fundamentals Exam 4

normal acid-base balance

(pH) 7.35 to 7.45 (PaCO2) 35 to 45 mm Hg (HCO3−) 21 to 28 mEq/L (PaO2) 80 to 100 mm Hg (O2 saturation) 95% to 100%

Application: Thigh-High Hose

1. Follow procedure steps 1 through 4 in the "Application: Knee-High Hose" section. 2. Have the patient bend the knee. Unroll each stocking over the knee, and have the patient straighten the knee. Smooth wrinkles.Bending the knee allows easy application of the hose and prevents possible trauma to the skin during application. Wrinkles and bunching of the hose can cause trauma to the skin and constrict blood flow, preventing venous return. 3. Unroll the remainder of each stocking on the upper leg, smoothing wrinkles.Wrinkles and bunching of the hose can cause trauma to the skin and constrict blood flow, preventing venous return. 4. Ensure that the top of each stocking is 1 to 3 inches below the buttock.Hose that fit correctly do not apply excessive pressure to the area or interfere with circulation.

Fitting and Application: Thigh-High Sequential Compression Device Sleeves

1. Measure around the thigh at the gluteal fold below the buttocks.This measurement is required for manufacturers' sizing charts. Accurate measurements ensure the correct fit, avoiding patient harm that can occur from estimating sizes. 2. Measure from the heel to the gluteal fold below the buttocks.This measurement is required for manufacturers' sizing charts. Accurate measurements ensure the correct fit, avoiding patient harm that can occur from estimating sizes. 3. Measure around the widest part of the calf.This measurement is required for manufacturers' sizing charts. Accurate measurements ensure the correct fit, avoiding patient harm that can occur from estimating sizes. 4. Compare the measurements to the manufacturer's sizing charts. If a patient's measurements fall between two sizes on the charts, take both sizes of sleeves, and put them on the patient to see which has the better fit.The correct fit ensures positive patient outcomes. If a sleeve is too small, it will constrict blood flow; if it is too large, it can cause skin irritation and will not promote venous blood return. 5. Place the device on the foot of the bed.The manufacturer's design prevents possible provider and patient injury. 6. Place the sleeve of the SCD under the patient's leg with the leg resting in the center of the sleeve.Proper positioning of the SCD sleeve allows proper fit and application, which decreases the risk of constricting the blood flow or diminishing optimal outcomes. 7. Wrap the sleeve around the leg, and fasten it with Velcro straps. Verify that two fingers fit between the leg and the sleeve when the sleeve is not inflated.The proper fit is necessary when the sleeve is inflated to maximize optimal outcomes and decrease the risk of constricting blood flow. 8. Repeat on the other leg if ordered. If a sleeve has been ordered for only one leg, leave the other sleeve in the package.The proper fit is necessary when the sleeve is inflated to maximize optimal outcomes and decrease the risk of constricting blood flow. 9. Verify that the knee is seen through the opening in the sleeve.Proper application and fit of the sleeve are needed to decrease the risk of constricting blood flow or diminishing optimal outcomes. 10. Connect the sleeve tubing for both sleeves to the device. Verify that there are no kinks in the tubing and that the arrows on the tubing align with the arrows on the machine.Proper connections are needed for the device to function correctly. 11. Turn on the device. Set the cooling control to on, and set the alarm to on. Ensure that the ankle pressure is 35 to 55 mm Hg.The cooling control feature ensures patient comfort and decreases skin irritation and breakdown caused by excess perspiration. The alarm provides safety notification in the event of malfunction. 12. Ensure that sequential inflation is occurring and that the machine is functioning properly.Proper function of the device optimizes patient outcomes.

Fitting: Thigh-High Hose

1. Measure from the heel to the gluteal fold below the buttocks.This measurement is required for manufacturers' sizing charts. Accurate measurements ensure the correct fit, avoiding patient harm that can occur from estimating sizes. 2. Measure around the widest part of the calf.This measurement is required for manufacturers' sizing charts. Accurate measurements ensure the correct fit, avoiding patient harm that can occur from estimating sizes. 3. Measure around the widest part of the thigh.This measurement is required for manufacturers' sizing charts. Accurate measurements ensure the correct fit, avoiding patient harm that can occur from estimating sizes. 4. Compare these measurements with the manufacturer's sizing charts. If a patient's measurements fall between two sizes on the charts, take both sizes of hose and try them on the patient to see which has the better fit.It is essential to have the correct fit to ensure positive patient outcomes. If a stocking is too small, it will constrict blood flow; if it is too large, it can cause skin irritation and will not promote venous return of blood. 5. Proceed to the "Application: Thigh-High Hose" section.

