NU271 / 280 Quiz 1
glomerulosclerosis
hardening of the renal glomerulus *gerontological consideration
GVHD (graft versus host disease)
immune reaction of donor tissue or a donor organ against the patient.
phlebitis
inflammation of a vein - pain and erythema along vein (graded by signs, symptoms, severity) - causes: chemical, mechanical, bacterial - should set up new IV site
extravasation
leakage of medication from the veins into the subcutaneous tissues
Creatinine
nitrogenous waste excreted in the urine normal range 0.6 - 1.2 mg/dL
PRBCs
packed red blood cells (plasma removed) Increases hmt & hgl without increasing fluid volume May be refrigerator stored for 42 days May be frozen for up to 10 yrs Indicated: blood loss due to trauma, sickle-cell anemia, neoplastic blood diseases, surgery, chemo
Which blood component is most likely to become contaminated with bacteria?
platelets s/s: fever, chills, vomiting, diarrhea, HTN
hypertonic solutions
>375 mOsm/L Ex: • 3% sodium chloride • 5% dextrose in lactated Ringer's • 20% dextrose in water • 10% dextrose in water • Dextrose 5% in 1/2 NSS • Dextrose 5% NSS • Albumin 25% Indications: severe dehydration/electrolyte imbalance, hypotonic dehydration
How is fluid status monitored?
-physical assessment, periodic weights, and accurate measurement of intake and output. -Laboratory values, particularly serum electrolytes, need to be monitored for further indications of fluid balance.
Tx for metabolic acidosis
-treat underlying cause -Resp. support (mechanical ventilation) -Give NaHCO3 for low pH -Fluid replacement -Insulin for diabetics to revers ketoacidosis & bring K back into cells -Antidiarrheals RN interventions: find underlying cause. monitor BP, pulse, RR, HR, peripheral vascular status, cautious admin of HCO3-
This or that: Treatment for a 45-year-old in hypovolemic shock from blood loss after a gunshot wound. Albumin or Mannitol
Albumin Rationale: Albumin expands the vascular space and is not contraindicated in bleeding disorders. Mannitol is an osmotic diuretic and will cause additional fluid loss.
What causes fluid shift from osmotic pressure? Select all that apply. - Albumin - Hypertonic fluids - Isotonic fluids - Hypotonic fluids - Mannitol
Albumin Hypertonic fluids Hypotonic fluids Mannitol
Sodium
135-145 mEq/L Mostly found in ECF Neuromuscular function / regulator of BP Most abundant cation in relation to water
IV gauge colors
16g - Gray 18g - Green 20g - Pink 22g - Blue 24g - Yellow 26g - purple (rarely used 16g, 24g, 26g) think: I'd turn green if somebody came at me with an 18g, twenty TWO rhymes with blue, and 20g is like a pink piggie
How many units of blood may be transfused through one administration set?
2
Normal ABGs: HCO3
22-26 mEq/L
If client only has one infusion site, may I administer IV fluids or medications while blood is transfusing?
Do not add fluids or medications to blood or blood products
Isotonic fluids
250-375 mOsm/L EX: 0.9% NaCl Ringer's Solution Lactated Ringer's 5% dextrose in water (becomes hypotonic in body) Indications: fluid deficits/challenges, dehydration
A registered nurse is caring for a patient experiencing fluid volume excess. Which assessment finding is anticipated? Dry mucous membranes Oliguria Concentrated urine output Edema
Edema Edema is a sign of excess fluid outside the vascular space in the tissues.
plasma
Fluid portion of blood 92% water, 7% plasma proteins (albumin, fibrogen, globulins, clotting proteins) Indications: bleeding/coagulation disorders, replace fluid volume d/t burns, liver failure, thrombocytopenia, hemolytic uremic syndrome
Which lab values are impacted by fluid volume deficit? Select all that apply.
