genetics, Caucasian and Jewish heritage, diagnosed at any age, smoking, infection, and stress. Nursing care same as Ulcerative Colitis. Decreased Hgb, hct, albumin, Folic acid and vitamin B12 Increased ESR, WBC,

Acute/Chronic Gastritis

inflammation in the lining of the stomach; acute- sudden onset, short duration, can result in gastric bleeding if severe Chronic- slow onset, profuse, and can damage parietal cells leading to pernicious anemia. S/S- Dyspepsia, indigestion, upper abd pain, N/V, reduced appetite, abd bloating/distention, Hematemesis, black tarry stools coffee ground emesis weight loss stools/vomitus positive for occult blood. Check for anemia (F= hgb <12) (M= hgb <14). Upper EGD (NPO 6-8 hrs, need ride after procedure, local anesthetic sprayed on throat may be sore afterwards. Monitor for chest perforation- chest/abd pain, fever, N/V, and abd distention.) Small freq meals, avoid caffeine, alcohol, and foods that trigger gastric irritation. Reduce stress and monitor for anemia and gastric bleeding.

Hepatitis

inflammation of liver cells; A&E (Always Enteric, fecal oral route) BCD (Blood/Blood products). Individuals can be infected w hepatitis and remain symptom free and unaware they are contagious. Vaccination recommended, isolation precautions, aseptic technique for prep and admin of parenteral meds. Sterile, single use disposable needles each injection, needleless systems or safety caps, PPE, avoid sharing utensils and bed linens, drink purified water (when traveling to undeveloped countries). High risk- unscreened blood transfusions (prior to 1992), hemodialysis, percutaneous exposure, unprotected sex w hep infected person, multiple partners, anal sex, food prepared by hep person, living in crowded spaces, military bases, LTC facilities. S/S:Influenza like symptoms (fatigue, decreased appetite w nausea, abd pain, joint pain), fever, vomiting, dark colored urine, clay colored stool, jaundice. Elevated liver enzymes and bilirubin, ELISA or RIBA (hep C), Immunoglobulins M and G (stage of hep A and B) Liver biopsy- definitive dx procedure to identify intensity of infection and degree of liver damage; fast for at least 2 hrs, supine position w RUQ exposed, utilize relaxation techniques, exhale and hold for at least 10 secs while the needle is inserted, resume breathing once needle is removed, pressure to minimize bleeding, right sidelying position and maintain for several hrs, monitor for abd pain and bleeding from site. Limit activity to promote liver healing, high carb, high cal diet w low to mod fat and protein. small freq meals.

Myocarditis

inflammation of the myocardium; dt viral, fungal, or bacterial infection, or systemic inflammatory disease (Crohn's). Findings include tachycardia, murmur, friction rub, cardiomegaly, chest pain and dysrrhythmia

Pericarditis

inflammation of the pericardium; commonly follows a respiratory infection. Findings include chest pressure/pain, friction rub, SOB, and pain relieved when sitting and leaning forward.

Total Iron binding capacity (TIBC)

iron study that reflects an indirect measurement of serum transferin, a protein that binds w iron and transport it for storage. Serum ferritin is an indicator of total iron stores in the body.Low serum iron and elevated TIBC indicates iron deficiency anemia

Peripheral Venous Disease

limb pain (aching pain and feeling of fullness or heaviness in legs after standing), DVT, thrombophlebitis, stasis dermatitis (brown discolorations of ankles and calves), edema, stasis ulcers around ankles, muscle cramping and aches, pain after sitting, and pruritis.

Sodium imbalances

major electrolyte found in ECF, essential for maintaining acid base balance, active and passive transport mechanisms, and irritability and conduction of nerve and muscle tissue. Hyponatremia= <136 mEq/L water moves from ECF into ICF causing cells to swell (cerebral edema) Hypernatremia= >145 mEq/L; increased sodium causes hypertonicity of the serum causing a shift of water out of the cells (dehydrated cells)

A nurse is collecting data from a client who has pancreatitis. The clients ABG reveal metabolic acidosis. Which of the following is an expected finding? SATA Tachycardia HTN Bounding pulse Hyperreflexia Dysrhytmia tachypnea

metabolic acidosis manifestations include dysrrhytmias, tachypnea, bradycardia, hypotension, weak peripheral pulses, hyporeflexia, flaccid paralysis, warm, dry flushed skin, kussmaul respirations.