Fitting and Application: Knee-High Sequential Compression Device Sleeves

1. Raise the bed to working height.Setting the bed at the correct working height for the provider prevents provider discomfort and possible injury. 2. Measure from the heel to the popliteal space (behind the knee).This measurement is required for manufacturers' sizing charts. Accurate measurements ensure the correct fit, avoiding patient harm that can occur from estimating sizes. 3. Measure around the widest part of the calf.This measurement is required for manufacturers' sizing charts. Accurate measurements ensure the correct fit, avoiding patient harm that can occur from estimating sizes. 4. Compare these measurements with the manufacturer's sizing charts.It is essential to have the correct fit to ensure positive patient outcomes. 5. Place the device on the foot of the bed.The manufacturer's design prevents possible provider and patient injury. 6. Place the sleeve of the SCD under the patient's leg with the leg resting in the center of the sleeve.Proper positioning of the SCD sleeve allows proper fit and application, which decreases the risk of constricting the blood flow or diminishing optimal outcomes. 7. Wrap the sleeve around the leg, and fasten it with Velcro straps. Verify that two fingers fit between the leg and the sleeve when the sleeve is not inflated.The proper fit is necessary when the sleeve is inflated to maximize optimal outcomes and decrease the risk of constricting blood flow. 8. Repeat on the other leg if ordered. If a sleeve has been ordered for only one leg, leave the other sleeve in the package.The proper fit is necessary when the sleeve is inflated to maximize optimal outcomes and decrease the risk of constricting blood flow. 9. Connect the sleeve tubing for both sleeves to the device. Verify that there are no kinks in the tubing and that the arrows on the tubing align with the arrows on the machine.Proper connections are needed for the device to function correctly. 10. Turn on the device. Set the cooling control to on, and set the alarm to on. Ensure that the ankle pressure is 35 to 55 mm Hg.The cooling control feature ensures patient comfort and decreases skin irritation and breakdown caused by excess perspiration. The alarm provides safety notification in the event of malfunction. 11. Ensure that sequential inflation is occurring and that the machine is functioning properly.Proper function of the device optimizes patient outcomes.

Application: Knee-High Hose

1. Raise the bed to working height.Setting the bed at the correct working height for the provider prevents provider discomfort and possible injury. 2. Roll the hose inside out around hands; the leg of the hose will be inside out, covering the foot of the hose.Rolling the hose in this way allows easy application and prevents possible trauma to the skin during application. 3. Have the patient point the toes; put each stocking over the toes and heel, and smooth wrinkles away from the foot.Pointing the toes allows easy application of the hose; wrinkles and bunching of the hose can cause trauma to the skin and constrict blood flow, preventing venous return. 4. Unroll the remainder of each stocking over the lower leg, smoothing wrinkles as the hose are unrolled.Wrinkles and bunching of the hose can cause trauma to the skin and constrict blood flow, preventing venous return. 5. Ensure that the top of each stocking is 1 to 2 inches below the knee.Hose that fit correctly do not apply excessive pressure to the area or interfere with circulation.

Sitting Down on a Chair While Using Crutches

1. The patient backs up to a chair that has armrests and stands in the tripod position.The tripod position is relatively stable, and it ensures the patient's safety before moving and reduces the risk for falls. 2. The patient makes sure that the stronger leg is against the back of the secure chair or locked wheelchair, balances, and then moves the crutches to the affected side, holding on to the hand bars.This position ensures patient safety while the patient is preparing to sit and reduces the risk for falls. 3. The patient reaches for the armrest of the chair with the arm on his or her stronger side and sits down.Using the stronger arm ensures safety and reduces the risk for falls. 4. Th patient lowers his or her body to the chair while holding onto the crutches on the weaker side and armrest on the stronger side.Holding onto the arm rest and crutches provide a wide base of support.

Procedure Rising From a Chair by Using Crutches

1. The patient moves to the front edge of the chair. Check that the chair is secure. If it is a wheelchair, make sure that the wheels are locked. By starting close to the edge of the chair, the patient eases the burden of lifting the body out of the chair. 2. The patient's strongest leg should be close to the chair. The patient's hand on the weak side holds the hand bar of the crutches, and the hand on the patient's strong side holds onto the armrest of the chair. This position provides the strongest base of support to facilitate lifting the body and standing. 3. The patient pushes up and off the chair and then balances. Taking the time to balance properly ensures patient safety before moving and reduces the risk for falls. 4. The patient moves the crutches to a tripod position (i.e., starting point for a gait). Crutches are held 6 inches in front of the patient and 6 inches to the side of each foot. The stable tripod position ensures the patient's safety before moving and reduces the risk for falls. 5. Proceed to the "Two-Point Gait," "Three-Point Gait," "Four-Point Gait," "Swing-To Gait," or "Sitting onto a Chair" section.

Three-Point Gait

1. The patient starts in the tripod position with the crutch tips on the floor approximately 6 inches in front of and 6 inches to the side of the patient's feet. The tripod position is relatively stable, and it ensures the patient's safety before moving and reduces the risk for falls. 2. The patient moves both crutches and the weak foot forward at the same time. Alternately, if the patient is non-weight bearing on one side, the leg can be held off the ground. This technique provides a wide base of support for the weaker foot. 3. The patient moves the strong foot forward. The crutches and weaker foot support the patient's weight, while the stronger foot moves forward. 4. Repeat procedure steps 2 and 3. 5. The patient ends in the tripod position. The tripod position is relatively stable, and it ensures the patient's safety before moving and reduces the risk for falls.

Two-point gait

1. The patient starts in the tripod position with the crutch tips on the floor approximately 6 inches in front of and 6 inches to the side of the patient's feet. The tripod position is relatively stable, and it ensures the patient's safety before moving and reduces the risk for falls. 2. The patient moves the right crutch and left foot forward at the same time. This pattern mimics walking and provides a wide base of support. 3. The patient moves the left crutch and right foot forward at the same time. This pattern mimics walking and provides a wide base of support. 4. Repeat procedure steps 2 and 3 to mimic walking. 5. The patient ends in the tripod position. The tripod position is relatively stable, and it ensures the patient's safety before moving and reduces the risk for falls.

Swing-To Gait

1. The patient starts in the tripod position with the crutch tips on the floor approximately 6 inches in front of and 6 inches to the side of the patient's feet.The tripod position is relatively stable, and it ensures the patient's safety before moving and reduces the risk for falls. 2. The patient moves both crutches forward at the same time.One leg (in the case of a patient who is non-weight bearing on one side) or both legs (in the case of a paraplegic) support the body weight while the crutches move forward. 3. The patient lifts the body and swings both legs to the crutches.The crutches support the body weight while the legs swing forward to the crutches. 4. Repeat procedure steps 2 and 3. 5. The patient ends in the tripod position.The tripod position is relatively stable, and it ensures the patient's safety before moving and reduces the risk for falls.