Hemoglobin and hematocrit Urine specific gravity Sodium Serum osmolality
Normal ABGs: PaCO2
35-45 mmHg
Normal ABGs: pH
7.35-7.45
Glucose range
70-100 mg/dL (fasting)
transfusion time parameters
-from time blood is removed from blood bank, transfuse within 4 hrs -start tranfusion within 30 min of receipt from blood bank -if transfusion is not taking place, blood must be returned to blood bank within 30 min
hypotonic solutions
<250 mOsm/L Ex: 0.45% NaCl 0.33% NaCl 2.5% DW Indications: DKA, hyperosmolar hyperglycemia, hypertonic dehydration
Normal bicarb
(HCO3) 22-26 mEq/L
Which findings could lead to the presence of edema? Select all that apply. Decrease in fluid pressure Decreased oncotic pressure Decreased albumin Decreased hydrostatic pressure Release of antidiuretic hormone
- Decreased oncotic pressure - Decreased albumin
Which types of fluid solutions would result in fluid shifting within the body? Select all that apply. Hypertonic Hypotonic Colloid Isotonic Crystalloid
- Hypertonic - Hypotonic - Colloid - Crystalloid
The nurse is caring for a patient with tachycardia and hypotension secondary to polyuria from hyperglycemia. Which prescriptions on the medication administration record should the nurse implement? Select all that apply. 0.9% NaCl 1000 mL over 2 hours Albumin 25 g in 100 mL intravenously over 4 hours - 1dose only Mannitol 20 g intravenously - 1 dose only 0.45% NaCl at 100 mL/hr intravenously D50.9% NaCl at 50 mL/hr intravenously
-0.9% NaCl 1000 mL over 2 hours -Albumin 25 g in 100 mL intravenously over 4 hours - 1 dose only
A patient has 3+ pedal and periorbital edema and a normal blood pressure. After reviewing the medication administration record, the nurse recognizes that which prescriptions will reduce the edema? Select all that apply. 0.9% NaCl 500 mL over 2 hours for SBP <90 mm Hg Albumin 25 g in 100 mL intravenously over 4 hours - One dose only Furosemide 40 mg intravenously - One dose only Compression stockings KCl 10 mEq in 100 mL 0.9% NaCl intravenously over 2 hours Albumin 25 g in 100 mL intravenously over 4 hours - One dose only Furosemide 40 mg intravenously - One dose only
-Albumin 25 g in 100 mL intravenously over 4 hours - 1 dose only -Furosemide 40 mg intravenously - 1 dose only -Compression stockings
Tx for respiratory acidosis
-If hypoxic: make sure they have a patent airway then give them O2, bronchodilators -Pneumonia: Postural drainage, percussion, suctioning, deep breathing exercises, fluids, elevate HOB, teaching and use of IS -Pneumothorax: Chest tube -Post-op: Cough & deep breathing exercises (bubbles for kids) RN interventions: maintain patent airway, ABGs, vitals, K+ levels, emotional support
Febrile nonhemolytic transfusion reaction
-Type II hypersensitivity reaction. Host antibodies against donor HLA antigens and WBCs. -Presents with fever, headaches, chills, flushing
The nurse is caring for a patient with a severed limb who was involved in a motorcycle accident. A tourniquet was placed on the limb before transport to the hospital, but the blood loss was significant. Which solution should the nurse infuse at a high rate of administration? 0.9% Sodium Chloride 0.45% Sodium Chloride D5% 0.45% Sodium Chloride 3% Sodium Chloride
0.9% Sodium Chloride Since there was a large blood loss, it is expected that the patient is severely hypovolemic. An isotonic solution is needed to restore the vascular volume.
Specific gravity of urine
1.010 - 1.030 Higher the number, the dryer the person
respiratory acidosis
A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2. Common causes: COPD Barbiturate or Sedative overdose Chest wall abnormality (obesity) Severe pneumonia Atelectasis Respiratory muscle weakness (Guillain-Barre syndrome) Mechanical hypoventilation To compensate, the kidneys conserve bicarb and secrete more H+ (acid) into the urine. Treatment: improve respirations
The nurse is caring for a patient with ascites from liver failure receiving IV albumin. What response will the nurse anticipate if the medicine is effective? Peripheral edema will increase. Urine output will decrease. Blood pressure will decrease. Abdominal girth will decrease.
Abdominal girth will decrease.
Tx for metabolic alkalosis
Anti-emetics (nausea & vomiting) Replace fluids and electrolytes Stop K+ wasting meds/diuretics & NG suctioning Monitor IV fluids and electrolyte supplements
This or that: Fluid replacement therapy for an 80-year-old male patient who is hypotensive. 3% Normal Saline or Normal Saline
Normal saline Rationale: An isotonic fluid would be indicated for replacement therapy for a hypotensive elderly patient to fill the vascular space. Three percent normal saline is a hypertonic solution and would cause fluid shifting and worsen cellular dehydration.
