Exam 1 Study Guide

magnesium

1.3-2.1

sodium

135-145

potassium

3.5-5.0

calcium

9-11

C

A client had a 20-gauge short peripheral catheter (SPC) inserted for antibiotic administration 48 hours ago. Which nursing intervention is appropriate? A. Discontinue the SPC. B. Relocate the SPC for infection control. C. Assess the SPC for redness, swelling, or pain. D. Change the occlusive dressing covering the SPC.

B

A client is diagnosed with C. difficile infection. What nursing action is the priority for the client? A. Provide meticulous skin care. B. Place the client on Contact Precautions. C. Give the client an antipyretic medication. D. Encourage the client to drink extra fluids.

B

A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour? A. 12 mEq (mmol) B. 15 mEq (mmol) C. 18 mEq (mmol) D. 20 mEq (mmol)

D

A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action? A. Contact the primary health care provider B. Document findings in the electronic health record C. Change the IV site to a new location D. Stop the infusion of the drug

C

A client shows the nurse two pictures of the same lesion, taken 1 month apart. Which assessment finding requires nursing intervention? A. The light pink color of the lesion is the same in both photographs. B. The lesion has almost disappeared by the time of the second photograph. C. The lesion borders have expanded and are shaped differently in the second picture. D. The lesion's well-approximated margins and size look no different in either photograph.

A,B,C,D,E

A client who was bitten by a spider develops cellulitis of the left lower arm. What assessment findings will the nurse expect when caring for this client? Select all that apply. A. Fever B. Pain C. Redness around the spider bite D. Warmth in the affected arm E. Swelling of the affected arm

C

A client with a large, irregularly shaped mole on the upper chest expresses concern about the cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a dermatologic health care provider. B. Ask if there are any other lesions that are bothersome. C. Perform a head-to-toe skin assessment and document the findings. D. Teach about the importance of avoiding excessive sun exposure and tanning beds.

C

A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse's best first action to prevent harm? A. Hold the next dose of the prescribed antidiarrheal drug B. Assess bowel sounds in all four abdominal quadrants C. Assess the client's response to the Chvostek test D. Increase the IV flow rate of the normal saline infusion

C

An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at 150 mL/hour has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention? A. Notify the health care provider B. Place the client on oxygen C. Sit the client upright in bed D. Assess the client's lung sounds

Medications that need to be stopped before surgery: Anticoagulants & MAOIS

Anticoagulants: (blood thinners) usually need to be stopped several days before surgery. Oral medications may need to be replaced with injected or intravenous (IV) medications. It is extremely important that both your surgeon and your physician (who has ordered the anticoagulants) discuss the optimum timing for stopping these medicines. Please be aware that many drugs and herbal products may be anticoagulants (blood thinners) although they are not used for that purpose. Prescription Anticoagulants Include: Warfarin (Codmadin), Enoxaparin (Lovenox), Clopidogrel (Plavix), Ticlopidine (Ticlid), Aspirin (in many versions), non-steroidal anti-inflammatory (NSAIDS) (in many versions), Dipyridamole (Persantine). Non-prescription (over-the-counter or herbal) anticoagulants include: Aspirin (in many versions), non-steroidal anti-inflammatory (NSAIDS) (in many versions), Vitamin E, Garlic, Ginger, Ginkgo Biloba. (No regional anesthia can be given in the setting og anticoagulant therapy). Monoamine Oxidase Inhibitors (MAOIS): Drugs in this group include some anti-depressants and most anti-Parkinson drugs. MAOIs can interfere with many of the medications used during anesthesia. If the medication needs to be stopped, it should be done one to two weeks (7-14 days) before surgery because it takes that long for the drug to be out of your system. You should discuss this with your surgeon and primary physician as early as possible. Drugs include: Tranylcypromine (Parnate, Sicoton), Phenelzine (Nardil, Nardelzine), Isocarbonazid (Marplan), Rasagiline (Azilect), Selegiline (Eldepryl, Deprenyl), Linezolid (Zuvox) (an antibiotic), St. John's Wort

Prevention of Skin Cancer Teaching

BIGGEST THING TO DO IS TEACH AVOIDANCE Avoid sun exposure between 11 AM and 3 PM. Use sunscreens with the appropriate skin protection factor for your skin type. Wear a hat, opaque clothing, and sunglasses when you are in the sun. Keep a "body map" of your skin spots, scars, and lesions to detect when changes have occurred. Examine your body monthly for possibly cancerous or precancerous lesions. Seek medical advice if you note any of these: A change in the color of a lesion, especially if it darkens or shows evidence of spreading A change in the size of a lesion, especially rapid growth A change in the shape of a lesion, such as a sharp border becoming irregular or a flat lesion becoming raised Redness or swelling of the skin around a lesion A change in sensation, especially itching or increased tenderness of a lesion A change in the character of a lesion, such as oozing, crusting, bleeding, or scaling

Hypocalcemia

Ca < 9 mg/dL

Hypercalcemia

Ca >11 mg/dL

Hypercalcemia

Cause: increased calcium intake & absorption (milk-alkali syndrome), shift of Ca++ from bone into ECF (prolonged immobilization, hyperparathyroidism, bone tumors, and nonosseous cancers that secrete bone-resorbing factors), decreased Ca++ output (use of potassium sparing diuretics) Signs & Symptoms: Bone pain, arrhythmia, cardiac arrest (bounding pulse), kidney stones, muscle weakness decrease, excessive urination, anorexia, constipation, fatigue, coma, diminished deep tendon reflexes, lethargy, confusion Interventions: increase activity/exercise, encourage oral fluids to maintain dilute urine, restrict high calcium intake

Hyponatremia

Cause: medications, heart/kidney/and liver problems, syndrome of inappropriate and anti-diuretic hormone, chronic severe vomiting or diarrhea and other causes of dehydration, drinking too much water, hormonal changes, ecstasy Signs/Symptoms: stupor/coma, anorexia (nausea/vomiting), lethargy (weakness/fatigue), tachycardia (thready pulse), limp muscles (muscle weakness), orthostatic hypotension, seizures/headache, stomach cramping (hyperactive bowels) diarrhea, seizures Interventions: administer IV sodium chloride infusions, diuretics, daily weights, safety (orthostatic hypotension = fall risk), airway precautions, limit water intake, teach about foods high in sodium

Hypervolemia

Causes: Excessive intake or inadequate excretion of fluid, excessive fluid administration, heart failure, increase in sodium intake, cirrhosis, heart failure, decreased renal output, kidney disease/kidney failure Signs & Symptoms: tachycardia w/ bounding pulse, neck vein distention, increased blood pressure, hypertension, sudden weight gain, dependent edema, tachypnea, wet lung sounds (crackles, dyspnea), pulmonary edema, polyuria Interventions: low sodium diet, daily I &O 's, daily weight, diuretics, high-fowlers or semi-fowlers position (easier to breathe)