Four-Point Gait

1. The patient starts in the tripod position with the crutch tips on the floor approximately 6 inches in front of and 6 inches to the side of the patient's feet.The tripod position is relatively stable, and it ensures the patient's safety before moving and reduces the risk for falls. 2. The patient moves the right crutch forward.In this pattern there are three points of support on the ground at all times. 3. The patient moves the left foot forward. 4. The patient moves the left crutch forward. 5. The patient moves the right foot forward. 6. Repeat procedure steps 3 through 5. 7. The patient ends in the tripod position.The tripod position is relatively stable, and it ensures the patient's safety before moving and reduces the risk for falls.

extra stuff on Acid/Base

Acid-Base Imbalances: What Are the Causes? Identify which acid-base imbalances go with the appropriate disorder. •Hyperventilation •Diuretic Therapy •Atelectasis •Acetylsalicylic Acid (aspirin) Poisoning •Massive Transfusion of Whole Blood •Severe Diarrhea •Pain •Excessive vomiting •Brain Injury •Gastrointestinal Suctioning •Renal Failure Acid-Base Imbalances: What Are the Causes? Identify which acid-base imbalances go with the appropriate disorder. •Hyperventilation-Respiratory Alkalosis •Diuretic Therapy- Metabolic Alkalosis •Atelectasis- Respiratory Acidosis •Acetylsalicylic Acid Poisoning- Respiratory Alkalosis (1st) & Metabolic Acidosis (2nd) •Massive Transfusion of Whole Blood- Metabolic Alkalosis •Severe Diarrhea Metabolic Acidosis Acid-Base Imbalances: What Are the Causes? Identify which acid-base imbalances go with the appropriate disorder. •Pain- Respiratory Alkalosis •Excessive Vomiting- Metabolic Alkalosis •Brain Injury- Respiratory Acidosis •Gastrointestinal Suctioning- Metabolic Alkalosis •Renal Failure- Metabolic Acidosis Acid-Base Imbalances: What Are Your Nursing Interventions? •Develop a set of nursing interventions for each of the acid-base imbalances, respiratory acidosis, respiratory alkalosis, metabolic acidosis, metabolic alkalosis. •They should have at least 3 to 4 interventions for each imbalance. Respiratory Acidosis •Assess for signs of respiratory distress •Administer oxygen as prescribed •Place patient in semi-fowler's position •Encourage turning, coughing, and deep breathing •Suction prn •Respiratory therapy as prescribed; i.e. nebulizer •Avoid medications the depress the respiratory system; i.e. opioids, sedatives, tranquilizers •Respiratory Alkalosis •Assist with breathing techniques; i.e. breathing into brown paper bag; use of rebreathing mask; voluntary holding of breath •Monitor electrolyte values, particularly potassium and calcium •Keep calcium gluconate on hand for tetany, if prescribed Metabolic Acidosis/Non-Diabetic •Assess for signs of CNS depression •Monitor I&O, •Monitor serum electrolyte values particularly for hypokalemia, which can lead to cardiac pattern changes •Be prepared to administer IV buffering agents; i.e. Sodium Bicarbonate Diabetic Ketoacidosis: •Give Regular Insulin IV as prescribed •Monitor for signs of circulatory collapse (caused by polyuria in hyperglycemic state), including shock Metabolic Alkalosis •Monitor serum potassium and calcium levels •Prepare to administer medications that promote kidney excretion of bicarbonate •Prepare to administer potassium chloride IV (Rider, added to intravenous fluids - NEVER directly as an IV push/bolus) •Institute safety precautions

2. A nurse caring for a hospitalized patient with diarrhea and dehydration is told in the shift report that the patient's laboratory results have just come in. Which abnormal laboratory values should be reported to the primary care provider? (Select all that apply). a. Sodium (Na) level 150 mEq/L b. Potassium (K) level 3.3 mEq/L c. Calcium (Ca) level 9.5 mg/dL d. Magnesium (Mg) level 1.0 mEq/L e. Chloride (Cl) level 101 mEq/L

Answer: a. Sodium (Na) level 150 mEq/L b. Potassium (K) level 3.3 mEq/L d. Magnesium (Mg) level 1.0 mEq/L The sodium, potassium, and magnesium levels are all abnormal levels that often can be seen in dehydrated clients with prolonged diarrhea. Normal sodium levels for adults range from 135 to 145 mEq/L. Normal potassium levels for adults range from 3.5 to 5 mEq/L. Normal magnesium levels for adults range from 1.3 to 2.1 mEq/L. The calcium and chloride values are within normal limits.

5. A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan? a. Calcium should be taken with vitamin D to increase calcium absorption. b. African American women are more prone to developing osteoporosis than are Asian American women. c. Increased phosphorus metabolism may lead to bone fragility. d. Aerobic exercise is more advantageous than weight-bearing exercise in preventing osteoporosis.

Answer: A .Calcium should be taken with vitamin D to increase calcium absorption. Vitamin D is required for calcium metabolism. Asian American women are more prone to osteoporosis than African American women. Phosphorus deficiency may lead to malformation of bones. Weight-bearing exercise is more beneficial than aerobic exercise in the prevention of osteoporosis.

