ATI/NCLEX REVIEW Part 1
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse?
"The tube will drain air from the space around the lung."
thoracentesis
(aspiration of fluid or air from the pleural space) is performed on patients with various problems. A thoracentesis may be used for removal of fluid and air from the pleural cavity or aspiration of pleural fluid for analysis.
calculate BSA
(take the square root of height in cm × weight in kg ÷ 3,600)
Magnesium
-1.3-2.1 mEq/L -contributes to many enzymatic and metabolic processes, particularly protein synthesis -modifies nerve impulse transmission and skeletal muscle response (unbalance= dramatic affect on neuromuscular processes)
Sodium
-135-145 mEq/L
Potassium
-3.5-5.0 -main ICF cation -regulates cell excitability -permeates cell membranes, thereby affecting cell's electrical status -Helps to control ICF osmolality and, consequently, ICF osmotic pressure
calcium
-9.0-10.5 mg/dL -major cation in teeth and bones; found in fairly equal concentrations in ICF and ECF -also found in cell membranes, where it helps cells adhere to one another to maintain their shape -acts as an enzyme activator w/in cells (muscles must have Ca to contract) -aids coagulation -affects cell membrane permeability and firing level
chloride
-98-106 mEq/L -Main ECF anion -helps maintain normal ECF osmolality -affects body pH -plays vital role in maintaining acid-base balance; combines with hydrogen ions to produce hydrochloric acid
restraints
-A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. -To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. -Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. -The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.
Flumazenil
-Benzodiazepine antagonist (antidote) -should be administered in small quantities such as 0.2 mg over 15 to 30 seconds but never as a bolus. -may be given undiluted in incremental doses. -adverse effects may include shivering and hypotension. The nurse should monitor the client's level of consciousness while recovering from sedation. -should be administered through a free-flowing IV line in a large vein because extravasation causes local irritation.
kidney function r/to fluid balance
-Capillary blood pressure forces fluid through the capillary walls and into Bowman's capsule at the proximal end of the tubule. -Along the length of the tubule, water and electrolytes are either excreted or retained (based on body's need) -Electrolytes such as Na and K are either filtered or reabsorbed throughout the same area. -Resulting filtrate which eventually becomes urine flows through tubule into collecting ducts and eventually into the bladder as urine.
antidiuretic hormone (ADH)
-aka vasopressin -produced by the hypothalamus -stored and released by the posterior pituitary -restores blood volume by reducing diuresis and increasing water retention
Atrial natriuretic peptide (ANP)
-cardiac hormone -stored in cells of atria -released when atrial pressure increases -hormone opposes renin-angiotensin system by decreasing blood pressure and reducing intravascular blood volume
ADH
-hormone secretion that is INHIBITED by decreased serum osmolality or increased blood volume -in turn less water is reabsorbed, making urine less concentrated
ADH
-hormone stimulated by increased serum osmolality or decreased blood volume -in turn increases kidney's reabsorption of water= more concentrated urine
aldosterone
-hormone that plays a role in maintaining blood pressure, fluid and electrolyte balance -secreted by adrenal cortex, regulates reabsorption of sodium and water w/in nephron and back into the bloodstream
hepatitis B
-is spread through exposure to blood or blood products and through high-risk sexual activity -Considered STD -High-risk sexual activities include sex with multiple partners, unprotected sex with an infected individual, male homosexual activity, and sexual activity with IV drug users -college students at high risk...IMMUNIZATION
Nursing Process Steps
1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation
assessment (first step in nursing process)
1. Gather healthy history 2. physical assessment 3. review of pertinent laboratory data etc.
urine specific gravity
1.005 - 1.030 (Usually 1.010 - 1.025)
Magnesium
1.3-2.1 mEq/L
sodium
135-145 mEq/L -main ECF cation -helps govern normal ECF osmolality (shift in Na concentrations triggers a fluid volume change to restore normal solute and water ratios) -helps maintain acid-base balance -activates nerve and muscle cells -influences water distribution (with chloride)
Normal urine osmolality
200 to 800 mOsm/kg
HCO3 values
22-26 mEq/L
normal bicarbonate
22-26 mEq/L
Potassium
3.5-5.0 mEq/L
PaCO2
35-45 mmHg The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?
normal pH of blood
7.35-7.45
PaO2
80-100 mmHg
calcium
9.0-10.5 mg/dL
chloride
98-106 mEq/L
crackles
A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?
enteral feedings
A client has had a laryngectomy as treatment for laryngeal cancer. Which nutritional interventions should be implemented for the client? -used for 10 to 14 days after a laryngectomy to avoid irritation to the sutures and reduce the risk of aspiration.
ineffective breathing pattern
A client is admitted with increased ascites related to cirrhosis. The client has a large round and firm abdomen. The client is not able to lie flat in bed and requests to be placed in a high Fowler's position to sleep. Which nursing diagnosis should receive top priority?