Hypovolemia

Causes: Increase GI output: Vomiting, Diarrhea, Fistula drainage, Ileostomy, GI suction Increase Renal output: Diuretics, Adrenal insufficiency, Salt-washing renal disorders Loss of Blood or Plasma: Hemorrhage, Burns Decreased fluid intake: Dysphagia, depression, elderly forget to drink Massive sweating without water & salt replacement; Fever, Unconscious, impaired thirst Signs/Symptoms: Confusion, increased respirations, thirst, dry mucous membranes, absence of tears & sweat, tachycardia w/weak (thready)or absent peripheral pulses, orthostatic hypotension to marked hypotension, decreased blood pressure, flat neck veins, decreased urinary output, cool/pale skin over extremities, sudden weight loss Interventions: measure I&O's, take daily weight monitor VS, assess for muscle strength, gait stability, LOC

Hypomagnesemia

Causes: Decreased magnesium intake & absorption (malnutrition, chronic alcoholism, chronic diarrhea, laxative misuse, steatorrhea (pancreatitis). Shift of mg into active form (rapid administration of citrated blood). Increase Mg+ output (aldosterone excess, use of thiazide or loop diuretics, steatorrhea, chronic diarrhea, or other GI losses) Signs/Symptoms: High HR (tachycardia), high BP (hypertension), high deep tendon reflexes, shallow respirations, twitches and seizures, irritability and confusion, positive Chvostek's sign, positive trousseaus sign, insomnia, muscle cramps and twitching, dysphagia, cardiac dysrhythmias Interventions: magnesium sulfate IV or PO, seizure precautions, and instruct the client to increase magnesium containing foods

Metabolic Acidosis

Causes: Diabetic Ketoacidosis (not enough insulin = high fat metabolism= excess ketone [acid]). Acute/Chronic kidney Injury, malnutrition, severe diarrhea Signs /Symptoms: high respiratory rate (Kussumal breathing- deep rapid breathing >20 breaths per minute), hyperkalemia (muscle twitching, weakness, arrhythmias), low blood pressure, confusion Interventions: Monitor intake and output, administer IV solution of sodium bicarb to increase bases and lower acids, initiate seizure precautions, monitor K+ levels

Respiratory Alkalosis

Causes: Losing CO2: tachypnea: increase in temperature, aspirin toxicity, hyperventilation Signs & Symptoms: Increase in heart rate, confused & tired, tetany, EKG changes, Positive Chvostek's sign Interventions: Provide emotional support, fix the breathing problem, encourage good breathing patterns, rebreathing into a paper bag, give anti-anxiety medications or sedatives to lower breathing rate, monitor K+ and Ca- levels

Hypocalcemia

Causes: calcium deficient diet, vitamin d deficiency, chronic diarrhea, laxative misuse, steatorrhea, hypoparathyroidism, hypoalbuminemia. alkalosis, chronic diarrhea Signs/Symptoms: convulsions, arrhythmias, tetany, spasms & stridor, numbness in fingers, face, and limbs, positive Chvostek's sign, positive trousseaus sign, muscle twitching, laryngospasm, cardiac dysrhythmias, seizures Interventions: administer calcium PO or IV, administer aluminum hydroxide and vitamin D, initiate seizure precautions, 10% calcium, consume food high in calcium

Hypokalemia

Causes: decreased potassium intake and absorption, excessive use of potassium free IV fluids, treatment of DKA with insulin, alkalosis, diarrhea, vomiting, or other GI losses, aldosterone excess, polyuria, use of potassium wasting diuretics, glucocorticoid therapy Signs/Symptoms: thready/ weak/irregular pulse, orthostatic hypotension, shallow respiration, anxiety, lethargy, confusion, coma, parathesia, hypoactive bowel sounds, nausea, vomiting, abdominal distention, ECG changes, bilateral muscle weakness, constipation Interventions: oral potassium supplements, liquid potassium chloride, potassium-retaining diuretic

Respiratory Acidosis

Causes: drugs (opioids & sedatives), edema (fluid in the lungs), pneumonia (excess mucus in the lungs), respiratory center of the brain is damaged, emboli (pulmonary emboli), spasms of the bronchial (asthma), sac elasticity damage (COPD & emphysema) Signs & Symptoms: high blood pressure, high respiration rate, high heart rate, restlessness, confusion, headache, and sleepy/coma Interventions: Administer O2, semi-fowler's position, turn, cough, and deep breathe (TCDB), pneumonia: high fluids to thin secretions & administer antibiotics, if CO2 >50, they may need an endotracheal tube, monitor potassium levels

Hypernatremia

Causes: hyperaldosteronism, kidney failure, corticosteroids, cushing syndrome, excessive ingestion of Na+, excessive administration of Na+ containing IVF, diabetes insipidus, impaired thirst, fever, increased metabolism, hyperventilation, excessive diaphroesis, watery diarrhea, dehydration Signs/Symptoms: flushed skin and dry, restless, anxious, confused, irritable, increased BP & fluid retention, edema, decreased urine output, agitation, low grade fever, thirst, & dry mucous membranes Interventions: if due to fluid loss: administer IV fluids If the cause is inadequate renal excretion of sodium: give diuretics to promote sodium loss Restrict sodium and fluid intake as prescribed

Hypermagnesemia

Causes: increased magnesium intake and absorption (excessive use of Mg+ containing laxatives and antacids). Decreased Mg+ output (end-stage renal disease, adrenal insufficiency) Signs & Symptoms: low energy (drowsiness), low HR (bradycardia), low BP (hypotension), low RR (bradypnea), low respirations (shallow), low bowel sounds, low DTRs, cardiac dysthymias Interventions: diuretics, iv administration, restrict dietary intake of Mg containing foods, avoid the use of laxatives and antacids containing magnesium, hemodialysis

Hyperkalemia

Causes: rapid infusion of stored blood, excessive ingestion of K+ from foods or salt substitutes, lactrogenic administration of large amounts of IV potassium, renal failure, tissue damage/cellular damage such as crash injury, burn, cytotoxic chemo, uncontrolled diabetes mellitus, acidosis, acute or chronic oliguria, adrenal insufficiency, use of potassium sparing diuretics Signs/Symptoms: Muscle cramps & weakness, urine abnormalities, respiratory distress, decreased cardiac contractility (decreased HR, and decreased BP), ECG changes, decreased deep reflex tendons Interventions: Monitor EKG, discontinue IV & PO potassium, initiate a potassium-restricted diet, potassium excreting diuretics, and avoid the use of salt substitutes or other potassium containing substances

Metabolic Alkalosis

Causes: too much antacids (too much sodium bicarbonate aka base), diuretics, excess vomiting (excess loss of hydrochloric acid (HCL) from the stomach), hyperaldosteronism Signs/Symptoms: Low respiratory rate: hypoventilation (<12 breaths per minute), low potassium levels (dysrhythmias, muscle cramps/weakness, vomiting, tetany, tremors, EKG changes) Interventions: Monitor K+ and Ca- levels, administer IV fluids to help the kidneys get rid of bicarbonate, replace K+, give antiemetics for vomiting, watch for signs of respiratory distress

What is included in preoperative checklist?

