Exam 1 Med Surg 2

Normal O2

80-100 mmHg

D) Evaluating the client's motor status

A client is admitted to the hospital with weakness in the right extremities and a slight difficulty with speech. Vital signs are within expected limits. What is the priority nursing action during the first 24 hours? A) Taking the client's temperature B) Monitoring the client's blood pressure for hypertension C) Obtaining the client's urine for a urinalysis D) Evaluating the client's motor status

B) Ignores the food on the left side of the tray when eating

A client who had a cerebrovascular accident (CVA, "brain attack") is starting to eat lunch. Which client behavior indicates to the nurse that the client may be experiencing left hemianopsia? A) Reports not being able to use the right arm to help eat meals B) Ignores the food on the left side of the tray when eating C) Asks to have food moved to the left side of the tray D) Drops the coffee cup when trying to use the right hand

A) Prevention of chronic fatigue

A client with chronic kidney disease is receiving medication to manage anemia. Which primary goal should the nurse include in the care plan from this information? A) Prevention of chronic fatigue B) Prevention of tubular necrosis C) Prevention of uremic frost D) Prevention of dependent edema

C) An obese client with leg trauma

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? A) A pregnant client with acute asthma B) A client with pneumonia who is immunocompromised C) An obese client with leg trauma D) A client with diabetes who has cholecystitis

C) Atrial fibrillation

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus? A) Respiratory infection B) Forearm laceration C) Atrial fibrillation D) Migraine headache

True

A patient has a gun shot wound to the right chest/ lung and there is fluid in the pleural space according to the X-ray. This could best be described as a Hemothorax. True or False

A) Elevate the head of the bed at least 30 degrees

A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, how should the nurse position the patient? A) Elevate the head of the bed at least 30 degrees B) On the right side C) Elevate the foot of the bed at least 30 degrees D) On the left side

False

A tension pnemothorax occurs when air enters the pleural space but can escape through a hole. True or False

flail chest manifestations

-*paradoxical breathing* -decreased CO -hypotension -inadequate tissue perfusion -hypoxemia -respiratory acidosis

rib fractures

-1-3 are life threatening and carry a high mortality rate -5-9 are the most common fractures -can be an underlying pulmonary or cardiovascular injury

Rule of Nines (adult)

-9% per arm --4 1/2 on front and 4 1/2 on back -9% for head --4 1/2 on front and 4 1/2 on back -18% each leg --9 on front and 9 on back -18% anterior trunk -18% posterior trunk -1 % genitals

Airway and Alveoli Abnormalities

-COPD -asthma -cystic fibrosis --adds additional workload and results in lung and thoracic muscle fatigue

Recovery phase of AKI

-GFR increases -BUN & creatinine decreases -may take up to 12 months -kidney function is restored

diuretic phase of AKI

-OU 1-3 L a day --can be up to 5 or more -hyponatremia -hypokalemia -dehydration -kidneys are no longer filtering

Oliguric phase of AKI often gets missed

-OU less than 400 ml a day -1-7 days after injury --lasts about 10-14 days -neck vein distention -bounding pulse -edema -HTN

signs of kidney rejection

-Oliguria -Edema -*Fever* -Increased BP -*Weight gain* -*Swelling and tenderness over the area*

Wearable Artificial Kidney (WAK)

-Recently developed and approved for use -Miniaturized dialysis machine -Carrier resembles a tool belt -Connects to patient via catheter -Designed to filter blood in ESRD -Can run continuously (no plug in or water hose)

hypoxemic RF causes

-V/Q mismatch -shunt -diffusion limitation -alveolar hypoventalation

Respiratory failure changes in breathing

-a change from rapid to slow breathing is a sign of transition from distress to failure

hypercapnic RF causes

-airway and alveoli abnormalities -CNS abnormalities -chest wall abnormalities -neuromuscular conditions

drug therapy for CKD

-antihypertensive drugs -diuretics -CCBs -ACE Inhibitors -ARBS -weight loss -sodium and fluid restriction

grafts

-artificial skin grafts are used first -then pts skin (try to get it from the thigh) -then a cadaver

