Med Surg 1 Lewis Ch. 20, ATI lab values 2017, Med/Surg: Evolve Chapter 33, Evolve Med surg practice questions, Chapter 46 Bowel Elimination, Chapter 40 - OXYgenation, Fluids and Electrolytes Chapter 41, Chapter 45 Urinary Elmination, Med/Surg: Chapte...

Hypotonic Solutions IV

-Thinner than body fluid -shift fluids from intravascular to tissue cells -usually used when there is a need to *hydrate cells* 1/2 NS

Ch 33

...

Ch 34

...

Ammonia

15 to 45 mcg/dL

Therapeutic INR (when receiving Coumadin)

2-3

Urine pH

4.6-8

What is the Universal blood recipient?

AB+

or which of the following is percutaneous coronary intervention (PCI) most clearly indicated?

Acute myocardial infarction

What is a pneumothorax?

Air in the pleural space = partial or complete lung collapse; as air increases, lung volume decreases

Deoxygenated Blood

Blood high in carbon dioxide and low in oxygen

Diffusion rate of CO2 vs O2

CO2 diffuses 20X faster than O2

The nurse is providing teaching to a patient recovering from an MI. Discussion regarding resumption of sexual activity should be

Discussed along with other physical activities.

COPD - s/s

Dyspnea Chronic cough Sputum production Wheezing/chest tightness Tripod-ing Clubbed nails Prolongued expiration Barrel chest "Pursed lip" breathing Hypoxemia Hypercapnia Polycythemia

What religion won't accept blood transfusions?

Jehovas Witness

1.