Consider these items when planning individualized preoperative teaching for patients & families: Addressing fears and anxieties Outlining the surgical procedure Explaining perioperative routines (ex: lines, catheters) to expect Teaching about methods of pain control in postoperative and recovery times frames Teaching about coughing, turning, deep breathing, and use of incentive spirometry Teaching about lower extremity exercises; stockings; and pneumonatic compression devices Teaching about splinting and its importance in pain management Reinforcing the importance of early ambulation

What is important to cover in pre-operative teaching?

Consider these items when planning individualized preoperative teaching for patients and families: Addressing fears and anxieties Outlining the surgical process Explaining preoperative routines (ex: NPO, blood samples, showering) Informing about invasive mechanisms (ex: lines, catheters) to expect Teaching about methods of pain control in the postoperative and recovery time frames Teaching about lower extremity exercises; stockings; and pneumatic compression devices Teaching about splitting and its importance in pain management Reinforcing the importance of early ambulation

Vancomyocin-resistant enterococci (VRE)

Enterococci are bacteria that live in the intestinal tract and are important for digestion. When they move to another area of the body, such as during surgery, they can cause an infection, which is usually treatable with vancomycin. In recent years many of these infections have become resistant to the drug. Risk factors: prolonged hospital stays, severe illness, abdominal surgery, enteral nutrition, and immunosuppression. Common infections caused by this include urinary tract infection, endocarditis, pelvic infection, and bacteremia. Place patients with this kind of infections on contact precautions to prevent contamination from body fluids It can live on almost any surface for days or weeks and still be able to cause an infection.

stage 3 pressure injury

FULL THICKNESS SKIN LOSS Subcutaneous tissue & underlying fascia may be damages or necrotic Damage extends down to but not through the underlying fascia; bone, tendon, & muscle are NOT exposed The depth can vary with anatomic locations; areas of thin skin (ex: the bridge of the nose) may show only a shallow crater, whereas thicker tissue area with larger amounts of subcutaneous fat may show a deep, crater-like appearance Undermining and tunneling may or may not be present

Stage 4 Pressure Injury

FULL THICKNESS SKIN LOSS WITH EXPOSED OR PALPABLE MUSCLE, TENDON, or BONE Full-thickness skin loss with exposed or palpable muscle, tendon, or bone Often includes undermining and tunneling common with sinus tracts possible Sinus tracts may develop Slough and eschar are often present on at least part of the wound

Skin Assessment

Family history of skin cancer Past surgery for removal of skin growths Recent changes in moles, birthmark, wart, scar Demographic information Occupational and recreational activities (sun exposure) USE ABCDE rule for early detection A- Asymmetry: This benign mole is not asymmetrical. Asymmetry is a warning sign of melanoma B- Border: A benign mole has smooth, even borders, unlike melanomas. The borders of an early melanoma tend to be uneven. These edges may be scalloped or notched C- Color: Most benign moles area all one color, often a single shade of brown. Having a variety of colors is a another warning sign D-Diameter: Benign moles usually have a smaller diameter than malignant ones. Melanomas are usually larger than a pencil eraser tip in diameter E-Evolving Common: Begning moles look the same over time. Any changes in size, shape, color, elevation, or another trait may indicate melanoma

Basal Cell Carcinoma

Genetic predisposition, UV exposure

A

How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance? A. Carbon dioxide loss through exhalation can raise arterial pH levels. B. Carbon dioxide retention during exhalation can lower arterial pH levels. C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance. D. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance.

C

In reviewing the electrolytes of a client, the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm? A. Deep tendon reflexes B. Oxygen saturation C. Pulse rate and rhythm D. Respiratory rate and depth

A

In the early postoperative phase, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? A. Blood pressure of 142/90 mm Hg B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing

Methicillin-resistant Staphylococcus aureus (MRSA)

Is a common bacteria found on the skin and perineum and in the nose of many people. It is usually not infectious when in these areas because of the number of bacteria is controlled by good hygiene measures. However, when skin or mucous membranes are not intact, localized infection such as boils or conjunctivitis may occur. If the organism enters into deep wounds, surgical incisions, the lungs, or the bloodstream, more serious or systemic infections occur that require strong antibiotics such as methicillin. These infections are one of the fastest growing and most common in health care today. They lead to increased hospital stays at a very high cost. The best way to prevent the spread of it is: Bathe patients with chlorhexidine wipes and administering nasal mupirocin ointment Performing frequent hand hygiene, including using hand sanitizers Avoiding close contact with people who have infectious wounds Avoiding large crowds Avoiding contaminated surfaces Using good overall hygiene Minocycline and Doxycycline are usually effective in treating it

Clostridium difficile (C. diff)

It destroys normal bowel flora and causes moderate to severe diarrhea It can be fatal. Especially among elderly patients. It is spread by direct contact among people and indirect contact with inanimate objects such as medical equipment and commodes. Patients who have 3 or more liquid stools within 24 hours with no laxative use are suspected of infection The patient should be placed on contact precautions to prevent infection transmission and the patients room should be disinfected with a sporicidal cleaning product Fever and abdominal pain and cramping commonly occur with diarrheal stools. Oral metronidazole and vancomycin have been the drugs to treat it

hyperkalemia

K > 5 meq/L

Hypokalemia

K< 3.5 meq/L

Cabapenem-Resistant Enterobacteriaceae (CRE)

Klebsiella and E.coli are types of enterobacteriacae that are located within the intestinal tract. They are a family of pathogens that are difficult to treat because they have a high level of resistance to carbapenems caused by enzymes that break down the antibiotics Examples of infections caused by this include urinary tract infection, pneumonia, and bacteremia.

Pressure Injury

Loss of skin integrity caused when skin and underlying soft tissue are compressed between a bony prominence and external surface for extended period of time. Mechanical forces create ulcers: Pressure Friction Shear Although they commonly occur over the sacrum, hips, and ankles, pressure injuries can occur on any body surface. For example, nasal cannula tubing that is too tight can cause pressure injuries behind the ears or in the nares.

Catheter Related Bloodstream Infection Prevention Bundle

Major components of this prevention bundle include: • Proper aseptic hand hygiene • Measuring upper arm circumference as a baseline before insertion (INS, 2016) • Maximal barrier precautions on insertion • Chlorhexidine skin antisepsis • Optimal catheter site selection and postplacement care with avoidance of the femoral vein for central venous access in adult patients • Daily review of line necessity with prompt removal of unnecessary lines Other helpful interventions include use of a checklist for sterility during the procedure, a line cart with all equipment, and a stop sign on the door of the room to stop unnecessary traffic through the room during the procedure. The checklist should be completed by another professional health care member who can stop the inserter when any breaks in technique are observed (INS, 2016). • Use a checklist during insertion to make sure that everything is done correctly. Tell anyone who violates the correct steps to stop the procedure immediately. • Hand hygiene before inserting a central line must be thorough (i.e., no quick scrub). Anyone who touches the central line must also perform thorough hand hygiene. • Maximal barrier precautions during line insertion require that the patient be draped from head to toe with a sterile barrier.