8. Which discovery found during an admission assessment of a patient transferred from a long-term care facility does the nurse recognize as the result of immobility? a. Bilateral elbow contractures b. Increased muscle tone c. Decreased cardiac workload d. Orthostatic hypertension

Answer: A Bilateral elbow contractures Joint contractures may begin within hours of immobility and cause irreparable damage to joint flexibility. Muscle tone decreases, and cardiac workload increases with immobility. Pooling of blood in the lower extremities and quickly changing position may cause a rapid drop, rather than increase, in blood pressure, known as orthostatic hypotension.

6. What nursing intervention would be most effective in preventing flaccidity in a hospitalized patient? a. Early ambulation after surgery b. Administering calcium with vitamin D c. Coughing and deep breathing exercises d. Referring the patient to occupational therapy

Answer: A Early ambulation after surgery Ambulation is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity. Calcium with vitamin D helps prevent osteoporosis. Coughing and deep breathing is important for the prevention of pneumonia associated with immobility, and occupational therapy is typically ordered to help patients regain their ability to complete activities of daily living (ADLs) independently.

2. After instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches? a. Adjusting the crutches so that they rest directly under the axilla b. Moving the opposing crutch and leg together for a two-point crutch walk c. Using a four-point crutch walk when not weight bearing on the left leg d. Placing the crutches 28 inches forward and then swinging both legs forward

Answer: B .Moving the opposing crutch and leg together for a two-point crutch walk Moving the opposing crutch and leg together provides needed stability for patients who can bear partial weight on each foot. Crutches must rest at minimum of two to three finger widths below the axilla to prevent brachial nerve damage. The four-point crutch walk is used by only patients who can bear weight on both legs. Crutches should be advanced no more than 6 to 8 inches, and a three-point crutch walk is not a swing-through gait.

1. An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair. Which action indicates the best method to transfer this patient? a. A two-person lift is performed, with one person on each side of the patient. b. The patient is steadied under the arms and pivoted on his left leg. c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP). d. A stand assist lift is used with the help of another nurse.

Answer: C A full-body sling lift is used with the help of unlicensed assistive personnel (UAP) According to safe patient handling algorithms, a full-body sling with the assistance of the nurse and UAP is indicated because the patient is uncooperative and able to bear only partial weight. Lifting a patient manually has the potential to injure the patient and the care providers. The stand and pivot technique is not indicated because the patient is uncooperative. The stand assist lift is not indicated because the patient is uncooperative.

4. Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury? a. Medulla oblongata b. Articular disk c. Brainstem d. Cerebellum

Answer: D Cerebellum Injury to the cerebellum directly affects a patient's ability to ambulate and control movement. The medulla oblongata regulates heart rate, breathing, blood pressure, and reflexive actions such as vomiting. The articular disk is fibrous connective tissue in the temporomandibular joint, which facilitates jaw movement. The brainstem connects the spinal cord to the hemispheres of the brain.

9. Which activity is important to include in the plan of care for a client with a peripherally inserted central catheter (PICC)? a. Use sterile technique when changing the PICC dressing. b. Change the IV tubing every 72 hours. c. Take blood pressure in the arm with the PICC line. d. Use only macrodrip tubing with IV infusions through the PICC line.

Answer: a. Use sterile technique when changing the PICC dressing. Because a PICC enters the body through a peripheral vein and is threaded up to the superior vena cava, resting just outside the right atrium of the heart, strict sterile technique is used during insertion and care of PICCs to prevent entrance of bacteria into the line. PICC tubing is usually changed every 24 hours. Never take blood pressure in an arm with a PICC. Macrodrip or microdrip tubing can be used for infusions through a PICC.

10. After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation? a. Warmth of bilateral upper extremities b. Lower extremity circulatory status c. Circumoral cyanosis d. Bowel sounds

Answer: b The nurse must document the date and time of initiating SCD placement and the results of a skin, circulatory, and neurologic assessment of the lower extremities. SCDs do not affect the upper extremities, cardiac or respiratory status leading to circumoral cyanosis, or bowel sounds.

5. A nurse in the emergency department is caring for an adult patient with numerous draining wounds from gunshots. The patient's pulse rate has increased from 100 to 130 beats/min over the past hour, and the patient is experiencing orthostatic hypotension. For which imbalance should the nurse assess? a. Respiratory acidosis b. Extracellular fluid volume deficit c. Metabolic alkalosis d. Intracellular fluid volume excess

Answer: b. Extracellular fluid volume deficit The draining wounds indicate hypovolemia, or extracellular fluid volume deficit. As circulating blood volume decreases, the heart rate increases to maintain normal cardiac output, and the patient may experience orthostatic hypotension and lightheadedness with position changes. Respiratory acidosis and metabolic alkalosis do not have as a symptom a rapidly increasing pulse rate. Intracellular fluid volume excess causes pulmonary congestion and cerebral edema.

9. Which nursing diagnosis is a top priority for a patient who is one day status post hip replacement? a. Impaired Health Maintenance b. Activity Intolerance c. Impaired Mobility d. Self Care Deficit

Answer: c Joint replacement surgery leads to Impaired Mobility. A priority for this patient would be to regain mobility. Patients with Impaired Health Maintenance have difficulty managing their own health. A patient with Activity Intolerance might not have the energy to ambulate but would not be immobile. Self Care Deficit refers to patients who are unable to perform activities of daily living (ADLs) independently.

4. The nurse is caring for a patient with hypocalcemia who does not like milk. Which food should the nurse encourage the patient to consume? a. Cod b. Eggs c. Spinach d. Tomatoes

Answer: c. Spinach Dark leafy vegetables such as spinach, kale, turnip greens, broccoli, Brussels sprouts, and cabbage are sources high in calcium.