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Continue to take vital signs every 15 minutes. c. Administer oxygen therapy at 100% per mask. d. Notify the anesthesia care provider (ACP) immediately. ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration. DIF: Cognitive Level: Analyze (analysis) REF: 356 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids. ANS: B The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable blood pressure and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU to a clinical unit is not appropriate. DIF: Cognitive Level: Analyze (analysis) REF: 353-354 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse positions an unconscious patient supine with the head elevated. c. The new nurse turns an unconscious patient to the side upon arrival in the PACU. d. The new nurse places a patient in the Trendelenburg position when the blood pressure drops. ANS: C The patient should initially be positioned in the lateral "recovery" position to keep the airway open and avoid aspiration. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness. DIF: Cognitive Level: Apply (application) REF: 354 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 4. An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which action by the nurse is most appropriate? a. Refer the patient for home health care services. b. Discuss the specific concerns regarding self-care. c. Give the patient written instructions regarding care. d. Assess the patient's support system for care at home. ANS: B The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care. DIF: Cognitive Level: Apply (application) REF: 362-363 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 5. The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the most appropriate? a. Reinsert the NG tube. b. Give the PRN IV opioid. c. Assist the patient to ambulate. d. Place the patient on NPO status. ANS: C Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains. DIF: Cognitive Level: Analyze (analysis) REF: 360 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 6. A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? a. Notify the patient's surgeon. b. Place the patient on bed rest. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline. ANS: C A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary. DIF: Cognitive Level: Apply (application) REF: 361 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 7. A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful? a. Teach the patient to fully exhale into the incentive spirometer. b. Administer ordered analgesic medications before these activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision. ANS: B An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities. When using an incentive spirometer, the patient should be taught to inhale deeply, rather than exhale into the spirometer to promote lung expansion and prevent atelectasis. DIF: Cognitive Level: Apply (application) REF: 358 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.4° F orally. ANS: C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or crackles, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems. DIF: Cognitive Level: Apply (application) REF: 353 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 9. A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Assess for bladder distention. c. Notify the anesthesia care provider (ACP). d. Demonstrate the use of the nurse call bell button. ANS: B Because the patient's assessment indicates physiologic stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should look for a cause such as bladder distention. Although hypoxemia is the most common cause, the patient's oxygen saturation is 96%. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Orientation of the patient to bed controls is needed, but is not likely to be effective until the effects of anesthesia have resolved more completely. DIF: Cognitive Level: Analyze (analysis) REF: 357 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit? a. Clarify the postoperative orders with the surgeon. b. Help with the transfer of the patient onto a stretcher. c. Document the appearance of the patient's incision in the chart. d. Provide hand off communication to the surgical unit charge nurse. ANS: B The scope of practice of UAP includes repositioning and moving patients under the supervision of a nurse. Providing report to another nurse, assessing and documenting the wound appearance, and clarifying physician orders with another nurse require registered-nurse (RN) level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 354 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 11. A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patient's pain. b. Orient the patient to the unit. c. Take the patient's vital signs. d. Read the postoperative orders. ANS: C Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer. DIF: Cognitive Level: Apply (application) REF: 350 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing ANS: B The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient. DIF: Cognitive Level: Apply (application) REF: 356 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 13. A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the ordered opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines. ANS: B Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action. DIF: Cognitive Level: Apply (application) REF: 357 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 14. A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? a. Perform a bladder scan. b. Encourage increased oral fluid intake. c. Assist the patient to ambulate to the bathroom. d. Insert a straight catheter as indicated on the PRN order. ANS: A The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful. DIF: Cognitive Level: Apply (application) REF: 360-361 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? a. Reinforce the dressing. b. Apply an abdominal binder. c. Take the patient's vital signs. d. Recheck the dressing in 1 hour for increased drainage. ANS: C New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing. DIF: Cognitive Level: Apply (application) REF: 355 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Ask the health care provider to prescribe a different antibiotic. ANS: A A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because a wound infection does not usually occur before the third postoperative day, a wound infection is not a likely source of the elevated temperature. DIF: Cognitive Level: Apply (application) REF: 359 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first? a. Elevate the patient's head. b. Suction the patient's mouth. c. Increase the oxygen flow rate. d. Perform the jaw-thrust maneuver. ANS: D In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake. DIF: Cognitive Level: Apply (application) REF: 351 | 352 | 323 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. b. The patient's temperature is 100.3° F (37.9° C). c. The 24-hour oral intake is 600 mL greater than the total output. d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating. ANS: A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require the health care provider to order diagnostic tests and/or anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities. DIF: Cognitive Level: Apply (application) REF: 363 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 19. A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing knee pain. c. Reassure the patient that postoperative pain is expected after knee surgery. d. Teach the patient that the effects of ketorolac typically last about 6 to 8 hours. ANS: A The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal antiinflammatory drugs (NSAIDs) improves pain control in postoperative patients. Patient teaching and reassurance are appropriate, but should be done after the patient's pain is relieved. If the patient continues to have pain after the morphine is administered, the health care provider should be notified. DIF: Cognitive Level: Apply (application) REF: 358 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 20. The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take? a. Cover the patient with a warm blanket and put on socks. b. Notify the anesthesia care provider about the temperature. c. Avoid the use of opioid analgesics until the patient is warmer. d. Administer acetaminophen (Tylenol) 650 mg suppository rectally. ANS: A The patient assessment indicates the need for active rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common in the immediate postoperative period, there is no need to notify the anesthesia care provider, unless the patient continues to be hypothermic after active rewarming. DIF: Cognitive Level: Apply (application) REF: 359 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 11.2 g/dL d. White blood cells 11,900/µL ANS: B Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. The potassium level is normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response. DIF: Cognitive Level: Apply (application) REF: 173 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 22. The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain ANS: D Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative day. The color and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along the suture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common after surgery. The nurse should have the patient cough and deep breathe, but there is no urgent need to notify the surgeon. DIF: Cognitive Level: Apply (application) REF: 361 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 23. After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100°F (37.8°C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration ANS: A The patient's history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon. Although the information about the other patients indicates a need for ongoing assessment and/or possible intervention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although the nurse will need to have the patient cough and deep breathe. Oral medications typically take more than 15 minutes for effective pain relief. DIF: Cognitive Level: Analyze (analysis) REF: 361 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment OTHER 1. While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Notify the patient's health care provider. ANS: A, C, B, D The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider. DIF: Cognitive Level: Apply (application) REF: 357 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Increase the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flow rate. d. Check the patient's temperature. ANS: A, C, B, D The first nursing action should be to increase the IV infusion rate. Because the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient's temperature should be assessed to determine the effects of vasodilation caused by rewarming. DIF: Cognitive Level: Analyze (analysis) REF: 355-356 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which of the following laboratory studies is abnormal before administering the dose?