A nurse is reviewing the chart of a client who ABG reveal metabolic acidosis. The nurse should recognize that which of the following conditions in the clients history increased the risk of metabolic acidosis? Diabetes Mellitus Myasthenia Gravis Asthma Cancer

metabolic acidosis means the clients pH levels are low and so is the bicarbonate levels. A client who has DM and have a high risk of Diabetic Ketoacidosis can result in metabolic acidosis. The other conditions can cause respiratory acidosis.

A nurse is completing the admission physical assessment of a client w a history of mitral valve insufficiency. Which of the following is an expected finding? Hoarseness Petechiae Crackles in the lung bases Splenomegaly

mitral valve insufficiency findings include- crackles in the lungs, A fib, S3/s4 sounds, palpitations, JVD, pitting edema, diminished lung sounds

Iron deficiency anemia

most common cause of anemia in children, adolescents, and pregnant women dt inadequate intake Most common cause of anemia in postmenopausal dt blood loss (also menstruating women experiencing menorrhagia). Ensure a diet containing adequate amts of iron rich foods or iron supplement. Individuals who are iron deficient but have elevated cholesterol levels should integrate iron rich foods that are not red or organ meats such as iron fortified cereals and breads, fish, poultry, and dried peas and beans. Regularly consume foods high in folate (spinach, lentils, bananas) and folic acid (fortified grains and juices) Iron supplements- Parental supplements (iron dextran) given for severe anemia only; administered using the Z track method. Hgb must be checked in 4-6 weeks to determine efficacy, Vitamin C increases oral iron absorption, should be taken between meals to increased absorption if tolerated. Low serum iron and elevated TIBC= iron deficiency anemia.

Hypertension

occurs when SBP >140 and DBP is >90. A normal BP is less than 120/80. essential (primary) HTN has no known cause. prolonged untreated or poorly treated HTN can lead to PVD that primarily affects the heart, brain, eyes, and kidney. Prehypertensive is SBP 120-139 and DBP 80-89. When elevated the BP should be taken sitting, lying, and standing. Hypertensive crisis can occur when the client doesnt follow the medication therapy regimen. It can cause severe headaches, blurred vision, dizziness, disorientation, epitaxis (nosebleeds). Administer IV antihypertensives such as nitroprusside (Nitropress), nicardipine (Cardene), and labetalol hydrochloride. Monitor BP q 5-15 min checking the LOC, pupils, muscle strength for any cerebrovascular changes.

Myocardial Infarction

pain is unrelieved by rest or NTG and lasts more than 15 mins. when the cardiac muscle suffers ischemic injury, cardiac enzymes are released into the blood stream providing specific markers of MI like troponin. MI can occur w/o cause often in the morning after rest, relieved only by opioids, symptoms last more than 30 mins, and associated w nausea, epigastric distress, dyspnea, anxiety and diaphoresis. Symptoms include anxiety (like impending doom), chest pain that may radiate to shoulder arm or jaw, crushing or aching pain, nausea, dizziness, pallor cool clammy skin, tachycardia/heart palpitations, diaphoresis, vomiting, decreased LOC. Thallium scan assess for ischemia or necrosis and appears as cold spots. must avoid smoking and caffeinated beverages 4 hrs prior to scan.

Ileostomy

performed when the entire colon must be removed d/t disease; Post operative output less than 1000 mL/day bile colored and liquid. After several day to weeks output will be betwen 500-1000 mL/day becoming more paste like as the small intestine assumes absorptive functioning of large intestine.

Cirrhosis

permanent scarring of liver usually caused by chronic inflammation and necrotic injury; Normal liver tissue is replaced w fibrotic tissue that lacks function. Postnecrotic cirrhosis- viral hep or certain meds/toxins, Laennec's cirrhosis- chronic alcoholism, Biliary cirrhosis- chronic biliary obstruction or autoimmune disease. Avoid drinking alcohol and stay current on immunizations. S/S- fatigue, weight loss, abd pain and distention, pruritis, confusion/difficulty thinking, personality and mentation changes, emotional lability, euphoria, depression, Altered slep/wake pattern, GI bleeding, Ascites, Jaundice and icterus (yellowing of eyes), Petechiae, ecchymoses, epitaxis, hematemesis, melena, palmer erythema, spider angiomas (red lesions on nose cheeks, upper thorax and shoulders), Dependent peripheral edema, Asterixis (liver flapping tremor) Fector hepaticus (liver breath-fruity or musty odor). Liver enzymes and bilirubin elevated initially, protein and albumin decreased, blood tests decreased, PT/INR prolonged, Elevated ammonia (Laculose=diarrhea), creatinine increased rt kidney function. High carb, high protein, mod fat, low sodium w multivitamins, folate, and thiamine.