8. The nurse is assessing the intravenous (IV) site in the right forearm and notices the area about 1 inch around it is cool, swollen, firm, and tender to touch. Which action should the nurse take first? a. Take patient's temperature b. Apply an ice pack to site c. Stop infusion and remove IV catheter d. Call the primary care provider immediately

Answer: c. Stop infusion and remove IV catheter The area around an IV infiltration is cool, swollen, firm, and tender to touch. The first intervention to take for an infiltrated IV is to stop the infusion and discontinue the IV by removing the catheter. Applying cold compresses may be appropriate for hyperosmolar fluids, but only after the IV infusion has been stopped. Taking the temperature would be an assessment to make if the complication of infection is suspected. The primary care provider does not need to be notified unless grade 3 or 4 infiltrations are noted (>6 inches edema).

6. A 65-year-old female patient is a two-pack-a-day cigarette smoker with a history of chronic obstructive pulmonary disease (COPD). What is the interpretation of her arterial blood gas values (pH 7.34, PCO2 55, PO2 82, HCO3− 32)? a. Partially compensated respiratory alkalosis b. Uncompensated metabolic acidosis c. Uncompensated respiratory alkalosis d. Partially compensated respiratory acidosis

Answer: d. Partially compensated respiratory acidosis Patients with COPD tend to have chronic carbon dioxide retention. The patient is slightly acidotic (i.e., arterial pH below 7.35) with a higher than normal partial pressure of carbon dioxide (PCO2), which is inverse and therefore a respiratory issue. The compensatory response to respiratory acidosis is buffering, as indicated by the higher than normal bicarbonate (HCO3−) level. The increase in bicarbonate only partially shifts the pH toward normal, but partial compensation prevents the acid-base imbalance from becoming life-threatening. The kidneys will continue to compensate in an attempt to bring the pH into the normal range.

7. A patient with a continuous IV of D5 0.9% NS running at 150 mL/hr begins to exhibit hallucinations and confusion. Which laboratory value should the nurse expect to check? a. Calcium b. Carbon dioxide c. Magnesium d. Sodium

Answer: d. Sodium Hypernatremia can be caused by hypertonic IV solutions such as D5 0.9% NS. Symptoms of severe hypernatremia include confusion, irritability, decreased level of consciousness, hallucinations, and seizures.

1. A patient has reported a 2-kg (4.4-lb) weight gain over the past 3 days. Which dietary factor should the nurse assess? a. Protein intake b. Potassium intake c. Calorie intake d. Sodium intake

Answer: d. Sodium intake A weight gain of 2 kg in 3 days suggests fluid retention. Increased sodium intake leads to increased fluid retention. Although it is important to ask the patient about intake of all nutrients, the other options cannot cause this much weight gain in 3 days.

10. The nurse has just begun an infusion of packed red blood cells (PRBC). Which of the following changes would indicate a transfusion reaction and warrants stopping the infusion? a. Respirations increased from 16/min to 20/min. b. Urine output in Foley catheter bag has 50 mL/h output of dark yellow urine. c. Heart rate decreased from 77 beats/min to 62 beats/min. d. Temperature increased from 100° degrees to 102.2° F

Answer: d. Temperature increased from 100° degrees to 102.2° F An increased temperature of more than 2 degrees Fahrenheit indicates a febrile nonhemolytic reaction, and the infusion should be stopped. The primary care provider and blood bank should be notified. The urine output is an adequate hourly amount. The heart rate is normal. The respiratory rate is not a significant change

7. Identify all nursing interventions that are necessary when caring for a quadriplegic patient injured 2 years earlier in a motor vehicle accident. (Select all that apply.) a. Monitoring respiratory status and breathing difficulties b. Assisting with feeding and activities of daily living (ADLs) c. Developing a care plan with the patient's power of attorney d. Using mechanical lifts to assist with transferring the patient e. Placing a gait belt around the patient's waist before ambulation

Answers: a.Monitoring respiratory status and breathing difficulties b.Assisting with feeding and ADLs d.Using mechanical lifts to assist with transferring the patient Quadriplegia is the result of a high spinal cord injury that affects a patient's ability to breathe without mechanical assistance and severely limits the patient's ability to move all extremities. Most quadriplegics are confined to a wheelchair and unable to ambulate even with assistance. Mechanical lifts should be used to safely transfer this type of patient. Quadriplegic patients should be given the opportunity to direct their care and fully participate in setting care plan goals.

3. For a patient with a nursing diagnosis of Dehydration, the nurse is alert to which signs and symptoms? (Select all that apply). a. Hypertension b. Flushed skin c. Dry mucous membranes d. Weak, thready pulse e. Pale yellow urine

Answers: b. Flushed skin c. Dry mucous membranes d. Weak, thready pulse Depending on the severity of fluid volume deficit, the patient may have hypotension. The skin is flushed and dry, the mucous membranes are dry, and the pulse is weak and thready. Hypertension occurs with fluid volume overload. For patients with fluid volume deficit, the urine is dark yellow and concentrated.