Hypomagnesmia

Mg < 1.5 mg/dL

Hypermagnesemia

Mg > 2.5 mg/dL

Hyponatremia

Na < 135 mEq/L

Hypernatremia

Na > 145 mEq/L

Proliferative Phase

Normal Wound Healing Begins about the fourth day after injury and lasts 2 to 4 weeks Fibrin strands from a scaffold or framework Mitotic fibroblast cells migrate into the wound, attach to the framework, divide, and stimulate the secretion of collagen Collagen, together with ground substance, builds tough and inflexible scar tissue Capillaries in areas surrounding the wound from "buds" that grow into new blood vessels Capillary buds and collagen deposits from the "granulation" tissue is the wound, and the wound contracts Epithelial cells grow over the granulation tissue bed

Maturation Phase

Normal Wound Healing Begins as early as 3 weeks after injury and may continue for a year or longer Collagen is reorganized to provide greater tensile strength Scar tissue gradually becomes thinner and paler in color The mature scar is firm and inelastic when palpated Chart 25-4 page 460

Inflammatory phase

Normal Wound Healing Begins at the time of the injury or cell death and lasts 3 to 5 days Immediate responses are vasoconstriction & clot formation After 10 minutes, vasodilation occurs with increase capillary permeability and leakage of plasma (and plasma proteins) into the surrounding tissue White blood cells (especially macrophages) migrate into the wound Signs & Symptoms of local edema, pain, erythema, and warmth are present

Patients at Risk for VTE

Obese patients Age 40 or older History of cancer or decreased cardiac output Decreased mobility, immobile, spinal cord injury History of VTE, PE, varicose veins, edema Oral contraceptives Smoking Hip fracture, total hip/knee surgery PE, pulmonary embolism; VTE, venous thromboembolism. These patients are at greater risk of having blood clots. That is why the initial assessment is so important. Information you gather on the assessment can possibly save a patient from danger or even death. Because surgical related VTE can be prevented, prophylaxis is a standard of care established by SCIP. VTE prophylaxis may involve devices drug therapy along with leg exercises and early ambulation to promote venous return. These are all things a nurse must make certain happen to avoid clots.

most common post-operative complications

Pneumonia Hemorrhage/shock Cardiac Arrest Respiratory arrest Clotting and VTE GI Bleed These serious complications can be prevented, or consequences reduced with collaborative care. Nursing observations and interventions are a part of critical rescue management for patient safety and quality care Signs & Symptoms to watch out for: Monitor emesis and stools for blood. Monitor for any changes in vital signs that may show the start of distress Always listen to you patient and make time to assess to avoid a situation. Remember patient safety. We will discuss each symptom and symptoms to watch for. Hypoxemia: Highest incidence occurs on 2nd postoperative day Interventions: Airway maintenance, Monitor (Spo2), Semi-Fowler's position, oxygen therapy-breathing exercises, mobilization as soon as possible

Droplet Precautions

Private room or a client whose body cultures contain the same organism Wear a surgical mask Place a mask on the client whenever they leave the room Adenovirus, Diphtheria (pharyngeal), Epiglottis, Influenza (flu), Meningitis, Parvovirus B19, Pertussis, Pneumonia, Rubella, Scarlet Fever, Sepsis, and Streptococcal pharyngitis

Contact Precautions

Private room or cohort client Use gloves & a gown whenever entering the client's room Colonization or infection with a multi-drug resistant organism Enteric infections (Clostridium difficle): when in contact with C.Diff, patient's hands must be washed with soap and water when performing hand hygiene Respiratory infections: RSV, influenza Wound & Skin Infections: cutaneous diphtheria, herpes simplex, impetigo, pediculosis, scabies, staphylococci, & varicella-zoster Eye Infections: conjunctivitis

Tinea (Fungal)

S/S: Annular or serpiginous patches are present with elevated borders, scaling, and central clearing. Itching is common. Lesions may be single or multiple. Distribution: Anywhere on the body; in adults, usually seen on the foot (tinea pedis, also known as "athlete's foot"). Nursing Implications: Teach patients to keep feet clean and dry, and to avoid public showers, locker rooms, and pools where fungi live. Advise patients to avoid sharing footwear and clothing. Topical antifungal therapy may be prescribed.

Methicillin-resistant Staphylococcus aureus (MRSA) (Bacterial)

S/S: Can range from mild folliculitis to extensive furuncles. Can be life threatening if a wound infection erupts or MRSA enters the bloodstream. Distribution: N/A Nursing Implications: See the Patient and Family Education: Preparing for Self-Management: Preventing the Spread of MRSA box and Chapter 21 for more information. If this patient is hospitalized, Transmission-Based Precautions must be instituted and IV antibiotics such as vancomycin or daptomycin may be given.

Carbuncles (Bacterial)

S/S: Collection of infected hair follicles. Lesion is a firm mass that is red, painful, and swollen; it drains through multiple openings. Abscess may develop. May have systemic flulike symptoms (fever, chills, malaise). Distribution: Back of neck, upper back, lateral thighs Nursing Implications: As above for furuncles.

Cellulitis (Bacterial)

S/S: Dermal and subcutaneous tissue infection. Often extends from another skin wound (e.g., ulcer, furuncle, carbuncles). Usually caused by Staphylococcus, community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), or group B streptococci. Infected area is red, warm, swollen, and painful. Can extend to lymph nodes and blood. Distribution: Can occur anywhere, but more common on lower legs, areas of persistent lymphedema, and areas of other skin wound. Nursing Implications: Systemic treatment with antibiotics is needed.

Candidiasis

S/S: Erythematous macular eruption occurs with isolated pustules or papules at the border (satellite lesions). Candidiasis is associated with burning and itching. Oral lesions (thrush) appear as creamy white plaques on an inflamed mucous membrane. Cracks or fissures at the corners of the mouth may be present. In the body, infected skin appears moist, red, and irritated; it usually burns and/or itches. Distribution: Skinfold areas: perineal and perianal region, axillae, beneath breasts, and between the fingers; under wet or occlusive dressings. Lesions possibly present on the oral or vaginal mucous membranes. Nursing Implications: Antifungal medications may be prescribed; route is dependent on where the infection is located. Teach the patient to keep skin clean and dry. If the patient is unable to self-turn, reposition frequently to enhance airflow to the skin.