Flushed Skin The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system.
A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg (10.7 kPa); PaCO2, 65 mm Hg (8.7 kPa); HCO3-,36 mEq/L (36 mmol/L). The nurse should assess the client for:
epidural
A disadvantage of lumbar epidural is the risk for hypotension, which can lead to altered tissue perfusion. Epidurals are associated with longer labor and hypothermia.
venturi mask
A nurse is assigned to care for a patient with COPD. The doctor has ordered oxygen at 6 L/min. Which of the following does the nurse need to obtain to give the O2?
elevated U wave
A nurse reviews the results of an electrocardiogram (ECG) for a patient who is being assessed for hypokalemia. Which of the following would the nurse notice as the most significant diagnostic indicator?
Administer oxygen via nasal cannula.
A patient admitted w/ sickle cell crisis What nursing intervention? Hemoglobin S forms a sickled shape in the presence of low oxygen tension, and oxygen is administered to prevent the condition of low oxygen tension.
pulmonary embolism
A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions?
airborne precautions
A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute?
Remove any weapons and dangerous items in his possession. Remind him that any feelings and problems he is having are typical in his current situation. Acknowledge any injustices/unfairness related to his experiences, and offer empathy and support. Ask him to talk about his upsetting experiences.
A soldier on his second tour of duty was notified of the date that he will be redeployed. As this date approaches, he is showing signs of excess anxiety and irritability and inability to sleep at night because of nightmares of explosive devices tragedies, all leading to poor work performance. His commanding officer refers him to the base hospital for an evaluation. What should the nurse do in order of priority from first to last? All options must be used.
respiratory acidosis
Acid-Base Balance Manifestations: Nausea, vomiting, abdominal pain, and diarrhea
respiratory alkalosis
Acid-Base Balance Manifestations: may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs).
renin
An enzyme that leads to the production of angiotensin II, a powerful vasoconstrictor. -The amount secreted depends on blood flow and the level of sodium in blood stream As soon as blood pressure reaches a normal level, the body stops releasing the enzyme
The nurse is responsible for teaching the patient who is receiving head and neck radiation how to protect his mouth. Which of the following teaching points should be included?
Avoid carbonated and caffeinated beverages. Use a bland mouth rinse before and after meals and at bedtime. Use fluoride preparations daily. Avoid acidic fruits and juices
Gold cap
Blood Tube: BMP, CMP, Hepatitis, tests
Green Cap
Blood Tube: BMP, CMP, troponin, lipids, liver panel, ammonia (on ice)
Lavender cap
Blood Tube: CBC, sedimentation, rate, hemoglobin A1C
Red cap
Blood Tube: Drug monitoring, biochemistry, immunology
Blue cap
Blood Tube: PT, PTT, INR, Fibrinogen, D-dimer, coagulation studies -Always use a waste tube first if cultures weren't drawn -tube must be full
pink cap
Blood Tube: Type & screen, type & crossmatch, RH, antibody screen -Follow Facility's Protocol for drawing/labeling -send to blood bank
gray cap
Blood Tube: lactate (lactic acid) (on ice)
purulent thick and yellow-green sputum
Bronchiectasis and a lung abscess usually are associated with
administering oxygen via face mask
By assisting the client to the semi-Fowler's position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse would secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could cause irritation. The nurse would apply the elastic straps above the client's ears to prevent skin breakdown. The nurse would ensure that the connectors between the oxygen equipment and humidifier are airtight; loosened connectors can cause loss of oxygen.
Atrial natriuretic peptide (ANP)
Cardiac Hormone: -suppresses serum renin levels -decreases aldosterone release from the adrenal glands -increases glomerular filtration, which increases urine excretion of sodium and water -decreases ADH release from the posterior pituitary gland -reduces vascular resistance by causing vasodilation
Chvostek's sign
Cheek, facial spasm when Cheek is tapped associates with hypocalcemia
Metformin (Glucophage)
Clients taking ...... are at risk for lactic acidosis when receiving contrast media.
hypervolemia
Clinical Manifestations: -SOB -edema -weight gain -distended neck and hand veins -heart failure -initially rising blood pressure and cardiac output; later falling values. -possible decreased hemoglobin and hematocrit, and protein
dehydration
Clinical Manifestations; dizziness fatigue weakness irritability delirium extreme thirst dry skin and mucous membranes poor skin turgor increased heart rate falling blood pressure decreased urine output seizures/coma (severe)
decreased compliance
Conditions associated with ............of the lungs include pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS)
According to the Joint Commission, which of the following is a focus of assessment related to quality of pain?