Metabolic Acidosis
Bicarb deficit. Occurs when an acid other than carbonic acid (ketoacid or lactic acid) accumulates or when bicarb is lost from body fluids. Common causes: DKA Lactic acidosis Starvation Severe diarrhea Renal tubular acidosis Renal failure GI fistulas Shock Compensation occurs by increasing CO2 excretion, often with Kussmaul's respirations (faster, deeper respirations) and the kidneys attempt to excrete the lactic or ketoacids. Treatment: Sodium Bicarbonate
The nurse is delivering 0.9% NaCl at 100 mL/hr to a patient admitted yesterday. Which assessment change should the nurse report to the healthcare provider? Bilateral crackles in the lungs Blood pressure of 112/76 mm Hg Pain at the IV site Increased urine output
Bilateral crackles in the lungs
central vein access
CVA describes when the tip of the IVAD terminates in the central vasculature at the level of the superior vena cava or the inferior vena cava -come in many sizes and can have single or multiple lumens -Multiple-lumen catheters (Fig. 10.6) provide separate fluid pathways that make it possible to deliver two or more solutions at the same time.
Calcium
Ca - 8.5-10.5 mg/dL -Most abundant mineral in body (bones/teeth) -cardiac muscle depolarization -req'd nerve impulse conduction -BP regulator -Inverse relationship with phosphorus Foods: salmon, dairy, cauliflower, dark leafy greens
What conditions cause fluid volume excess? Select all that apply. Cirrhosis Diarrhea Adrenal gland disorder Hemorrhage Heart failure
Cirrhosis Adrenal gland disorder Heart failure
Chloride
Cl- 96-106mmol/L -most abundant extracellular anion -combines with cations to form: NaCl, CaCl, KCl -all sources from diet & medication -"chloride shift" used to maintain pH in body FOODS: cured meats, salt, dairy
Central line complications
Complications of central venous infusion therapy include infection, loss of patency, and air embolism S/S: tachycardia, CP, dyspnea, hypotension, cyanosis, ⬇LOC
The nurse is preparing a healthy patient for an elective outpatient surgery. The provider tells the nurse to, "Go ahead and start an IV with some fluids, I'll be back in 30 minutes to take the patient to surgery," then hangs up the phone. What should the nurse do next? Hang a bag of 0.9% NaCl at a low rate. Start the IV but do not start a solution. Contact the provider back to obtain a complete order. Do not do anything since the surgery is in 30 minutes and the patient is healthy. Contact the provider back to obtain a complete
Contact the provider back to obtain a complete order.
What is the best indicator of kidney function in a client who is experiencing fluid and electrolyte imbalances? Blood urea nitrogen level Creatinine level Urine output Urine pH level Absence of microalbuminuria
Creatinine level
This or that: Fluid therapy for a 22-year-old female patient who is pregnant and admitted with hyperemesis gravidarum after vomiting for the last seven days. Colloid or Crystalloid
Crystalloid Rationale: Crystalloid therapy would be used in fluid replacement for a pregnant patient with hyperemesis. More specifically, an isotonic solution is indicated initially to restore the vascular volume and followed by a hypotonic solution to rehydrate the cells. Colloid therapy would not be indicated. The use of colloid therapy would be contraindicated because fluid would pull from the extravascular to the intravascular space.
A patient comes into the emergency department after being knocked unconscious from a car accident. He is disoriented and is vomiting. The CT scan shows cerebral edema. Which fluid should the nurse request from the practitioner for rehydration? 5% D5W Lactated Ringer's D5 0.45% NaCl5% Albumin
D5 0.45% NaCl This hypertonic solution will move the fluid from the cells into the vascular space, decreasing cerebral edema and increasing vascular hydration.
This or that: Fluid replacement for a 28-year-old female with severe hyponatremia and low blood pressure from adrenal insufficiency and a lack of aldosterone. Isotonic Solution or Hypertonic Solution
Hypertonic solution Rationale: A hypertonic solution will increase serum sodium levels while shifting fluid into the circulation and creating vascular expansion, thereby raising the blood pressure. An isotonic solution would not correct the hyponatremia, only the low blood pressure.