Herpes Simplex (Viral)

S/S: Grouped vesicles are present on an erythematous base. Vesicles, which may evolve to pustules, rupture, weep, and crust. Lesions last 2-6 wk. Older lesions may appear as punched-out, shallow erosions with well-defined borders. Lesions are associated with itching, stinging, or pain. Secondary bacterial infection with necrosis is possible in immunocompromised patients. Distribution: Type 1 classically on the face and type 2 on the genitalia, but either may develop in any area where inoculation has occurred; recurrent infections occur repeatedly in the same skin area. Nursing Implications: This infection is very transmissible; teach to have others avoid contact with lesions. Topical and/or oral antiviral drugs may be prescribed. Teach that ultraviolet light, skin irritations, fever, fatigue, menses, or stress may increase chance of reactivation.

Herpes Zoster (Varicella Zoster) (Viral)

S/S: Lesions are similar in appearance to herpes simplex and also progress with weeping and crusting (Fig. 23.8). Grouped lesions present unilaterally along a segment of skin following the pathway of a spinal or cranial nerve (dermatomal distribution). Eruption is preceded by deep pain and paresthesia. Postherpetic neuralgia is common in older adults. Secondary infection with necrosis is possible in immunocompromised patients. Distribution: Anterior or posterior trunk following involved dermatome; face, sometimes involving trigeminal nerve and eye In complicated cases, full-thickness skin necrosis has been noted. Nursing Implications: Teach that antiviral drugs such as acyclovir, valacyclovir, or famciclovir, if prescribed, are most helpful in the first 72 hours following eruption. Vaccination is available, and is recommended for those older than 60. Teach about possible complications including Bell palsy, or eye infection if the virus is introduced to the eyes. Compresses, calamine lotion, or baking soda can be soothing.

Furuncles (Bacterial)

S/S: Often called "boils" Inflammation of the hair follicles. Usually associated with Staphylococcus aureus. Initial nodule is deep, firm, red, and painful (1-5 cm in diameter).Lesion changes in a few days of cystic nodule (cellulitis may be present). Distribution: Areas of hair-bearing skin, especially buttocks, thighs, abdomen, posterior neck regions, and axillae. Nursing Implications: Warm compresses can be used. If abscess forms, it will need incision and drainage. Systemic antibiotics may be prescribed.

Cutaneous Anthrax (Bacterial)

S/S: caused by bacillus anthracis. Usually caused by contact with an infected animal (ex: by a farm worker, veterinarian, etc). Often resembles an insect bite, and itches but is painless. May have only one lesion, or multiple ones. In days, the vesicle center sinks inward and begins necrosing. Surrounding tissues has a significant edema. Eschar forms regardless of treatment. Systemic symptoms are flulike (ex: fever, chills, lymphadenopathy) Distribution: May be localized or systemic Nursing Implications: Oral or IV antibiotics are prescribed based on whether infection is localized or systemic. Cutaneous anthrax has been used in bioterrorism; ask questions to determine if the patient has been exposed to animals. If not, report to the appropriate authorities per agent policy.

Folliculitis (Bacterial)

S/S: inflammation of the hair follicles. Can be caused by bacteria, viruses, or fungi, or can be noninfectious (ex: trauma, or plugging of the follicle). Lesions appear as pustules and papules with surrounding erythema. Can be caused by poor hygiene, prolonged skin moisture, occlusive clothing. Distribution: Most commonly scalp and extremities; although can occur anyplace on the body where there is hair. Nursing Implications: Teach proper hygiene methods. Remind patient to keep skin (especially folds) clean and dry. Topical antibiotics may be prescribed.

stage 1 pressure injury

SKIN INTACT Area usually over bony prominence is red, does not blanch with external pressure Observable pressure-related alterations of intact skin For patients with darker skin that does not blanch, observe pressure related alteration of intact skin; changes are compared with an adjacent or opposite area & include one or more of these: Skin color (darker or lighted than the comparison area) Skin temperature (warmth or coolness) Tissue consistency (firm or boggy) Sensation (pain, itching) The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.

stage 2 pressure injury

SKIN NOT INTACT Partial-thickness skin loss of epidermis or dermis Ulcer is superficial, may appear as abrasion, blister (open or fluid-filled), or shallow crater Bruising is not present

Airborne Precuations

Single room under negative pressure Doors remain closed Health care workers wear a respiratory mask (N95 or higher level) Think "MTV": Measles, Tuberculosis, & Varicella (Chickenpox) & disseminated herpes-zoster (Shingles)

Unstageable Pressure Injury

Skin loss is full thickness; and the base is completely covered with slough or eschar, obscuring the true depth of the wound

What is informed consent, and the nurses' role?

Surgery of any type involves invasion of the body and therefore informed consent from the patient or legal guardian. Consent implies that the patient has sufficient information to understand: » The nature of and reason for surgery » Who will be performing the surgery and whether others will be present during the procedure (ex: students, vendors) » All available treatment options, and the benefits and risks associated with each option » The risks associated with the surgical procedure and its potential outcomes » The risks associated with the use of anesthesia » The risks, benefits, and alternatives to use of blood or blood products during the procedure Informed consent protects the patient from unwanted procedures and protects the surgeon and the agency from lawsuit claims related to unauthorized surgery or uninformed patients. It is the surgeon's responsibility to provide a complete explanation of the planned surgical procedure and to have the consent form signed before sedation is given and before surgery is performed. The perioperative nurse is NOT responsible for providing detail information about the surgical procedure. The nurse's role is to CLARIFY facts that have been presented by the surgeon and dispel myths that the patient, family, or caregiver may have about the surgical experience. The nurse must verify that the consent form is signed, dated, and times, and he or she may serve as a witness to the signature, not to the adequacy of the patient's understanding which is the surgeons responsibility.

Regional anesthesia

Temporary interruption of nerve conduction, is produced by injecting an anesthetic solution near the nerves to be blocked. Is the injection or infusion of local anesthetics to block a group of sensory nerve fibers. The anesthetics produce temporary loss of sensation by inhibiting nerve conduction.

C

The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema? A. Foot and ankle B. Forehead C. Sacrum D. Chest

C

The handgrasp strength of a client with metabolic acidosis has diminished since the previous assessment 1 hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team

A

The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? A. "When I eat shrimp, my tongue swells and I have trouble breathing." B. "I'm feeling more anxious about my surgery than I thought I would be." C. "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement." D. "My sister had anesthesia a few months ago and she said she didn't like the way she felt."

C

The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which assessment finding requires immediate nursing intervention? A. Increased itching B. Temperature of 100°F C. Presence of new plaques on leg D. Expression of impaired self-image

A

The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? A. Perform thorough auscultation of the lungs B. Assess response to pinprick stimulation from feet to mid-chest level C. Determine level of consciousness and response to environmental stimuli D. Compare blood pressure findings from preoperative assessment to the present

C,D

The nurse is caring for a client who is to undergo surgery at 6:00 a.m. today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that apply. A. Blood pressure 130/72 mm Hg B. Serum potassium 3.5 mEq/L C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday E. Has not had food or water since 9:00 p.m. last night

C, D, E

The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. A. "Why do you think you're going to get hooked?" B. "Don't worry, I won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."