Description in the client's own words
dehydration
Diagnostics: Na > 145 urine specific gravity > 1.030 increased BUN increased hemoglobin
Rubella (German Measles)
Disease that has a teratogenic effect on the fetus. An infected child must be isolated from pregnant women.
"Support the neonate's head and back with the forearm."
During a home visit the nurse observed a mother giving her infant a bath. The nurse documents "Risk for injury (fall) related to parent's knowledge deficit." Which instruction by the nurse bestaddresses this nursing diagnosis?
tracheostomy tube management
Early complications include bleeding, pneumothorax, air embolism, aspiration, subcutaneous emphysema, recurrent laryngeal nerve damage, and posterior tracheal wall penetration.
infiltrated IV assessment
Edema, both distal and proximal to the site, as well as dependent edema, may indicate an infiltrated IV. An infiltrated IV in the hand will likely present as swollen fingers.
PQRST
Evaluate a patient's chief complaint using which model?
Which of the following arterial blood gas results would be consistent with metabolic alkalosis?
Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.
metabolic alkalosis
Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.
decrease
Fluid volume excess, diabetes insipidus, and hyponatremia are all factors that ........ urine osmolality.
glomuerular filtration rate
GFR: the nephrons filter about 180L/day = 1-2L of urine/day (30ml/hr) and the remaining 178L are reabsorbed
emphysema
High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended
renin
If blood flow to the kidneys diminishes (hemorrhage), or the amount of sodium reaching the glomerulus drops, the juxtaglomerular cells secrete more..... If blood flow to the kidneys increases, or the amount of sodium reaching the glomerulus increases, juxtaglomerular cells secrete less ...... A drop-off in......secretion reduces vasoconstriction and helps to normalize blood pressure.
ventricular fibrilation
Irregular rate without P waves, bizarre and variable QRS
tracheostomy tube management
Long-term complications include airway obstruction, infection, and dysphagia.
position after placement of ventriculoperitoneal shunt
Lying flat on the back is the appropriate position for this client. This position keeps the head level with the body, which reduces the risk of cerebrospinal fluid flowing too rapidly, leading to rapid decompression, which can result in tearing of the cerebral arteries.
Na, Cl, Ca, HCO3
Major electrolytes of ECF
respiratory alkalosis
May be caused by: extreme anxiety....hyperventilation fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication
pneumothorax and chest tube insertion
Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.
laryngeal cancer
Persistent hoarseness (longer than 2 weeks) is usually the earliest symptom of.....
Spironalactone (Aldactone)
Potassium sparing diuretic. Aldosterone antagonist. Loss of Na + H20. used for hypertension, edema, ascities with hepatic disease. Treat primary hyperaldosteronism. ADVERSE effects: Gynecomastia, impotence, menstrual irregularity, Teach NO K+ supplements or salt substitutes.
Which of the following are true statements about effective radiation therapy?
Slower-growing tissues at rest (muscle) are more radioresistant. Tumors that are well oxygenated are more sensitive to radiation. Tumors that are small in size and dividing rapidly are more sensitive
Pneumococcal pneumonia
Sputum that is rust colored suggests infection with
iron
The client should increase daily dietary consumption of .......when taking epoetin alfa for chronic renal disease?
Priority after Thyroidectomy
The greatest risk to the client following a thyroidectomy is hypocalcemia leading to tetany, which is indicated by tingling around the mouth. Therefore, this is the priority finding and should be reported to the provider.
lungs and kidneys
The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?
Ease the client to the floor. Maintain a patent airway. Obtain vital signs. Record the seizure activity observed.
The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.
activity limitations post mastectomy
The nurse should instruct the client to avoid raising the elbow above the shoulder until drains are removed. This will prevent injury and discomfort to the client.
Thoracentesis position
The nurse should instruct the client to lean forward on pillows and across an overbed table to widen the intercostal spaces and make it easier to access and drain the pleural fluid.
Avoid tobacco smoke. Reduce indoor humidity to less than 50%.
What should the nurse include in the teaching plan for a pediatric client and family to help control the child's exposure to allergens?
Give the medication undiluted in incremental doses. Be alert for shivering and hypotension. Use only a free-flowing IV line in a large vein. Monitor the client's level of consciousness.
When administering flumazenil intravenously for reversal of sedation, what should the nurse do?