Prothrombin time (PT)

What happens in atelactasis?

The alvoeli collapse

Which of the following statements best describes the electrical activity of the heart represented by measuring the PR interval on the ECG?

The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers

For which of the following dysrhythmias is defibrillation primarily indicated?

Ventricular fibrillation

Diastole

When the ventricles fill with blood

Examples of crystalloids

dextrose, NACL, lactated ringers, KCL

A 19-yr-old male patient has a plaster cast applied to the right arm for a Colles' fracture after a skateboarding accident. Which nursing action is most appropriate?

elevate arm on two pillows for 24 hours *rationale* must be elevated above the heart

Third spacing

fluid collection in areas that do not normally have fluid or has minimum amount of fluid

A patient is admitted with the diagnosis of severe left-sided HF. The nurse expects to auscultate which adventitous lung sounds?

inspiratory crackles in lung bases *rationale* Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung bases.

Ostomy

location of an ostomy influences the consistency of stool

What factors affect diffusion?

membrane thickness, surface area, pressure differences, coefficient of the gas

Dysuria

pain or burning while urinating

impaired chest wall movement

reduces the level of tissue oxygenation

Tunneled catheters

silver impregnated cuff is antimicrobial uses Hickman or Groshong needle

NaCl

sodium chloride, or normal saline 0.9%

Breathing exercises improve:

ventilation, oxygenation and sensations of dyspnea*(difficult or labored breathing*

ch 32

...

Which of the following activities can you delegate to nursing assistive personnel? SATA 1) measuring oral intake and urine output 2) preparing IV tubing for routine change 3) Reporting an IV container that is low in fluid 4) Changing an IV fluid container

1, 3

What Beta Blockers are used to treat HTN? What will you see a decrease in, post admin? What are side effects and considerations ass. w/ b blockers?

1. Cardioselective (β1): Atenolol (Tenormin) Metoprolol (Lopressor) 2. Non-cardioselective (β1, β2) Propranolol (Inderal) Decreased HR, BP, contractility, CO and SBP Bradycardia Hypotension Fatigue Weakness Use with caution in heart failure, asthma, diabetics

Magnesium

1.3.-2.1 mg/dL

Fluid intake of pt w/ indwelling or intermittent catheter

2000-2500mL -cranberry, apple juices and prune juice help prevents infections

Normal aPTT

30 to 40 sec

pCO2

35-45 mm Hg

COPD stats

4th cause of death in US More in women and whites

WBC

5,000-10,000

Total protein

6 to 8 g/dL

pH

7.35-7.45

Glucose

70-105 mg/dL

hich of the following individuals would the nurse identify as having the highest risk for CAD?

A 45-year-old depressed male with a high-stress job

Which patient is at greatest risk for sudden cardiac death (SCD)?

A 52-yr-old African American man with left ventricular failure

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which of the following health problems is the patient experiencing? A. Atelectasis B. Bronchospasm C. Hypoventilation D. Pulmonary embolism

A. Atelectasis

What does APA stand for?

American Psychological Association

S2

Aortic and pulmonic close -pressure decreases -systole

A nurse is caring for a client who is experiencing excess fluid volume evidenced by significant dependent edema. A 1,000-mL fluid restriction is prescribed. which nursing intervention is most important?

Assess extent of edema daily

A patient in asystole is likely to receive which of the following drug treatments?

Atropine and epinephrine

Causative Organisms for pneumonia:

CAP: Mycoplasma Strep Haemophilus Legionella Immunocompromised Pneumocystis carinii Viruses: Influenza A Adenovirus Varicella-zoster Togavirus (rubella) Paramyxovirus Herpes simplex Cytomegalovirus Ebstein-Barr

LDL (low-density lipids)

Desirable less than 130 mg/dL

What are the rules regarding chest tubes and clamping?