B

The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-to-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D. "Let's try some relaxation exercises to help address the discomfort you are feeling."

A, C, D

The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A. Left arm prosthesis B. Skin turgor <3 seconds C. Blood pressure 160/100 mm Hg D. Presence of chest rigidity E. Has been NPO since midnight F. Expressed concern about surgery payment

A, C, D, E

The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply. A. Begin practicing leg exercises prior to surgery. B. Repeat leg exercises several times daily for each leg. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

A,B,C,D,E

The nurse takes a history for a client admitted to the hospital. Which factors in the nursing history indicate that the client is at risk for infection? Select all that apply. A. Diabetes mellitus type 2 for 20 years B. 52-pack year history of cigarette smoking C. Admitted from a long-term care facility D. Has a history of multiple urinary tract infections E. Is 84 years of age

B

The primary health care provider has prescribed 1 L of D5NS to infuse at a rate of 125 mL/hr. The nurse begins the infusion at 0700 (7 a.m.). When will the nurse anticipate completion of the infusion? A. 1300 hours (1 p.m.) B. 1500 hours (3 p.m.) C. 1900 hours (7 p.m.) D. 2100 hours (9 p.m.)

B

The surgery for a client scheduled for an 8:00 a.m. procedure is delayed until 11:00 a.m. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? A. Administer at 8:00 a.m. as originally prescribed. B. Adjust the administration time to be given at 10:00 a.m. C. Do not administer, as preoperative prophylactic antibiotics are optional. D. Hold the antibiotic until immediately following surgery, and then administer.

Bacterial Infections

These infections are bigger and more complex than viruses, though they can still spread through the air. This pathogen is a single cell, and it can live and reproduce almost anywhere on its own: in soil, in water and in our bodies. Broad-spectrum antibiotics were developed to kill this pathogen in our bodies and in the food supply by inhibiting their growth. But they are extremely adaptive and can quickly evolve to evade antibiotics. They share their antibiotic-resistant genes with each other, meaning more strains generate resistance to the drugs we use. Types: Folliculitis Furuncles (boils) Cellulitis Methicillin-resistant Staphylococcus aureus Cutaneous anthrax

Fungal Infections

This pathogen are more complicated organisms than viruses and bacteria—they are "eukaryotes," which means they have cells. Of the three pathogens, these are most similar to animals in their structure. There are two main types of this pathogen: environmental, which are yeast and mold that often live in soil and don't generally cause infection in most healthy people; and commensals, which live on and in us and generally don't hurt us. Commensal type of this pathogen, may play a beneficial role in our overall health. Certain environmental types reproduce "spores," particles that can enter our body through the lungs or on the skin. These types can be especially damaging for people with weakened immune systems, as it can spread quickly and damage many organs. They are slower to mutate, so they are easier to target with antifungal medications than bacteria are with antibiotics. Types: Ø Dermatophyte infections Ø Tinea (and location; ex: tinea capitus) Ø Candida albicans

Viral Infections

This pathogen can accomplish nothing—it needs to enter a living thing to perform its only function, which is to replicate. When this pathogen gets inside a human body, it can hijack a person's cellular machinery to produce clones of itself, overtaking more cells and continuing to reproduce. It is also capable of infecting any living thing, including bacteria and fungi. It is also the smallest germ, making them generally the easiest to contract—they're so tiny they can spread through the air in a cough or a sneeze. Some are spread by mosquitoes or through bodily fluid. When it reproduces faster than the immune system can control it, it begins to destroy cells and harm the body. Since each type of this pathogen is very different, no one drug exists to attack whichever pathogen is in your body. Vaccines give preemptive protection from certain pathogens by training the body's immune system to recognize and attack a specific pathogen. Types: Ø Herpes Simplex Virus (HSV) » Type I » Type II Ø Herpes Zoster (Varicella)

Third Intention

Trauma: Phase of Wound Healing delayed closure; high risk for infection with resulting scar

First Intention

Trauma: Phase of Wound Healing edges brought together with skin lined up in correct anatomical position

Second Intention

Trauma: Phase of Wound Healing requires gradual filling in of dead space with connective tissue

Type 1: Rapid or Immediate

Type of Hypersensitivity Reaction Acute inflammation occurs when IgE responds to an antigen such as pollen and causes the release of histamine and other vasoactive amines from basophils, eosinophils, and mast cells. Examples this type of reactions include: angioedema, anaphylaxis, and allergic asthma ; atopic allergies such as hay fever and allergic rhinosinusitis; and allergies to substances such as latex, bee venom, peanuts, iodine, shellfish, drugs, and many other allergens. Allergens can be contacted in these ways: Inhaled (plant pollens, fungal spores, animal dander, house dust, grass, ragweed) Ingested (foods, food additives, drugs) Injected (bee venom, drugs, biologic substances such as contrast dyes) Skin or mucous membrane contacted (latex, pollens, foods, environmental proteins) Some reactions occur just in the areas exposed to the antigen such as the mucous membranes of the nose and eyes, causing symptoms of rhinorrhea, sneezing, and itchy, red, watery eyes. Other reactions may involve all blood vessels and bronchiolar smooth muscle, causing widespread blood vessel dilation, decreased cardiac output, and bronchoconstriction. This condition is known as anaphylaxis, which is a medical emergency and must be treated immediately Release of Histamine: 5 cardinal signs warmth, redness, swelling, pain, decreased function

Type 3: Immune Complex-Mediated

Type of Hypersensitivity Reaction Result from excess antigens causing immune complexes to form in the blood Most autoimmune disorders are caused by this reaction Lupus: Chronic, progressive autoimmune disorder Tissue integrity is lost via excessive inflammation and overactive immunity leading to organ failure and death

Type 2: Cytotoxic

Type of Hypersensitivity Reaction: Body makes autoantibodies directed against self-cells that have some from protein attached to them Inappropriate immunity develops to an adult's own tissues In response, the body's antibodies or lymphocytes are directed against the body's own healthy, normal cells and tissues (not just against invaders) Autoimmune disorders are common, chronic, progressive, self-perpetuating Examples: Ankylosing spondylitis (AS) Autoimmune hemolytic anemia Autoimmune thrombocytopenic purpura Celiac Disease (CeD) Crohn's disease (CD) Diabetes (type 1) Dermatomyositis Erythema nodosum leprosum (ENL) Glomerulonephritis Goodpasture syndrome Graves' disease Hashimoto thyroiditis Hepatitis Idiopathic Addison disease

Type 4: Delayed

Type of Hypersensitivity Reaction: T-lymphocytes (T-cells) are the activated immune system component triggering the excessive responses Antibodies and complement are not involved Sensitized T-cells (from a previous exposure) respond to an antigen by releasing chemical mediators and triggering macrophages to destroy the antigen Occurs hours to days after exposure Edema, induration, ischemia, tissue damage at site of exposure (ex: dermatitis) Examples: Poison Ivy Graft rejection Positive TB skin tests Sarcoidosis is the growth of inflammatory cells in different parts of the body The growths most commonly occur in the lungs, lymph nodes, eyes, and skin

Hay Fever

Type of Type 1 Hypersensitivity Reaction Management first focuses on symptom relief and patient education. Teach the patient about correct use of the drug therapy prescribed. When the specific allergen is identified, such as animal dander, teach him or her to avoid coming into contact with the allergen. If symptoms do not respond to typical drug therapy or if they are severe and chronic, the patient may need immunotherapy for greater relief. Drug therapy for symptom relief can be effective in reducing the allergic response and making the patient more comfortable. Drugs commonly include decongestants and intranasal steroid spray. Antihistamines, leukotriene inhibitors, and mast cell stabilizers block or reduce the amount of chemical mediators in nasal and sinus tissues and prevent local edema and itching. Decongestants constrict blood vessels and decrease edema. Analgesics may be given for pain.