BE FAST in stroke

-balance -eyes -face -arms -speech -time

CNS abnormalities

-drug OD -brainstem/spinal cord injuries

Rib fracture manifestations

-dyspnea -*point tenderness* -chest wall pain -crepitus -ecchymosis

goals of care for AKI

-eliminate cause -manage S&S -monitor for hyperkalemia -increase calories --fats & carbs --limit protiens -restrict sodium

phases of burn managment

-emergent (resuscitative) -acute (wound healing) -rehabilitative (restorative)

neuromuscular coniditons

-exposure to toxins -muscular dystrophy -MS -Gullian Barre syndrome (immune system attacks itself)

chest wall abnormalities

-flail chest -fractures -kyphoscoliosis -obesity -spasms -mechanical restrictions

care for kidney transplant

-fluid and electrolyte balance -immunosuppression therapy -watch for rejection

concerns with burns

-fluid loss -edema -decreased blood flow after airway; these should be assessed and treated immediately

V/Q mismatch causes

-increased secretions -bronchospasms -atelectasis -pain -pulmonary embolus

phases of ARDS

-injury/exudative phase --edema, shunting, atelactisis --increased WOB & RR, decreased tidal volume & CO2 -reparitive phase --hypoxemia worsens --widespread fibrosis --if stopped here; reversiable -fibrotic or chronic/late phase --lung tissue is completely remodeled --decreased lung compliance and area for gas exchange --pulmonary HTN

ARDS management

-mechanical ventilation --higher levels of PEEP -respiratory therapy --O2 --positioning strategies -fluid balance maintainence

CKD: goals of tx

-preserve existing kidney function -decrease CV disease -prevent complications -provide comfort

emergent burn phase

-resolve immediate life threatening problems --usually lasts 48 hrs from time of burn -watch for hypovolemic shock and edema -airway management, fluid therapy, and wound care --analgesics

Respiratory failure treatment

-respiratory therapy (O2) -mobilization of secretions --hydration and positioning --suctioning, coughing -Positive Pressure Ventilation (PPV) --BiPAP --cPAP -drugs --bronchodialators -corticosteriods -benzos/opiods

Goals of care for burn pts

-secure airway -support circulation by fluid replacement -comfort/analgesics -infection prevention -temp regulation -emotional support

causes of ARDS

-sepsis (most common) -injury to the lun

manifestations of chest trauma

-tachypnea & tachycardia -respiratory distress -increased accessory muscle usage -central cyanosis (on the truck) -absent or decreased breath sounds on affected side -dyspnea -chest pain -hypotension

CKD manifestations

-uremia -decreased kidney function -nausea/vomiting -polyuira --kidneys can't filter anymore -altered carb metabolsim

unconscious burn patient

-usually a result of hypoxia --same as AMS

Flail chest management

-ventilatory support -pain management -fluid replacement --monitor for hypovolemia -serial CXR, ABG, CBC, CMP and pulse ox --monitor for hypoxemia and cardiac failure

5 stages of CKD

1) GFR greater than or = to 90 mL/min (normal) 2) GFR 60-89 mL/min (mild decrease) 3) GFR 30-59 mL/min (moderate decrease) --biggest variety of clinical manifestations 4) GFR 15-29 mL/min (severe decrease) 5) GFR less than 15 mL/min (failure)

normal CO2

35-45 mmHg

sucking chest wound

An open or penetrating chest wall wound through which air passes during inspiration and expiration, creating a sucking sound -decreased ventilaition and perfusion -management: 3 sided tape dressing

risk factors for CKD

DM & HTN (main) -ethnic minorities -family hx -obesity -aging population

D) Fracture of several consecutive ribs in two or more separate places.

Flail chest is best described as: A) The presence of lymphatic fluid in the pleural space B) Fractures that are not apparent on a visual examination of the chest wall. C) Fracture of two ribs on both sides causing a stable segment. D) Fracture of several consecutive ribs in two or more separate places.