Don't clamp during transport or if disconnected May be clamped: briefly to change drainage system and to check for leaks Removal requires MD order

Risk factors for pneumonia:

Extended ICU stays, intubations, impaired LOC, ETOH head injury, seizures, overdose, immobility, immunosuppresive therapy, smoking, corticosteroids, cancer, chemo, malnutrition, chronic illness, age, NG feedings, coma

Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply.)?

Ezetimibe (Zetia), Gemfibrozil (Lopid), torvastatin (Lipitor)

Pneumonia: S/S

Fever, chills, crackles, rhonchi, SOB, chest pain, (productive) cough, fremitus, myalgias, sore throat, fatigue, restlessness, lethargy, splinting, tachypnea, use of accessory muscles, decreased chest movement, pleural friction rub, mental status changes

Asthma - risk factors

Genetics Immune response Allergens Exercise Air pollutants Nose/Sinus problems GERD Respiratory infections Influenza Rhinovirus Drugs/Food additives NSAIDS, ASA β-blockers Psychologic factors

What is "type and cross matching"?

It's a process used to determine blood type compatibility between donor and recipient. Determines Rh and ABO.

Decsribe laryngeal polyps MCC S/S TX

MCC: smoking, intubation, singers S/S: hoarseness TX: voice rest, hydration, sx

Phosphate

Most Abundant Anion(-) in the ICF

K+

Most Abundant Cation(+) in the ICF

Dysrhythmias

Rhythm disturbances that tis suppose to take place in the SA node. -occurs in response to ischemia (inadequate blood supply to organ or tissue)

What are modifiable cardiovascular risk factors?

Tobacco Use Substance abuse Physical inactivity Obesity Psychological factors Chronic disease

The patient has frostbite on the distal toes of both feet. The patient is scheduled for amputation of damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability?

arteriogram showing blood vessel *rationale* Arteriography determines viable tissue for salvage based on blood flow observed in real time and is considered the gold standard for evaluating arterial perfusion. Only arteriography determines where tissue perfusion stops and amputation needs to occur. Bilateral peripheral pulse assessment and areas of black, indurated, cold, and pale skin indicate ischemia

Frank-Starling Law of the Heart

as myocardium stretches, the strength of the subsequent contraction increase

Which of the following medications listed a patient's medication history possibly causes GI bleeding? SATA 1) Aspirin 2) Cathartics 3) Antidiarrheal opiate agents 4) NSAIDS

aspirin and NSAIDS *rationale* rectal bleeding for both

What is the "door to balloon" core measure?

balloon will be in place and blown within 90 minutes of arriving at the hospital.

Left Sided Heart Failure

caused by decreased function of the left ventricle

The nurse notes that the patient's foley catheter bag has been empty for 4 hours. The priority action would be to:

check for kinks in the tubing *rationale* kinks in tubing prevent flow of urine. To keep the drainage system patent, check for kinks or bends in the tubing.

Dyspnea

clinical sign of hypoxia -SOB associated with exercise or excitement

Which of the following may cause Clostridium difficile infection?

contact with C.Dif and overuse of antibiotics (kills normal flora allowing other infections)

Heart deliverances

delivers deoxygenated blood to the lungs for oxygenation and oxygen and nutrients to the tissues

Atrial fibrillation i

epresented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating.

Diffusion

exchange of respiratory gases in the alveoli and capillaries

Patients with lung disease have difficulty with that

excretion of carbonic acid (CO2) -allows blood to be more acidic

breathing at an abnormally slow rate resulting in increased carbon dioxide in blood

hypoventilation

The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus?

immobilize the fracture post op *rationale* The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

Right Sided Heart Failure

impaired functioning of the right ventricle -results from pulmonary disease from chronic LS HF

Implanted CVAD's

implanted port titanium or plastic resevoir subcutaneous pocket under the skin self-sealing septum made of silicone

Airway Resistance

increase in pressure that occurs as the diameter of the airway decreases from mouth/nose to alveoli. rationale: increases from asthma and tracheal edema diseases

What is surfactant? What does it do? Where is it produced?