3. What bony prominences are at greatest risk for skin breakdown on a patient who is restricted to bed rest and placed in the side-lying position? (Select all that apply.) a. Sternum b. Ears c. Elbows d. Hips e. Coccyx

Answers: b.Ears, c.Elbows, d.Hips The patient's ears, elbows, and hips are in contact with the bed surface in the side-lying position. Breakdown on the sternum would be a potential risk if the patient were in prone position. The coccyx experiences the most pressure when a patient is sitting or in the supine position.

hypermagnesemia

Below 1.3 mEq/L expected findings · increase nerve impulse transmission · hyperactive deep tendon reflexes · paresthesias · muscle Tetany (Cramp; Spasm) · positive Chvostek etrasseaus signs · Tetany · Seizures · insomnia · hypoactive bowel sounds · Constipation · abdominal distention · paralytic ileus · Dysrhythmias · tachycardia · hypertension · ECG waveform changes or PVC nursing care · discontinue magnesium - losing meds · magnesium replacement · encourage foods high in magnesium (grains, dark green vegetables)

Hypokalemia

Below 3.5 results of K loss from the body decreases intake and absorption of K or movement of K into cells expected findings · weak, irregular pulses, hypo tension, OH, respiratory distress · ascending bilateral muscle weakness with respiratory collapse and paralysis · muscle cramping, decreased muscle tone · hyperactive reflexes · paresthesias · mental confusion · premature ventricular contractions (PVC) · bradycardia, blocks, ventricular tachycardia · flattening or flat and or inverted T waves · increased V waves, and ST depression · Decreased motility · hypoactive bowel sounds · abdominal distention · Constipation · N & V · Anorexia · anxiety nursing care · replace K · encourage K rich foods (avocados, dried fruit, potatoes, spinach,) · Monitor /maintain adequate urine output · monitor for shallow, ineffective respirations · cardiac rhythm · monitor digoxin patients · monitor LOC · monitor bowel sounds and distention

isotonic (hypovolemia)

Causes · Hemorrhage · burns · vomiting · Addison's disease · fever · excessive perspiration lab findings · urine specific gravity > 1.030 · increase hematocrit · M > 52 · F > 48 · Bun > 20 Interventions · administer fluids · vital signs · I & O · labs

Mobility and immobility

Contracture permanent fixation of a joint - occurs in bedridden patients food drop one or more common contractures, results in permanent planter flexion dangling patient sits on the side of the bed before standing, is important to prevent injury to previously non ambulatory patients canes top of the cane should be level with hip joint and the patient's arm patients should hold the cane on stronger side and move pain forward first followed by weaker than stronger leg

hypoxemia

In situations of hypoxemia (decreased oxygen concentration in arterial blood), the PaO2 decreases: • PaO2 of 60 to 80 mm Hg: Mild hypoxemia • PaO2 of 40 to 60 mm Hg: Moderate hypoxemia • PaO2 less than 40 mm Hg: Severe hypoxemia

Mrs. G., who has CHF, has been having diarrhea for three days. You have noticed some LOC changes and she is breathing shallowly. The Dr. orders ABGs: pH 7.44 PaCO2 50 mm Hg HCO3 31 mEq/L What is the acid base disturbance? Is this Compensated or Uncompensated? What are some causes of this disorder?

Metabolic Alkalosis Causes: diarrhea and hypoventilation and diuretics and change in LOC

Mrs. D. is a 45 year old female admitted with a history of diabetes. She has a temperature of 101.8, P = 110, RR = 30, B/P = 90/70. Labs are drawn and reveal glucose of 780 mg/dl, positive ketones, and the following ABGs: pH 7.25 PaCO2 30 mm Hg HCO3 20 mEq/L What is the acid-base disturbance? Is this Compensated or Uncompensated? What are some causes of this disorder?

Metabolic acidosis d/t renal failure, ASA overdose, starvation , and ketoacidosis

Blood types and antigens

O+ RH O- none A+ A, RH A- A B+ B, RH B- B AB+ A,B,RH AB- A,B

Ms. P., a 22 year old female, is admitted with an acute onset of fever, chills, and RUQ pain. Her vital signs are: T = 99.6, P = 125, RR = 32, B/P = 140/84. Her ABG results are: pH 7.53 PaCO2 30 mm Hg HCO3 22 mEq/L What is the acid base disturbance? Is this Compensated or Uncompensated? What are some causes of this disorder?

Respiratory Alkolosis Pain, fever, hyperventilation

Mr. M is a 65-year-old male admitted with a decreased LOC. He has a history of chronic bronchitis and heart failure. His vital signs are: T = 102, HR= 104, RR = 28- shallow and B/P = 90/60. ABG results are as follows: pH 7.2 PaCO2 75 mm Hg HCO3 26 mEq/L What is the acid-base disturbance? Is this Compensated or Uncompensated?

Respiratory acidosis may be caused by Pneumonia, hypoventilation and pneumothorax.

Respiratory acidosis

UNDERLYING CAUSES Hypoventilation due to: Chest injury Asthma attack Pulmonary edema Brainstem injury Medications: Anesthetics, opioids, sedatives CLINICAL MANIFESTATIONS Headache Altered level of consciousness, irritability, confusion Dyspnea Tachycardia Muscle twitching Uncompensated ABG results: pH <7.35 PaCO2 >45 mm Hg HCO3− normal Partially compensated ABG results: pH <7.35 PaCO2 >45 mm Hg HCO3− >28 mEq/L As compensation continues, the pH increases. INTERVENTIONS Assess vital signs, especially rate and depth of respirations, pulse oximetry. Assess breath sounds. Assess cardiac rhythm. Administer oxygen as ordered. Monitor ABG results. Have mechanical ventilation available. Encourage deep breathing and coughing. Encourage fluid intake.

Respiratory alkalosis

UNDERLYING CAUSES Pain Hyperventilation Salicylate overdose Nicotine overdose Increased metabolic states CLINICAL MANIFESTATIONS (rapid, shallow breathing) Numbness, tingling of fingers Muscle cramping Palpitations Anxiety, restlessness ECG changes ABG results: pH >7.45 PaCO2 <35 mm Hg HCO3− normal Partially compensated ABG results: pH >7.45 PaCO2 <35 mm Hg HCO3− <21 mEq/L As compensation continues, the pH decreases. INTERVENTIONS Assess vital signs. Encourage patient who is tachypneic to take slow, deep breaths. Have patient breathe into a paper bag. Monitor ABGs. Provide reassurance and emotional support to anxious patient.