TBSA (total body surface area)

Helps judge the size of a wound and burns

C) Patient may sit on the side of the bed and lean forward on bedside table

How would you position the patient for a thoracentesis? A) Place the patient in a supine position with the head of the bed up. B) Place patient on the unaffected side during the procedure. C) Patient may sit on the side of the bed and lean forward on bedside table

true

Hypercapnic respiratory failure is commonly defined as a PaCO2 less than 45mm/Hg in combination with acidemia. true or false

hypercapnic respiratory failure

INCREASED CO2 (greater than 45mm Hg) and DECREASED pH (less than 7.35) -Telling us it's a VENTILATION problem

A) Tripod

If a COPD or asthma patient is experiencing dyspnea and they are working hard to breathe, which position should you place the patient in? A) Tripod B) Supine C) Downward dog D) Inverted

Parkland formula

Method of calculating fluid repletion in burn patients. 2-4mL x kg x TBSA -infuse 1st 1/2 in 8 hrs -infuse 2nd 1/2 over the remaining 16 hrs

ischemic stroke

Most common type of stroke in older people, occurs when the flow of blood to the brain is blocked by the narrowing or blockage of a carotid artery.

Nutrition for burn patients

NPO until bowel sounds return -then oral fluids with high protein, high calorie tube feedings --promotes healing -no ice chips/water

B) Tidaling

Normal fluctuation of the water within the water-seal chamber is called__________. A) Bubbling B) Tidaling C) Brisk Bubbling D) Fluttering

D) Notify the primary healthcare provider.

On the second day after surgery, a client reports pain in the right calf. What should the nurse do first? A) Apply a warm soak. B) Elevate the leg above the heart. C) Document the symptom. D) Notify the primary healthcare provider.

V/Q mismatch treatment

Oxygen & treat the cause

hypoxemic respiratory failure

PaO2 is 60 mm Hg or less when the patient is receiving oxygen of 60% or greater. -OXYGENATION problem

true

Pulmonary embolism is caused by a fat embolus in the pulmonary artery which can cause the death if not treated. True or false

AKI manifestations

RIFLE (creatinine increases as GFR decreases) -Risk -Injury -Failure -Loss of function -End stage -oliguric, diuretic, and recovery phase

intracerebral stroke

Rupture of small vessels inside the brain, most deadly type of stroke -sudden onset of sx --nausea and vomiting --sudden severe headache --decreased LOC -progression can be over minutes or hours -very poor prognosis -HTN is most common cause

true

Stroke is considered to be a leading cause (one of the top 5) of death in the United States. True or false

A) Decrease pain so the patient can breathe adequately

The best goal of treatment when patients have fractured ribs is to: A) Decrease pain so the patient can breathe adequately B) Emphasize deep breathing and coughing C) Educate the patient on how to splint with fractured ribs D) Strap the chest with tape or a binder to help with breathing

B) Increase risk of pulmonary embolism

The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client? A) Produces a normal sinus rhythm B) Increase risk of pulmonary embolism C) Increase in cardiac output D) Increased cardiac output

D) Atherosclerotic plaques within arteries

The healthcare provider makes the diagnosis of transient ischemic attacks (TIAs). The client asks the nurse, "What causes TIAs?" When preparing a response in language the client will understand, the nurse considers that TIAs are caused by which factor? A) Multiple emboli ascending from the lower extremities B) Developmental defects in arterial walls C) Genetic valvular heart disease D) Atherosclerotic plaques within arteries

true

The major cause of respiratory failure is the lung's inability to meet the O2 needs of the tissue. true or false

C) Exhibits confusion and restlessness

The nurse suspects the early stage of ARDS in any seriously ill patient who manifests what? A) Has diffuse crackles and rhonchi B) Has a decreased breath sounds and increase weight gain C) Exhibits confusion and restlessness D) Develops respiratory acidosis rapidly

true

The signs and symptoms of Respiratory failure occurs when the compensatory mechanisms fail and the patient exhibits tachycardia, tachypnea, and mild hypertension. true or false

B) signs of bleeding

Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Which is the priority nursing assessment? A) Tissue compatibility B) signs of bleeding C) electrolyte level D) apical heart rate

C) Hypertension and Diabetes

What are two causes of chronic renal disease? Select all that apply. A) Hydration and controlled diabetes B) Weight Loss and Hypertension C) Hypertension and Diabetes D) Weight gain and Diabetes

C) Inadequate O2 transferred to the blood

What is acute respiratory failure? A) A Hypocapnic episode B) It is a disease that affects lung function C) Inadequate O2 transferred to the blood D) Adequate CO2 is removed from the lung

A) Hemorrhage

What is an acute, life-threatening complication for which a nurse should assess a client in the early postoperative period after a radical nephrectomy? A) Hemorrhage B) Sepsis C) Renal failure D) Paralytic ileus