lipoprotein lowers alveolar surface tension made by Type II alveolar cells sighs promote secretion

Patient lays in what postion for the removal of a PICC?

low semi-fowlers and doing valsalva maneuver to prevent air embolism, remaining like this for 30 minutes after

The nurse instructs a client with a full thickness burn injury of the legs about an appropriate diet. The nurse determines teaching is successful if the client selects which menue?

meat and orange juice rationale: protein great to prevent catabolism and vitamin C promotes wound healing

Normal Saline

most safest because it exerts the same osmotic pressure as fluids in interstital spaces surrounding the bowel

Removal of a PICC

never pull against resistance! x-ray if stuck use fluid gectures take 1-2" at a time keeps hands close to site so end isn't flopping around

A 28-yr-old woman with a fracture of the proximal left tibia in a long leg cast and complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority?

notify HCP *rationale* when a patient condition changes, RN must notify always

Vagal Stimulation

slows the HR, occurs during straining while defecating, taking rectal temperatures, enemas, and digital removal of impacted stool

COPD - tx

smoking cessation vaccination Bronchodilators Β2 adrenergic agonists Anticholinergic agents Methylxanthines Corticosteroids ICS O2 therapy

This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request?

"Excess edema and complications are prevented when the leg is elevated for 24 hours." *rationale* or the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome

The nurse instructs a 68-yr-old woman with hypercholesterolemia about natural lipid-lowering therapies. The nurse determines further teaching is necessary if the patient makes which statement?

"I will take garlic instead of my prescription medication to reduce my cholesterol." *rationale* Current evidence does not support using garlic in the treatment of elevated cholesterol.

A 62-year-old woman patient is scheduled for a percutaneous transhepatic cholangiography to restore biliary drainage. The nurse discusses the patient's health history and is most concerned if the patient makes which statement? "I am allergic to bee stings." "My tongue swells when I eat shrimp." "I have had epigastric pain for 2 months." "I have a pacemaker because my heart rate was slow."

"My tongue swells when I eat shrimp." The percutaneous transhepatic cholangiography procedure will include the use of radiopaque contrast medium. Patients allergic to shellfish and iodine are also allergic to contrast medium. Having a pacemaker will not affect the patient during this procedure. It would be expected that the patient would have some epigastric pain given the patient's condition.

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which of the following

2.2

HCO3

21-26 mmole/L

You assess four patients. Which patient is at greatest risk for the development of hypocalcemia?

28 year-old who has acute pancreatitis *rationale*People who have acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. This is called *steatorrhea*. This process decreases absorption of dietary calcium and also increases calcium output by preventing resorption of calcium contained in gastrointestinal fluids

You assess four patients. Which patient is at greatest risk for the development of hypocalcemia? 1) 56 year old with acute kidney renal failure 2) 40 year old with appendicitis 3) 28 year old who has acute pancreatitis 4) 65 year old with hypertension and asthma

3) 28 year old who has acute pancreatitis Rationale: Acute pancreatitis precipitates calcium as a soap in the abdomen, causing hypocalcemia. Hungry bone syndrome is hypocalcemia after surgery for hyperparathyroidism (HPT) in patients with severe prolonged disease (secondary or tertiary HPT in renal failure). Serum calcium is rapidly deposited into the bone.

Which of the following defining characteristics is consistent with fluid volume deficit? 1) A 1-lb weight loss, pale yellow urinte 2) engorged neck veins when upright, bradycardia 3) Dry mucous membranes, thready pulse, tachycardia 4) Bounding radial pulse, flat neck veins when supines

3) Dry mucous membranes, thready pulse, tachycardia Rationale: With lack of volume, patients will slow down to compensate for the fluid loss

Phosphorus

3.0-4.5 mg/dL

Albumin

3.5-5 g/dL

Potassium

3.5-5.0 mEq/L

How long after being brought up from the blood bank must the blood be infused?

30 minutes

Asthma - stats

300m world 22m US Occurs at all ages 50% during childhood 33% before the age of 40 After puberty, 66% - women + higher death rate

Which patient do you plan to teach regarding water restriction?