Anaphylaxis

Type of Type 1 Hypersensitivity Reaction is a severe and potentially life-threatening reaction to a trigger such as an allergy. It usually develops suddenly and gets worse very quickly. Symptoms: feeling lightheaded or faint, breathing difficulties- such as fast, shallow breathing, wheezing, a fast heartbeat, clammy skin, confusion and anxiety, and collapsing or losing consciousness Causes: Food-including nuts, milk, shellfish, eggs, and some fruit Medicines-including some antibiotics and non-steroidal anti-inflammatory drugs (NSAIDS) like aspirin Insect stings- particularly wasp and bee stings General anaesthetic Contrast agents- dyes used in some medical tests to help certain areas of your body show up better on scans Latex- a type of rubber found in some rubber gloves and condoms Interventions: Raise feet & legs Discontinue IV fluids or antibiotic Call Rapid Response Team Assess patient Apply oxygen Raise head of bed Administer Epinephrine 1 mg/ml 0.3 to 0.5 ml IM

Angioedema

Type of Type 1 Hypersensitivity Reaction is a severe type I hypersensitivity reaction that involves the blood vessels and all layers of the skin, mucous membranes, and subcutaneous tissues in the affected area. The most common drugs associated with angioedema are angiotensin-converting enzyme inhibitors (ACEIs) used for hypertension (United States Food and Drug Administration [FDA], 2014) and NSAIDs. Although only about 1 in 1000 adults taking these drugs develops angioedema, they are commonly prescribed, which accounts for the high incidence of the response among users of ACEIs and NSAIDs. Nurse role same as anaphylaxis. Keep patient calm and maintain airway.

Purulent Exudate

Type of Wound Exudate Colonization with Staphylococcus Greenish-blue pus causing staining of dressings and accompanied by a "fruity odor" Colonization with Pseudomonas Beige pus with a "fishy" odor Colonization with Proteus Brownish pus with a "fecal" odor Colonization with aerobic coliform and Bacteroides (usually occurs after intestinal surgery)

Serosanguineous Exudate

Type of wound exudate Blood tinged amber fluid consisting of serum and red blood cells Normal for first 48 hr. after injury Sudden increase in amount precedes wound dehiscence in wounds closed by first intention

A

What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1-hour time period? A. Plasma volume osmolarity increases; blood pressure increases B. Plasma volume osmolarity decreases; blood pressure increases C. Plasma volume osmolarity increases; blood pressure decreases D. Plasma volume osmolarity decreases; blood pressure decreases

D

What teaching will the nurse provide when educating about carbon monoxide prevention? A. "Carbon monoxide is only dangerous if accompanied by fire." B. "Black smoke can be seen when carbon monoxide is in the air." C. "Your skin will turn a blue color if you have carbon monoxide poisoning." D. "Put carbon monoxide detectors in your home, because this is an odorless gas."

A,C,D,E

When preparing to discharge a client who has a history of pediculosis, what teaching will the nurse provide? Select all that apply. A. Nits can be removed with a fine-tooth comb. B. Parasites eventually die off without treatment. C. Wash bed linens in hot water to remove lice and eggs. D. Lice can live on clothing items and any surface that is covered by fabric. E. Lice can infest any place on the body with hair, including eyelashes and axillae.

D

When teaching a community group about burn prevention, which education will the nurse include? A. "Have a smoke detector in one central spot in the home." B. "If you use home oxygen, turn it down when you are smoking." C. "Set your water heater temperature below 160°F (71°C.)." D. "Plan several ways of escape from the home in case the primary exit is blocked."

C

Which action will the nurse perform first for a client in anaphylaxis to prevent harm? A. Applying oxygen by nonrebreather mask B. Administering IV diphenhydramine C. Injecting epinephrine D. Initiating IV access

B

Which assessment data is most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L? A. Asking about the use of sugar substitutes B. Determining what drugs are taken daily C. Measuring the client's response to Chvostek testing D. Asking about a history of kidney disease

C

Which client statement regarding treatment of a skin infection requires intervention by the nurse? A. "I am not going to share my clothes with anyone else." B. "Because I am over 60, I am going to get the shingles vaccine." C. "It is important to keep my skin very moist, so I will use lotion." D. "If I get a fever or chills, I will contact my primary health care provider."

A, D, F

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply. A. Blood pressure B. Deep tendon reflexes C. Hand-grip strength D. Pulse rate and quality E. Skin turgor F. Urine output

D

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? A. The client has calf muscle cramping. B. The serum chloride level is low. C. The urine specific gravity is high. D. The hematocrit is 52%.

A,D

Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply. A. Calcium B. Chloride C. Hydrogen D. Potassium E. Sodium F. Sulfate

C

Which new-onset condition or symptom in a client who has systemic lupus erythematosus (SLE) now taking hydroxychloroquine does the nurse deem to have the highest priority for immediate reporting to prevent harm? A. Increased bruising B. Increased daily output of slightly foamy urine C. Failure to see letters in the middle of a word D. Sensation of nausea within an hour of taking the drug

C

Which normal physiologic process contributes most to the need for acid-base balance? A. Continuous organ production of bicarbonate from carbonic acid B. Continuous alveolar exchange of oxygen and carbon dioxide C. Continuous metabolic production of free hydrogen ions D. Continuous kidney formation of urine from blood

D

Which set of client arterial blood gas (ABG) values indicates to the nurse that some mechanisms are working to partially compensate for an acid-base imbalance? A. pH 7.42; Pao2 92 mm Hg; CO2 41 mm Hg; HCO3 − 28 mEq/L (mmol/L) B. pH 7.46; Pao2 98 mm Hg; CO2 38 mm Hg; HCO3 − 30 mEq/L (mmol/L) C. pH 7.22; Pao2 60 mm Hg; CO2 80 mm Hg; HCO3 − 22 mEq/L (mmol/L) D. pH 7.29; Pao2 78 mm Hg; CO2 82 mm Hg; HCO3 − 36 mEq/L (mmol/L)

B

Which specific information will the nurse teach to the client with systemic lupus erythematosus newly prescribed belimumab therapy? A. Avoid injecting it in a site near a cutaneous lesion. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because it causes extreme drowsiness.