A client has been receiving parenteral therapy while in the hospital. As a result of fluid administration, fluid shifting is noted with the cells of the body becoming more edematous. Which type of fluid would the nurse anticipate being responsible for cellular swelling? Hypotonic solution Hypertonic solution Lactated Ringer's solution Normal saline
Hypotonic solution
This or that: Fluid replacement for an 18-year-old male patient with a normal blood pressure, experiencing leg cramps after completing a marathon. Hypotonic Solution or Hypertonic Solution
Hypotonic solution Rationale: A hypotonic solution shifts fluid out of the vessels into the cells, which improves the dehydration causing the leg cramps. A hypertonic solution would pull more fluid from the already dry cells.
Infiltration of vein
IV comes out of vein and fluid leaks into tissues
Acute intravascular hemolytic reaction
Immediate incompatibility (within 10 min) Stop the blood. Supportive care: oxygen, Benadryl, airway management. S/S: Nausea, vomiting, pain in lower back, hypotension, increase in pulse rate, decrease in urinary output, hematuria.
Potasssium
K - 3.5 - 4.5 mEq/L -Mostly ICF -CV function, skeletal & smooth muscle conduction -Helps move glucose into cell with insulin -Helps maintain H ion concentration in acid-base balance -Mg deficiency will potentiate K deficiency Foods high: potatoes, banana, OJ, leafy greens, dried fruit, molasses
This or that: Fluid requirement for a 58-year-old male patient admitted with hypokalemia who requires intravenous potassium replacement therapy. KCl As IVP Bolus or KCl With IV Solution
KCL with IV solution Rationale: Potassium replacement therapy is considered a high-alert medication and should never be administered as an IVP bolus, which could cause dysrhythmias and cardiac arrest. Safety considerations require that potassium be administered as part of an IV solution over an extended period of time.
The nurse is caring for a patient with a bowel obstruction who has been vomiting at home for 3 days before coming to the hospital. Which priority prescription should the nurse request when contacting the healthcare provider? Hydroxyethyl starch (HES) Lactated Ringer's Dextran Mannitol
Lactated Ringer's
This or that: Fluid therapy for a healthy 38-year-old male who is admitted for a simple outpatient surgical procedure. Lactated Ringer's (LR) or D5W
Lactated Ringer's (LR) Rationale: In this clinical situation there is no reason to suspect a fluid imbalance before surgery. An isotonic fluid (LR) would be indicated for short-term fluid therapy, such as this. Five percent dextrose in water (D5W) is a hypotonic fluid that could potentially cause fluid shift into the cells.
Tranfusion related acute lung injury (TRALI)
Leading cause of transfusion related deaths No clearly identified at-risk pops or causes known.
A client is experiencing symptoms of fluid volume excess. Which actions should the nurse take? Select all that apply. - Limit daily intake of fluid and sodium - Monitor daily weight - Offer oral fluids - Eliminate sodium-containing IV fluids - Administer diuretics, as ordered
Limit daily intake of fluid and sodium Monitor daily weight Eliminate sodium-containing IV fluids Administer diuretics, as ordered
this or that: Fluid therapy for a 16-year-old female trauma patient who has head trauma and suspected cerebral edema following an automobile accident. Mannitol or Albumin
Mannitol Rationale: Mannitol is an osmotic diuretic that decreases cerebral edema. Albumin is a protein that draws fluid into the vascular space and would make cerebral edema worse.