34 year old with hyponatremia *rationale* Hyponatremia involves excessive water for the amount of sodium in the blood; the body fluids are too dilute. Therefore water restriction is the most common therapy for hyponatremia.

Hematocrit for female

37-47%

Number the steps to irrigating a NG in correct order: 1) slowly aspirate the syringe 2) reconnect the NG tube to suction 3) Tells the patient to breathe slowly and relax 4) Perform hand hygiene and apply clean gloves 5) Insert tip of syringe into NG tube and slowly inject 30 mL

4 - Perform hand hygiene apply clean gloves 3 - tells the patient to breathe slowly and relax 5 - Insert tip of syringe into NG tube and slowly inject 30 mL 1 - slowly aspirate the syringe 2 - reconnect the NG tube to suction

An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to:

4) initial kegal exercises *rationale* -kegel exercises strengthen pelvin floor muscles and help in urine control

RBC for females

4.2-5.4 million

RBC for males

4.7-6.1 million

Hematocrit for male

42-52%

Place the following steps for IV catheter insertion in the correct order: 1) perform hand hygiene 2) Open and prepare infusion set 3) select appropriate vein and insert catheter 4) use 2 identifiers to ensure correct patient 5) Assess for risk factors such as age or platelet count 6) carefully check the health care provider's order for the IV therapy

6 5 4 1 2 3 See skill 41-1 assess first then implement. Always check the orders

Place the following steps for IV catheter insertion in the correct order: 1) Perform hand hygiene 2) open and prepare infusion set 3) select appropriate vein and insert catheter 4) use 2 identifiers to ensure correct patient 5) assess for risk factors such as age or platelet count 6) carefully check the health care provider's order for the IV therapy

6, 5, 4, 1, 2, 3

Fluid makeup in the body?

60-body weight is water 40 is ICF 20 is ECF

You assess four patients. Which patient has greatest risk for hypomagnesemia?

72 year old with chronic alcoholism *rationale* Patients who have chronic alcoholism are at high risk for hypomagnesemia because of decreased magnesium intake and absorption and increased magnesium excretion.

A cleansing enema is ordered for a 55-year old patient before intestinal surgery. The nurse understands that the maximum amount of fluid given is

750-1000 mL *rationale* More than 1000 mL of fluid causes distention to the point of rupturing the bowel.

Atmosphereic Pressure

760 mm Hg at sea level

pO2

80-100 mm Hg

Total Calcium

9-10.5 mg/dL

Describe a febrile nonhemolytic transfusion rxn

90% of all reactions; fever, chills; recipient's antibodies react to antigens in the donor's blood

Chloride lab value

96-106

Chloride

98 to 106 mEq/L

HgA1c

<6.5%

PaO2 values to remember

>60 = adequate, O2 sat >90 = adaquate

Which of these patients do you expect will need teaching regarding dietary sodium restriction? 1) an 8 year old with a fracture femur scheduled for surgery 2) A 65 year old recently diagnosed with HF 3) a 50 year old recently diagnosed with asthma and diates 4) a 20 year old with vomiting and diarrhea from gastroenteritis

A 65-year-old recently diagnosed with HF

The nurse recognizs which patient needs to use a fracture pan for a bowel movement?

A patient recovering from hip surgery *rationale* A fracture pan is used for a patient with back or lower-extremity health issues. Because a fracture pan is shallow in comparison to a regular bedpan, the fracture pan prevents disturbing the patient's body alignment.

Which of the following statements by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? A. "It is essential that you maintain aseptic technique to prevent peritonitis." B. "You will be allowed a more liberal protein diet once you complete CAPD." C. "It is important for you to maintain a daily written record of blood pressure and weight." D. "You will need to continue regular medical and nursing follow-up visits while performing CAPD."

A. "It is essential that you maintain aseptic technique to prevent peritonitis."

Which of the following events in the surgical suite represents a violation of aseptic technique? A. A drape contacts the leg of the table that supports the sterile field. B. The cuff of the scrub nurse's sterile gown contacts the sterile field. C. The sterile field was established at 0650 and the current time is 0900. D. Bacteria are present in the nares and upper respiratory passages of the nurse.