Inform the anesthesiologist. (monitors client's physical status and must must have knowledge of all known allergies for client safety)
When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?
turn onto the affected side
Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall?
elbow restraints
Which type of restraint is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair?
myasthenia gravis
a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles
total laryngectomy
a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.
partial laryngectomy
a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing.
ascites
accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia
increases
acidosis is a factor that .......... urine osmolality
Vancomycin (Vancocin)
an antibiotic, is irritating to tissues and can cause damage if allowed to infiltrate. The nurse should evaluate the patency of the current IV, and if it is infiltrated, secure a new site prior to hanging the next dose.
interferon agents in conjunction w/ chemotherapy
are a type of biologic response modifiers (BRMs) used in conjunction with chemotherapy to reduce the risk of infection by shortening the period of neutropenia through bone marrow stimulation. The suppression of bone marrow creates the need for interferon use, not a result of the use.
crackles
are adventitious breath sounds that are high-pitched, discontinuous, and popping; they may or may not clear with coughing and are moist. Often associated w/ heart failure
Angiotensin II
causes peripheral vasoconstriction and stimulates the production of aldosterone. Both ........and aldosterone raise blood pressure.
aplastic anemia
characterized by an absence of all formed blood elements caused by the failure of blood cell production in the bone marrow
Acute Respiratory Failure
defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
Kawasaki's
disease is an autoimmune disease in which blood vessels become inflamed.
Nifedipine
drug that stops uterine contractions that occur in preterm labor by relaxing the smooth muscle of the uterus.
sub q
epoetin alfa is administered....?
lungs and kidneys
facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.
flail chest
fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected?
nephron
functional unit of the kidney that forms urine
Tumors are classified by
grade 1 to grade 4 by the degree of malignancy (how they grow), and cell type
5% NaCl
hypertonic solution
Oral intake is controlled by the thirst center, located in which of the following cerebral areas?
hypothalamus
0.45% NaCl
hypotonic solution
hypervolemia
increased blood volume (excess of isotonic fluid (water and sodium) in ECF Caused by: too much fluid consumption, impaired output, too much sodium retained -kidney failure -cirrhosis -heart failure -steroid therapy
activity intolerance
is a common problem for clients with aplastic anemia due to decreased hemoglobin. Alternating activity with periods of rest and assisting the client with activities of daily living are appropriate nursing interventions.
pneumothorax
is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds.
Clopidogrel Bisulfate (Plavix)
is an antithrombotic and antiplatelet aggregate used to lessen the chance of a heart attack or stroke. Bleeding precautions are implemented to limit client exposure to injury-causing events that may lead to internal or external bleeding.
ringworm
is caused by a fungal infection on the skin, standard hand hygiene
cardiac tamponade
is compression of the heart resulting from fluid or blood within the pericardial sac.
alcoholism
is currently the most common cause of symptomatic hypomagnesemia.
pulmonary contusion
is damage to the lung tissues resulting in hemorrhage and localized edema.
first assistant
is involved with the client's preoperative care
circulating nurse
is not sterile and obtains and opens sterile equipment, adjusts lights, and keeps records
amniocentesis
is the best means for determining fetal lung maturity. The lecithin/sphingomyelin ratio (L/S) helps measure the amount of lung enzyme surfactant. A ratio of 2:1 or greater means the lungs are mature enough to withstand extrauterine life.
bronchoscopy
is the direct inspection and examination of the larynx, trachea, and bronchi for diagnosis of infectious, inflammatory, and malignant disease of the chest through a flexible or rigid fiberoptic bronchoscope
venturi mask
is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means. It is used primarily for patients with COPD because it can accurately provide appropriate levels of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive.
Lactated Ringer solution and normal saline (0.9% NaCl)
isotonic solution
sodium and chloride
major electrolytes in the ECF, along with calcium and bicarbonate
potassium, phosphate, magnesium
major electrolytes of ICF
extreme anxiety
may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss.
normal range is 3,000 to 5,000 cells/mm3 [3 to 5 X 109/L]
normal absolute neutrophil count
200 to 800 mOsm/kg
normal urine osmality
simple pneumothorax
occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula.
albumin
protein in blood; maintains the proper amount of water in the blood -"water magnet" (attracts -When fluid filters through a capillary this protein remains behind in the diminishing volume of water -as the concentration of the protein increases, fluid begins to move back into the capillaries
PQRST
provocative/palliative, quality, region/radiation, severity, timing
dehydration
results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes;
scrub nurse
s sterile and assists the surgical team by handing instruments to the surgeon, preparing sutures, receiving specimens to be sent to the lab, and counting sponges and needles.
myasthenia gravis and opioid overdose
suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.
nitroglycerin
taking up to three doses, 5 min apart if chest pain persists.
DKA
the deep, rapid respirations occurring in this disorder (Kussmaul's respirations)
In relation to the structure of the larynx, the cricoid cartilage is
the only complete cartilaginous ring in the larynx.
renin
to help maintain a balance of sodium and water, as well as to maintain a healthy blood volume and blood pressure, special cells (juxtaglomerular cells) near each glomerulus secrete and enzyme called......
Absolute Neutrophil Count (ANC)
total number of WBC's x percentage of neutrophils
bronchitis
yields a small amount of purulent sputum.