Metabolic acidosis

UNDERLYING CAUSES Shock Trauma Cardiac arrest Diabetic ketoacidosis Chronic renal failure Salicylate overdose Sepsis Chronic diarrhea CLINICAL MANIFESTATIONS Kussmaul respirations Hypotension Headache Decreased level of consciousness Weakness Nausea, vomiting, anorexia ABG results: pH <7.35 PaCO2 normal HCO3− <21 mEq/L Partially compensated ABG results: pH <7.35 PaCO2 <35 mm Hg HCO3− <21 mEq/L As compensation continues, the pH increases. INTERVENTIONS Assess vital signs, especially respiratory rate and rhythm, blood pressure, and pulse oximetry. Monitor cardiac rhythm. Monitor ABGs and serum electrolytes, glucose, and BUN or creatinine. Monitor level of consciousness. Have mechanical ventilation available as needed. Administer sodium bicarbonate as ordered.

Metabolic alkalosis

UNDERLYING CAUSES Vomiting Nasogastric suctioning Overuse of bicarbonate antacids Hypokalemia Loop and thiazide diuretics CLINICAL MANIFESTATIONS Hypotension Mental confusion Muscle twitching, tetany Increased deep tendon reflexes Numbness, tingling of fingers and toes Seizures Anorexia, nausea, vomiting Polyuria ABG results: pH >7.45 PaCO2 normal HCO3− >28 mEq/L Partially compensated ABG results: pH >7.45 PaCO2 >45 mm Hg HCO3− >28 mEq/L As compensation continues, the pH decreases. INTERVENTIONS Assess vital signs, especially cardiac rate and rhythm, respiration rate and depth, pulse oximetry, blood pressure. Monitor ABGs and serum electrolytes, especially potassium. Assess level of consciousness. Administer oxygen as ordered. Initiate seizure precautions. Treat hypokalemia if appropriate.

Hypercalcemia

above 10.5 mg/dL high calcium caused by: thiazide diuretics, long term glucocorticoids, paget's disease, hyperthyroidism, bone cancer expected findings · Decreased reflexes · bone pain · dysrhythmias (short and Qt & St intervals) · increase risk for a blood clot · anorexia · N&V · Constipation · weakness, lethargy · confusion, decreased level of consciousness · personality change · hypercalciuria nursing care · restrict calcium and increase fluid intake · monitor for pathological fractures

Hypernatremia

above 145 mEq/L causes a shift of water out of the cell expected findings · hyperthermia · tachycardia · OH · restlessness · fatigue · disorientation · muscle twitching · seizures · decreased LOC · reduce or absent tendon reflex · thirst · dry or sticky mucous membranes · dry and swollen tongue that is red · increased motility, hyperactive bowel sounds · abdominal cramping, nausea · edema, warm flustered skin, oliguria nursing care · monitor LOC · provide oral hygiene and other measures to decrease thirst · monitor I&O and alert provider of an adequate urine output · maintain prescribed diet (low sodium, no added salt ) · encourage fluids · if access sodium occurs administer diuretics(loop) if impaired kidney function is the cause · If fluid loss occurs administer hypotonic or isotonic (non sodium) IV fluids

NORMAL LEVELS FOR MAGNESIUM 1.3-2.1 mEg/L

above 2.1 mEg/L causes: kidney or adrenal impairment ;increase intake of medications containing magnesium (laxatives, anti acids) expected findings · diminished deep tendon reflexes · muscle paralysis · shallow respirations · decrease respiratory rate · bradycardia · hypo tension · cardiac arrest · dysrhythmias · ECG changes (prolonged PR interval) · lethargy nursing care · vital signs · LOC · reflexes (notify PCP for absence or changes) · administer loop diuretics and magnesium free IV fluids if kidney function is adequate · admit calcium gluconate for severe cardiac changes

Hyperkalemia

above 5.5 results of an increased intake of K and movement of K out of cells or inadequate extraction expected findings · slow, irregular pulse, hypo tension · irritability, confusion, weakness with ascending flaccid paralysis, paresthesia · Increased motility, diarrhea, abdominal pain, hyperactive bowel sounds nursing care · ECG monitoring · decrease K intake · stop K infusion · withhold oral K · provide K restricted diet

Fluid volume deficit

access loss or inadequate intake of fluid two types : isotonic and hypertonic isotonic (hypo hypovolemia) · Occurs when water and sodium are lost at the same rate · circulating volume decreases but serum osmolarity remains unchanged hypertonic or dehydration circulating fluid decreases in serum osmolarity increases · a 2% loss is mild · 5% loss is moderate · 8% loss is severe · 15% loss is life threatening (fatal )

Blood transfusions (1 unit of blood is 240mL)

always check · doctor's orders · purpose of transfusion -> why are they receiving blood -> explain procedure and how frequently and strict protocol -> use therapeutic communications · lab -> what labs 1. hemolytic reactions : destruction of RBC's Iv site · 20G or less (18 -24G ) · when you use smaller you may need to slow the transfusion · must be completed within 4 hours · no meds with blood transfusions · only Saline supplies · primary and secondary tubing · one liter normal Saline (0.9 sodium chloride ) · one prefilled syringe - NS to flush before transfusion · check patency and see of Iv line · pump · alcohol wipes Administer at a rate of two ML /min for the 1st 15 minutes. monitor patient for the 1st 15 minutes for · flushing · fever · dyspnea · hypo tension · itching · pam · chills 2. if reaction occurs stop transfusion immediately 3. change all tubing in set 4. hang new Iv solution 5. notify PCR 6. send blood product and tubing to lab or blood bank

neurologic

assessment of hydration · Chvostek sign (spasm of the facial muscle ) · Trousseau (spasm of muscle and wrist ) · DTR · tremas · confusion, agitation, coma