A. A drape contacts the leg of the table that supports the sterile field.

Which of the following nursing diagnoses is a priority in the care of a patient with renal calculi? A. Acute pain B. Deficient fluid volume C. Risk for constipation D. Risk for powerlessness

A. Acute pain

In planning postoperative interventions to promote ambulation, coughing, deep breathing, and turning, the nurse recognizes that which of the following actions will best enable the patient to achieve the desired outcomes? A. Administering adequate analgesics to promote relief or control of pain B. Asking the patient to demonstrate the postoperative exercises every 1 hour C. Giving the patient positive feedback when the activities are performed correctly D. Warning the patient about possible complications if the activities are not performed

A. Administering adequate analgesics to promote relief or control of pain

Allergic vs. febrile vs. hemolytic rxns 1. Symptoms of each

A. Allergic - facial flushing, hives/rash, increased anxiety, decreased BP, dyspnea B. Febrile - fever, chills, anxiety, headache, tachydardia, tachypnea C. Hemolytic - chest pain, low back back pain, fever, chills, tachycardia, apprehension, decreased BP, increased resp. rate

The nurse is assigned to the care of a 64-year-old patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in management of the diabetes, which of the following should be the nurse's initial intervention? A. Assess patient's perception of what it means to have diabetes. B. Ask the patient to write down current knowledge about diabetes. C. Set goals for the patient to actively participate in managing his diabetes. D. Assume responsibility for all of the patient's care to decrease stress level.

A. Assess patient's perception of what it means to have diabetes.

A patient in asystole is likely to receive which of the following drug treatments? A. Atropine and epinephrine B. Lidocaine and amiodarone C. Digoxin and procainamide D. β-Adrenergic blockers and dopamine

A. Atropine and epinephrine

The nurse is assisting a diabetic patient to learn dietary planning as part of initial management of diabetes. The nurse would encourage the patient to limit intake of which of the following foods to help reduce the percent of fat in the diet? A. Cheese B. Broccoli C. Chicken D. Oranges

A. Cheese

The nurse has been teaching a patient with diabetes mellitus how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does which of the following? A. Chooses a puncture site in the center of the finger pad B. Washes hands with soap and water to cleanse the site to be used C. Warms the finger before puncturing the finger to obtain a drop of blood D. Tells the nurse that the result of 120 mg/dl indicates good control of diabetes

A. Chooses a puncture site in the center of the finger pad

The nurse is evaluating a 45-year-old patient diagnosed with type 2 diabetes mellitus. Which of the following symptoms reported by the patient is considered one of the classic clinical manifestations of diabetes? A. Excessive thirst B. Gradual weight gain C. Overwhelming fatigue D. Recurrent blurred vision

A. Excessive thirst

Lab results are back for a 54-year-old patient with a 15-year history of diabetes. Which of the following lab results follows the expected pattern accompanying macrovascular disease as a complication of diabetes? A. Increased triglyceride levels B. Decreased low-density lipoproteins C. Increased high-density lipoproteins D. Decreased very-low-density lipoproteins

A. Increased triglyceride levels

Eight months after the delivery of her first child, a 31-year-old woman has sought care because of occasional incontinence that she experiences when sneezing or laughing. Which of the following measures should the nurse first recommend in an attempt to resolve the woman's incontinence? A. Kegel exercises B. Use of adult incontinence pads C. Intermittent self-catheterization D. Dietary changes including fluid restriction

A. Kegel exercise

A surgical patient's premedication regimen includes midazolam (Versed). The most likely desired effects of this medication are A. Monitored anesthesia care and amnesia. B. Induction and maintenance of anesthesia. C. Analgesia and prevention of intraoperative vomiting. D. Relaxation of skeletal muscles and facilitation of endotracheal intubation.

A. Monitored anesthesia care and amnesia.

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take? A. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. B. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. C. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. D. Ask the patient to hold the

A. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.