A) sucking chest wound

What is another name for a open pneumothorax? A) sucking chest wound B) air leak C) flail chest D) tracheal deviation

D) to correct hypoxemia

What is the primary goal for administering O2 to a patient in Acute respiratory failure? A) To decrease anxiety B) To help increase CO2 C) To maintain SaO2 at 85% D) To correct hypoxemia

A) Restlessness

Which assessment finding should cause the nurse to suspect the early onset of hypoxemia? A) Restlessness B) Hypotension C) Central cyanosis D) Cardiac dyrhythmia

C) Slow, shallow respirations as a result of sedative overdose

Which patient with the following manifestations is most likely to develop hypercapnic respiratory failure? A) Large airway resistance as a result of severe bronchospasm B) Rapid, deep respirations in response to pneumonia C) Slow, shallow respirations as a result of sedative overdose D) Slow, shallow respirations as a result of sedative overdose

A)Thromboembolic disorders

Which risk is associated with estrogen therapy in a client who smokes? A)Thromboembolic disorders B) Multiple pregnancies C) Hypocalcemia D) Vaginal bleeding

B) Hypovolemia due to blood loss

Which situation is a cause of pre-renal Acute Kidney injury? A) Enlarged Prostate B) Hypovolemia due to blood loss C) Blood Pressure Medication D) Renal stones

full thickness burn (3rd & 4th degree(

a burn involving destruction of the entire skin; extends into subcutaneous fat, muscle, or bone and often causes severe scarring -charred black and white spots -patient can no longer feel the burn -surgical intervention is required for healing

dialysis

a procedure to remove waste products from the blood of patients whose kidneys no longer function -corrects fluid and electrolyte imbalances

thrombotic stroke (ischemic)

a stroke resulting from thrombosis or narrowing of the blood vessel -most common type -HTN & DM are the most common cause --commonly proceeded by a TIA

pneumothorax

air in the pleural cavity "collapsed lung" -open pneumothorax: lung on injured side begins to collapes and shift towards the uninjured side -spontaneous (simple): plueral space is exposed to positive pressure --bleb rupture -traumatic: usually the result of a penetrating trauma

tension pneumothorax

air that enters the chest cavity is prevented from escaping -trachea shifts** --jugular vein distention -venous return to the heart decreases -Cardiac Output decreases -severe respiratory distress --anxiety

management of chest trauma

airway and ventilation -O2 -CT placement --small accumulations may not require chest tubes -intubation with ventalating support

rehabilitation phase of burns

begins when the wounds have healed and pt can help in self care -Manifestations include new skin appearing flat and pink, then raised and hyperemic; itching occurs with healing. -Complications are skin and joint contractures and hypertrophic scarring. --physical therapy is continued

Acute care (burns)

begins with mobilization of extracellular fluid and diuresis and ends with wounds completely covered by skin or grafts --can take weeks to months -watch closely for changes in potassium and sodium -watch for signs of infection -removal of necrotic tissue and the placement of skin grafts are part of this phase

eschar tissue

black in color and usually dry and leathery in appearance -necrotic

shunting

blood exists the heart without participating in air exchange -automatic: bypasses the lung -intrapulmonary: goes to the lung but no exchange occurs --causes extreme V/Q mismatch

hemothorax

blood in the pleural cavity -dx by chest x-ray -tx: chest tube depending on percentage

Transient Ischemic Attack (TIA)

brief episode of loss of blood flow to the brain, usually caused by a partial occlusion that results in temporary neurologic deficit (impairment); often precedes a CVA

partial thickness burn (2nd degree)

burn involving epidermis and dermis that usually involves blisters -painful -heals in 14-21 days "deep partial thickness"

Superficial burn (1st degree)

burn involving only epidermis -causes redness and swelling but no blisters -painful for the patient "superficial partial thickness"

Resp Failure Manifestations

can develop gradually or suddenly -mental status change is the *earliest* sign -early: tachycardia, tachypnea, mild HTN --monitor WOB -severe morning headache -cyanosis: late sign -metabolic acidosis -death

circumference burns

cause fluid shifts in the patient -decrease in pulse -usually seen as a 3rd or 4th degree -tx: escharotomy or fasciotomoy