B, C, G

Which statement(s) regarding type I hypersensitivity reactions is/are true? Select all that apply. A. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine. B. The response is characterized by the five cardinal symptoms of inflammation. C. Type I responses are usually directed against non-self but the response is excessive. D. Susceptibility for developing a type I hypersensitivity response follows an X-linked recessive pattern of inheritance. E. This type of hypersensitivity reaction is most strongly associated with systemic lupus erythematosus. F. Responses always occur within minutes of exposure to the allergen. G. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

A,E

Which statement(s) regarding type III hypersensitivity reactions is/are true? Select all that apply. A. Type III responses are usually directed against self cells and tissues. B. Susceptibility for developing a type III hypersensitivity response follows an autosomal dominant pattern of inheritance. C. The hypersensitivity starts as a type II reaction that progresses to a type III reaction. D. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. E. Rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity. F. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

A,B,D

Which statements by assistive personnel indicate understanding regarding infection control measures needed to care for a client who has possible Clostridium difficile infection? Select all that apply. A. "I'll wear an isolation gown when providing direct care." B. "I'll wear gloves when providing direct care." C. "I'll wear a mask each time I enter the client's room." D. "I'll use a hand sanitizer when I can't wash my hands." E. "I'll wear goggles to protect my eyes."

D

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia to prevent harm? A. 72-year-old taking the diuretic spironolactone for control of hypertension B. 62-year-old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hr C. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

C,D

With which clients does the nurse remain alert for the possibility of metabolic alkalosis? Select all that apply. A. Client who has been NPO for 36 hours without fluid replacement B. Client receiving a rapid infusion of normal saline C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate D. Client who has had continuous gastric suction for 48 hours E. Client having a sudden and severe asthma attack F. Client with uncontrolled diabetes mellitus

Circulating Nurse

a nurse who assists the scrub nurse and the surgeons during surgery, positioning the patient and equipment, obtaining additional supplies, and adjusting lighting as needed. provides additional supplies and sterile instruments as needed during the operation and assist the other team members in monitoring the status of the patient or helping with the repositioning of the patient during the procedure.

central venous line

a type of intravenous line (IV) that is inserted into a large vein in the body Ex: Single Lumen Central Catheters, Multilumen Central Catheters, (Peripherally inserted central catheter) PICC Problems: Catheter migration-movement of a properly placed catheter tip to another vein Catheter dislodgment- movement into or out of the insertion site Catheter rupture- catheter broken, damaged, or separated from the hub or port Lumen Occlusion- Lumen is partially or totally blocked Catheter related bloodstream infections (CRBSI): most serious problems, often resulting in death, Common in patients with VADs and peripheral catheters, Pathogenic organisms invade the patient's circulation

Hypersensitivity

an exaggerated response by the immune system to a particular substance or allergen This kind of reaction is classified into four basic types: determined by differences in timing, pathophysiology, and symptoms Each type may occur alone or along with one or more of the other types

Local Anesthesia

causes the loss of sensation in a limited area by injecting an anesthetic solution near that area this kind of anesthesia is the infiltration of an anesthetic medication to induce loss of sensation to a body part. Health care providers often use this kind of anesthesia during brief surgical procedures such as removing a skin lesion or suturing a wound by applying anesthetics topically on skin and mucous membranes or injecting them subcutaneously or intradermal to anesthetize a body part. This kind of anesthetics also block motor and autonomic functions, depending on the amount used and the location and depth of administration. Smaller sensory nerve fibers are more sensitive this kind of anesthetics than are large motor fibers. As a result, the patient loses sensation before losing motor function; conversely motor activity returns before sensation.

Squamous Cell Carcinoma

chronic skin damage

peripheral IV line

consists of a short catheter inserted into any vein not in the chest or abdomen. Assessment: § Assess the IV insertion site and transparent dressing on IV site. Check IV insertion site for signs and symptoms of phlebitis or infection. Check for fluid leaking, redness, pain, tenderness, and swelling. IV site should be free from pain, tenderness, redness, and warmth to the touch, or swelling. Complications: infiltration, hematoma, an air embolism, phlebitis, extravascular drug administration, and intra-arterial injection

Melanomas

genetic predisposition, UV exposure, chemical carcinogens, precursor lesions

PACU Nurse

monitoring post-operative patient's levels of recovery and consciousness from anesthesia and providing updates to the treatment as needed. Treating pain, nausea, and other post-operative symptoms of anesthesia and administering medication as prescribed.

Respiratory Acidosis

pH is <7.35 & CO2 >45

Metabolic Acidosis

pH is <7.35, & HCO3 <22

Metabolic Alkalosis

pH is >7.45 & HCO3 >26

Respiratory Alkalosis

pH is >7.45 and CO2 <35

maligant hyperthermia

rare muscle disorder that is chemically induced by anesthetic agents It is an inherited muscle disorder, which is an acute, life-threatening complication of certain drugs used for general anesthesia It is characterized by many problems, including inadequate thermoregulation. The reaction begins in skeletal muscles exposed to the drugs, causing increased calcium levels in muscle cells and increased muscle metabolism. Serum calcium and potassium levels are increased, as is the metabolic rate, leading to acidosis, cardiac dysrhythmias, and a high body temperature. Recognize that you must monitor surgical patients at all times for the cluster of elevated end-tidal carbon dioxide level, decreased oxygen saturation, and tachycardia to identify symptoms of this disease. If these changes begin, respond by alerting the surgeon and anesthesia provider immediately.

Preop Nurse

responsible for assessing the patient's physical, psychologic, and social states; preparing the patient for surgery; and implementing nursing interventions - Confirm patient's ID, PROCEDURE, SITE, SURGEON with patient. - DOCUMENT ALL DATA - Check patient's name against ID bracelet and chart - Confirm discontinue of Anticoagulants 5 to 10 days before surgery, Aspirin 10 days before - Confirm medical history, chart, clearance, medical diagnosis

Actinic Keratosis

sun-damaged skin

General anesthesia

the blockage of all body sensations, causing un-consciousness and loss of reflexes. A patient who gets this kind of anesthesia is completely unconscious (or "asleep"). They can't feel any pain are not aware of the surgery as it happens, and don't remember anything from when they are "asleep". Patients can get this kind of anesthesia through an IV (into a vein) or inhale it through their nose or mouth. A tube places in their throat helps the person breathe while they are under this anesthesia.

Risk Factors for Pressure Injuries

» A: Aging Skin » V: Vascular disorders » O: Obesity » I: Immobility » D: Diabetes » S: Skin friction » P: Poor nutrition » R: Reduced RBCs (anemia) » E: Edema » S: Sensory deficits » S: Sedation