Magnesium
Mg - 1.4-2.1 mEq/L -mostly found in ICF -cardiac cell function & depolarization -assist with vasodilation & BP regulation -2nd most abundant intracellular electrolyte (K=1) Foods: broccoli, avocado, tuna, beef, pork, grains, raisins, milk (many laxatives contain mg)
An elderly client who is hypotensive has been admitted to the nursing unit for fluid replacement therapy. What intravenous solution would the nurse expect to administer? 3% saline Lactated Ringer's Albumin Normal saline
Normal saline
Respiratory Alkalosis
Occurs with hyperventilation (blowing off too much CO2 so pH rises) or hypoxemia. Common causes: Hyperventilation (by hypoxia, PE, anxiety, fear, pain, exercise, fever) Stimulated respiratory center caused by septicemia, encephalitis, brain injury, salicylate poisoning Mechanical hyperventilation Compensated respiratory alkalosis is rare. Aggressive treatment of the cause is essential, but buffering may occur including renal secretion of bicarb. Treatment: slowing respirations, rebreathing exhaled CO2 (breathing into a bag)
Phosphorus
P 2.5-4.5 mg/dL -main ion of ICF -most is combined with calcium in bones/teeth -main component of ATP -major role in conversion of glycogen to glucose -primary urinary buffer by binding w/hydrogen -moves into cell with glucose FOODS: dairy, fish, chicken, nuts, eggs
Normal PaO2 value
PaO2 80-100 mmHg
PICC line
Peripherally Inserted Central Catheter (PICC) -Used for long term medication, antibiotics, nutrition -Larger vein used (usually upper extremities) -Due to length of catheter, to maintain patency, sufficient fluid must be used for full flushing (before & after use and periodically when not in use) -10ml (flushing) syringes to be used for low pressure
Which compensatory mechanism would be initiated in the body in response to a low volume state? Inhibition of hypothalamus osmoreceptors Increase in urine output Inhibition of aldosterone release Release of antidiuretic hormone
Release of antidiuretic hormone
Tx for respiratory alkalosis
Removal of the cause Reduce fever Breathe into a paper bag May have to sedate client to decrease respiratory rate Treat anxiety Diuretics for pulmonary edema RN interventions: Monitor ABGs, vitals, encourage slow deep breathing, emotional support, ADLs
signs of alkalosis
Respiratory: Lethargy, Light-headedness, confusion Tachycardia, dysrhythmias N/V, epigastric pain Tetany, numbness, tingling of extremities, hyperreflexia, seizures Hyperventilation Metabolic: Dizziness, irritability, nervousness, confusion Tachycardia, dysrhythmias N/V, anorexia Tetany, tremors, tingling of fingers and toes, muscle cramps, hypertonic muscles, seizures Hypoventilation (compensatory)
signs of acidosis
Respiratory: Drowsiness, diorientation, dizziness, HA, coma Decreased BP, VFib, warm flushed skin Seizures Hypoventilation with hypoxia Metabolic: Drowsiness, confusion, HA, coma Decreased BP, dysrhythmias, warm flushed skin N/V, diarrhea, abdominal pain Kussmaul's (compensatory)
Normal SaO2
SaO2 >95%
How to determine Acid-Base Imbalances
Step 1: Determine if pH is acidotic or alkalotic. Anything less than 7.4 is acidosis, anything greater than 7.4 is alkalosis Step 2: What is causing the abnormal pH? Look at PaCO2 and HCO3. If CO2 is high or HCO3 is low that is what's causing the acidosis. If CO2 is low or HCO3 is high that is what's causing the alkalosis. If it's the CO2 that's causing the acidosis/alkalosis then it's respiratory. If it's the HCO3 that's causing the imbalance then it's metabolic Step 3: What's the other one doing? Is it abnormal too? (i.e. if CO2 is high is HCO3 also high or in normal limits). If the other is in normal limits it's un-/noncompensated. If the other is also abnormal it's either partially compensated (if the pH is not within normal limits) or fully compensated (pH is back within normal limits)
An older adult patient is admitted to the emergency department for hypovolemia. After 500 mL of 0.9% NaCl is delivered intravenously over 1 hour, the assessment shows: blood pressure of 167/88 mm Hg, heart rate 110 beats per minute, and crackles bilaterally. What should the nurse determine from this situation? The patient has been properly rehydrated. The patient continues to be hypovolemic. The patient is showing signs of hypervolemia. The patient is showing no change in condition.
The patient is showing signs of hypervolemia.
transfusion reaction
a serious, and potentially fatal, complication of a blood transfusion in which a severe immune response occurs because the patient's blood and the donated blood do not match steps to take: 1. Stop tranfusion 2. Perform physical assessment (compare to VS from prior to transfusion) 3. Notify HCP 4. Notify BB 5. Obtain Blood and Urine samples ASAP 6. Document 7. Advise Patient
autologous transfusion
a transfusion of blood donated by a patient for their personal use Benefits: reduced allergy or reactions, esp. for rare blood type Restrictions: low body weight, low hematocrit, infections (HIV, Hep B)
Cryoprecipitate
an insoluble concentrate of certain coagulation factors obtained from fresh frozen plasma
BUN
blood urea nitrogen 8-20 mg/dL
2016 National Patient Safety Goal: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections.
• Perform hand hygiene prior to line manipulation and dressing changes; use aseptic technique. • Disinfect catheter hub and injection port when accessing. • If assisting or supervising line insertion, maintain sterile technique, and speak up if sterile technique is broken; complete or collect line insertion checklist. • Educate patient and/or family prior to insertion regarding prevention of central line infection.