Chemical burns

caused by contact with chemicals that can burn the skin Treat by flushing burn with lots of cool water to remove chemical, or brush powdered chemical off skin with clean cloth -caused by acids, alkalines or organic compounds

Kyphoscoliosis

combination of kyphosis and scoliosis, which may produce a severe restrictive lung defect as a result of poor lung expansion

primary goal of wound care

coverage and prevention of infection

acute tubular necrosis

damage to the renal tubules due to presence of toxins in the urine or to ischemia -sepsis is most common cause

smoke inhalation injury

damage to the respiratory tract as a result of inhaling hot gases that may contain toxic substances -airway is always the first assessment on burn patient

Prerenal AKI

decreased renal blood flow from decreased systemic blood flow -decreased OU (oliguria) -can be from severe dehydration, HF, decreased CO

Intrarenal AKI

direct damage to the kidneys by inflammation, toxins, drugs, infection, or reduced blood supply -prolonged ischemia=nephrotoxins -hemoglobin from hemolyzed RBCs -myoglobin from necrotic tissue

burn patient history

drug and alcohol hx is very important for burn patients -detox will add more stress to the body and slow down the healing process

Postrenal AKI

due to obstruction of urine flow - can occur anywhere post kidney (ureter, bladder, urethra)

penetrating chest trauma

foreign object penetrates chest wall -gunshot -stabbing

flail chest

fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment

Electrical Burns

frequently associated with significantly greater internal injuries than would be suspected from the appearance of entrance and exit wounds. --May cause arrest through ventricular fibrillation activity -type, exposure, path, and time of contact should be assessed

perineal burns

higher risk for infection

shunting treatment

mechanic ventilation and FIO2

CVD & CKD

most common cause of death in CKD is CVD -if you have one, test for the other

V/Q mismatch

most common cause of hypoxemia -should be a 1:1 ratio --1 ml of air to 1 ml of blood flow

blunt chest trauma

most common form of chest trauma -hardest to ID --MVCs --falls

needle thoracostomy

needle/catheter placed in the pleural space to drain air -14 to 16 G into the 2nd intercostal space midclavicular --mostly done outside of the hospital (field work)

hemorrhagic stroke

occurs when a blood vessel in the brain leaks or ruptures; also known as a bleed

Acute Respiratory Failure

one or both of the gas exchanging functions are inadequate -insufficient O2 transfer to blood -inadequate CO2 is removed from the lungs

excision

process of cutting out, surgical removal of dead tissue from burns

Chronic Kidney Disease (CKD)

progressive, irreversible loss of kidney function -can be asymptomatic early on --up to 80% of GFR can be lost without exhibiting symptoms

Acute Kidney Injury (AKI)

rapid-onset disease of the kidneys resulting in a failure to produce urine -acute tubular necrosis (most common cause) -reversiable -infection is the most common cause of death -increase in BUN, creatinine, and potassium -high mortality rate

kidney transplant

replacement of a diseased kidney with one that is supplied by a compatible donor -most effective form of tx, but hardest to come by -reverses the patho of kidney disease in the body -less expensive than dialysis after the first year

acute respiratory distress syndrome (ARDS)

respiratory insufficiency marked by progressive hypoxia -sudden progressive form of acute respiratory failure

Embolic Stroke (Ischemic)

sudden onset with severe clinical manifestations -warning signs are less common -commonly reoccur -pt stays conscious

peritoneal dialysis

the lining of the peritoneal cavity acts as the filter to remove waste from the blood -catheter is inserted through the anterior abdomin -inflow, dwell, and drain

hemodialysis

the process by which waste products are filtered directly from the patient's blood -vascular access is required --have to have rapid blood flow -heparin is usually mixed into solution -one needle pulls blood into machine, gets filtered, and returned back to pt

cerebral aneurysm (hemorrhagic stroke)

the widening or abnormal dilation of a blood vessel in the brain -majority in the circle of willis -incidence increases with age and risk increases in women -"silent killer" -Loss of consciousness may or may not occur -high mortality rate

CRRT (continuous renal replacement therapy)

typically done in the ICU. It is special because *never more than 80ml is out of the body at one time*. Thus, it does not stress the cardiovascular system as much -uremic toxins and fluids are removed while acid base status and electrolytes are adjusted slowly