Hyponatremia

below 136 mEq/L results from access of water in the plasma or loss of sodium rich foods expected findings · increase ECF volume · vital signs- hyperthermia, tachycardia, rapid thready pulse, hypo tension, OH · headache, confusion, lethargy, muscle weakness, fatigue · decreased deep tendon reflex · seizures · coma · increase motility · hyperactive bowel sounds · abdominal cramping · anorexia · N & V nursing care · Monitor I&O at the same time daily using same scale · vital signs · LOC · change position slowly · follow prescribed fluid restrictions · monitor muscle weakness · encourage food high in sodium (for example cheese, milk, condiments) severe administer hypertonic oral and IV fluids as prescribed.

Hypocalcemia

below 9 mg/dL low calcium expected findings · numbness and tingling · frequent /painful muscle spasms · hyperactive deep tendon reflexes · positive Chvostek's sign (tapping on the facial nerve causing facial twitch) · positive Trousseau's sign (hand/ finger spasm) · larygospasms · Weak, thready pulse · tachycardia or bradycardia · dysrhythmias · prologue QT interval and ST segments · hyperactive bowel sounds · diarrhea · abdominal cramping · seizures nursing care · oral or IV calcium supplements and vitamin D · initiate seizures and fall precautions · keep emergency equipment on standby. · encourage foods high in calcium, including dairy products and dark green vegetables

Isotonic fluid excess

causes · HF · renal failure · cirrhosis lab · urine in specific gravity < 1.005 · decrease hematocrit · M< 42 · F< 37 · Bun< 7 interventions · vitals · I& O · edema and jvd · lung sounds · labs

hypertonic (dehydration)

causes · diabetes insipidus · diabetic keto acid · administration of osmotic diuretics · hypertonic eternal feeding tubes · hypertonic IV fluids · prolonged vomiting and diarrhea labs · urine in specific gravity > 1.030 · increase hematocrit · M > 52 · F > 48 · Bun > 20 · sodium > 145 interventions · fluids · vitals · I & O · neurologic changes · labs

hypotonic fluid excess

causes · excessive water intake · prologue use of hypotonic IV solutions · SIA DH lab · urine specific gravity < 1.005 · decrease hematocrit · M< 42 · F< 37 · Bun< 7 · sodium < 135 interventions · vitals · I&O · neurologic changes · labs

Common IV solutions

hypotonic 0.33% NS · provide sodium, chloride, and free water · Allows the kidneys to select amount of electrolytes to retain or excrete 0.45% NS · fluid replacement for clients who do not need extra glucose · used for establishing renal function · may cause cardiovascular collapse or increased ICP isotonic D5W · becomes free water after dextrose is metabolized · does not contain sodium (can lead to hypernatremia ) · useful in Iv medication administration · can cause hyperglycemia 0.9% NS · Used to re establish normal ECF levels in patients with hypovalemia · helps with NACL replacement but continued use can lead to hypernatremia / hyperchloremia · Do not use in HF, edema , or hypernatremia patients D5 0.2% NS · Maintenance of fluids when less sodium is required · dextrose provides 170 calories /L lactated ringer · resembles blood plasma · contains an A comma K, CA, CL, lactate · used when there is a loss of fluid and electrolytes, as in burns, severe diarrhea, or during surgery · do not use in patients with renal or liver disease hypertonic D5 0.45% NS · Treats hypovolemia and maintains normal fluid balance, especially post op D5 0>9% NS · fluid replacement · provides calories, sodium, chloride · prolonged use can lead to hypernatremia · do not use in cardiac or renal failure · monitor for fluid overload D5 LR · Same as lactated ringer solution but adds calories with dextrose · useful when patience caloric intake is reduced · monitor for fluid overload 3% NS · treat severe hyponatremia · administer in the ICU where patient can be monitored

Fluid volume access

when intake exceeds output is isotonic or hypotonic · 2% again is mild · 5% is moderate · 8% is severe Edema- abnormal circulation of fluid in the interstitial spaces (3rd spacing ) four causes · increase hydrostatic pressure due to fluid overload · decrease production of circulating plasma proteins · obstruction of lymphatic drainage · increased capillary probability due to tissue damage

cardio

· JVD · ECG · pulses · blood pressure

respiratory

· abnormal lung sounds · diminished lung sounds · respiratory rate

foods with sodium

· breads, cereal · chips · cheese, processed meats aka lunch meats · hotdogs, bacon, ham · commercially canned foods table salt

foods with magnesium

· cashews · halibut · Swiss vhard · leafy greens (vegetables) · tofu · wheat germ · dried fruit

foods with calcium

· cheese, ice cream, milk, yogurt, spinach, tofu

foods with potassium

· fish (not shellfish) · whole grains · nuts · broccoli, cabbage, cucumbers · potatoes with skin · spinach · avocados · bananas, apricots, cantaloupe · nectarines, oranges, Tangerines · tomatoes

musculoskeletal

· muscle strength

Administration of IV fluids

· right patient · right solution · right route · right time · right documentation · right reason · right response only LPN 5 can do IV therapy

elimination

· stool characteristics (Constipation or diarrhea ) · N&V · urine output