Pica

persistent eating of substances not normally considered food (non-nutritive substances), such as soil or chalk, for at least a month; can limit the healthy food choices a client makes. Can be a cause of anemia.

CT scan

provides 3D imaging of renal/urinary system to assess for kidney size and obstruction, cysts, or masses. IV contrast dye (iodine based) may be used to enhance imaging. SAME nursing interevntions as KUB w/o contrast and excretory urography w contrast dye (w/o bowel prep) Contrast dye can cause acute kidney injury.

Cardiac enzymes: Creatinine kinase MB (up to 3 days), Troponin T (14-21 days), Troponin I (7-10 days) and myoglobin (24 hr)

released into the bloodstream when the heart muscle suffers ischemia; specific markers in diagnosing MI

A nurse is collecting data from a client who ABG results shows respiratory alkalosis. The nurse should expect which of the following physical findings? Irritability tingling extremities asthma cancer

respiratory alkalosis is when the CO2 levels are low and pH is elevated. the nurse should expect to see tingling, numbness, anxiety, tachpnea, palpitations, chest pain, kussmaul respirations.

a nurse is collecting data on a client for HTN. Which of the following actions by the client increases his risk for HTN? SATA Drinking 8oz of non fat milk daily eating popcorn at the movie theater walking 1 mile daily at 12 min/mile consuming 360z of beer daily getting a massage once a week

risks factors of HTN includes: Excessive salt intake (like popcorn at the movies), high alcohol consumption, smoking, stress, hyperlipidemia, and sedentary lifestyle or physical inactivity.

Heart Failure Grade

scale indicates how little or how much activity it takes to make the client symptomatic (chest pain, or SOB) Class I- no symptoms w activity Class II- symptoms w ordinary activity Class III- symptoms w minimal exertion Class IV- symptoms w rest

Hypocalemia

serum calcium less than 9.0 (hypercalemia more than 10.5) Risk factors- lactose intolerance, malabsorption syn (Crohns disease), hypoalbuminemia, ESKD, post thyroidectomy, hypoparathyroidism, inadequate calcium intake, Vitamin D deficiency, Pancreatitis, hyperphosphatemia, sepsis and meds blocking parathyroid function and cause hyperphosphatemia (chelate calcium) or prevent calcium absorption S/S= Paresthesias of fingers and lips (early sign), muscle twitching/tetany, freq painful muscle spasms at rest (Charley horse), Hyperactive DTR, Positive chovsteks and Trousseaus sign, decreased HR and hypotension, hyperactive BS, diarrhea, abd cramping. Prolonged QT and ST intervals Implement sz precautions, encourage foods high in calcium (dark green veggies, dairy products).

Hypomagnesemia

serum magnesium level less than 1.3 mg/dL (Hypermagnesemia level more than 2.1) Risk factors- malnutrition and alcohol ingestion. S/S- increased nerve impulse transmission (hyperactive DTRs, paresthesias, muscle tetany), positive chovsteks and trousseaus sign, hypoactive BS, constipation, abd distention, parlytic ileus. D/C meds that cause magnsium excretion (loop diuretics), admin oral sulfate (can cause diarrhea and increased magnesium depletion), encourage foods high in magnesium (dairy and dark green veggies). Monitor IV magnesium sulfate closely.

S/S of Hyperkalemia

slow, irregular pulse; hypotension. Restlessness, irritability, weakness to the point of ascending flaccid paralysis, paresthesias, Increased GI motility, n/v, diarrhea, hyperactive BS, Oliguria. Metabolic acidosis (pH <7.35) PVCs, V Fib, peaked t waves, widened QRS Provide cardiac protection (calcium gluconate or calcium chloride), withhold potassium supplementation, avoid foods high in potassium, promote movement of K+ from ECF to ICF (IV fluids w dextrose and regular insulin) loop diuretics admin (promote depletion of K+), Admin sodium polystyrene sulfonate (Kayexalate) avoid salt sub containing potassium

Fecal Occult Blood/ Stool tests

stool sample collected and tested for blood, ova, and parasites. Stools may also be collected to test for DNA changes in the vimentin gene. A positive finding for blood indicates GI bleeding (cancer, colitis, ulcer). A positive for ova and parasites indicates GI parasitic infection. A change in vimentin gene can be indicator of colorectal cancer. Clostridium difficile is an opportunistic infection that becomes established dt immunocompromise or antibiotic use. Provide client crads impregnated w guaiac to mail to provider or a specimen collection cup. If cards are used three samples are usually required. Avoid red meats and anticoagulants that may give false read.

A nurse is reinforcing teaching w a client who has a prescription for sulfasalazine (Azulfidine). Which of the following should the nurse include in the teaching? Take med 1 or 2 hr after eating May cause yellowing of the sclera Notify provider if experience sore throat This medication can turn stool black

sulfasalazine (Azulfidine) is an anti inflammatory that should be taken w/ meals, avoid sun exposure, increase fluid intake, urine and skin can appear yellow, color can damage soft contacts. Report sore throat, rash, fever, and bruising.

Ostomies

surgically created opening from inside of the body to the outside; can be located in any various areas of the body. Can be permanent or temporary. Stoma should appear pink and moist; Output should be more liquid and acidic the closer the ostomy is to the proximal small intestine. Empty ostomy bag when 1/4-1/2 full. Foods that can cause odor (fish, eggs, asparaagus, garlic, beans, and dark green leafy veggies) and foods may cause gas (dark green leafy veggies, beer, carbonated drinks, daiy products, and corn); Yogurt helps decrease gas. Avoid high fiber foods the first two months after surgery, chew well, increase fluid intake. Filters, deodorizers, and breath mints minimize odor while pouch is open. Stomal ischemia/necrosis- pale pink or bluish/purple stoma indictates serious impairment of blood flow.

Esophageal varices

swollen, fragile blood vessels in the esophagus; often medical emergency w hemorrhage. The client may not experience no manifestations until the varices begin to bleed- Valslava maneuver, lifting heavy objects, coughing, sneezing, alcohol consumption. Bleeding varices- hypotension and tachycardia. Vasopressin (Desmopressin) and octreotide (Sandostatin) are avoided dt multiple adverse effects.

A nurse is caring for a client who has HF and asks how to limit fluid intake to 2,000 mL/day. Which of the following is an appropriate response? Pour the amt of fluid you drink into two empty 2 L bottles to keep track of how much you drink Each glass contains 8 oz, there are 30 ml per oz so you can have a total of 8 glasses of fluid each day This is the same as 2 qts or about the same as two pots of coffee Take sips of water or ice chips so you will not take in too much fluid

to maintain an accurate measurement of fluid intake the client should take two empty 2 L bottles measuring 2000 ml to keep track of how much fluid they are drinking

Lipid profiles

total cholesterol (screening for heart disease; <200), HDL (good cholesterol; 35-80 F 35-65 M), LDL (bad cholesterol; makes up 70% of TC; <130), and triglycerides (evaluating for atherosclerosis; 35-135 F 40-160 M Older adults over 65 YO- 55-220)

Urine Bilirubin "urobilinogen"

urine test to determine the presence of bilirubin in the urine; suspected liver or biliary tract disorder. A positive or elevated finding indicates possible liver disorder (cirrhosis, hepatits) or biliary obstruction. Use a dipstick or 24 hr urine collection

A nurse is collecting data on a client who has a new diagnosis of an AAA. which of the following data collected by the nurse supports this diagnosis? SATA elevated BP Palpable abd pulsations Bruit heard on auscultation client report back pain client report difficulty swallowing

with a AAA the client will experience elevated BP, back pain, bruit, and a pulsating abdominal mass.

A nurse is admitting a client w a suspected occlusion or rupture of a graft of the abd aorta. Which of the following is an expected clinical finding? Increased UO Bounding pedal pulses Increased abd girth Redness of the lower extremities

with an occlusion or rupture of a graft, expected clinical findings include; decreased UO, decreased/ absent pedal pulses, abd distention, and pallor or cyanosis of the LE

A nurse is collecting data from a client who has chronic PAD. Which of the following should the nurse expect to see? Edema around the ankles/feet Uleraction around the medial malleoli Scaling edema of the lower legs w stasis dermatitis Pallor on elevation/ Rubor dependency

with peripheral arterial disease the arteries that carry the blood away from the heart is not getting to the LE. You will see pallor when the legs are elevated and redness when dependent.