A patient has sought care following a syncopal episode of unknown etiology. Which of the following nursing actions should the nurse prioritize in the patient's subsequent diagnostic workup? A. Preparing to assist with a head-up tilt-test B. Assessing the patient's knowledge of pacemakers C. Preparing an intravenous dose of a B-adrenergic blocker D. Teaching the patient about the role of antiplatelet aggregators

A. Preparing to assist with a head-up tilt-test

A patient is admitted with diabetes mellitus, malnutrition, and cellulitis. The patient's potassium level is 5.6 mEq/L. The nurse considers that which of the following could be a contributing factor for this lab result (select all that apply)? A. The level may be increased as a result of dehydration that accompanies hyperglycemia. B. The patient may be excreting extra sodium and retaining potassium because of malnutrition. C. The level is consistent with renal insufficiency that can develop with renal nephropathy. D. tThe level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia.

A. The level may be increased as a result of dehydration that accompanies hyperglycemia. C. The level is consistent with renal insufficiency that can develop with renal nephropathy. D. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia.

For which of the following dysrhythmias is defibrillation primarily indicated? A. Ventricular fibrillation B. Third-degree AV block C. Uncontrolled atrial fibrillation D. Ventricular tachycardia with a pulse

A. Ventricular fibrillation

What medications are Hyperkalemia associated with?

ACE and Potassium sparing

1.ID: 36254503 The nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which of the following injection sites should the nurse use to administer this medication safely?

Abdomen, anterior-lateral aspect

The nurse is reviewing the home medication list for a 44-year-old man admitted with suspected hepatic failure. Which medication could cause hepatotoxicity? Nitroglycerin Digoxin (Lanoxin) Ciprofloxacin (Cipro) Acetaminophen (Tylenol)

Acetaminophen Many chemicals and drugs are potentially hepatotoxic (see Table 39-6) and result in significant patient harm unless monitored closely. For example, chronic high doses of acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) may be hepatotoxic.

Tx for Tb

Active TB: 6 mo/4 drugs (INH, rifampin, pyrazinamide, ethambutol), side effect non-viral hepatitis!! Latent TB infection: 6-9 mo/1 drug (INH) BCG vaccine - causes false-positive PPD but not IGRA

What is a critical step when inserting an indwelling catheter into a male patient?

Advance the catheter to the bifurcation of the drainage and balloon ports *rationale* Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic urethra causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter drainage tubing to the bed sheets increases the risk for accidental pulling or tension on the catheter. The advancement of the catheter until flows and then inserting ¼ inch more is not unique to the male patient.

Primary HTN risk factors:

Age Alcohol use Cigarette smoking Diabetes Elevated serum lipids Excess dietary sodium Gender (w) Family history Obesity Sedentary lifestyle Socioeconomic status Stress Ethnicity: African Americans have highest incidence of HTN

Where diffusion of respirator gases occurs?

Alveolar Capillary Membrane examples of slow diffusion: when increased thickness occurs, gases will take longer to transfer across the membrane. Disease such as pulmonary edema, pulmonary infiltrates, or pulmonary effusion (thickened membranes)

Flushing a CVAD

Always use a 10 ml syringe Scrub port with alcohol for 15 sec. prior to accessing Use SAS(H) technique Use pulsating flush technique to break up fibrin Maintain IV at KVO rate - Central line/PICC - 10ml NACL after meds and every shift, 20ml after TPN - Implanted port - 10ml NACL+2ml heparin after meds, 20ml+2ml heparin after TPN

What two toxic substances decrease the oxygen-carrying capacity of blood

Anemia and inhalation of toxic substances like CO (Carbon Monoxide). -these reduces the amount of hemoglobin available -hemoglobin binds with CO making less hemoglobin available for oxygen

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which of the following symptoms?

Anorexia and nausea

Treating pneumonia:

Antibiotics Empiric therapy MDR organisms O2 Analgesics Antipyretics Hydration - Oral/IV

Stable angine - tx

Antiplatelets, nitroglycerin, lipid-lowering agents, β-adrenergic blockers, Ca-channel blockers Manage risk factors Re-establish blood flow Surgery

Asthma - s/s - mild vs severe

Anxiety Expiratory wheezing Dyspnea Cough Prolonged expiration Tachycardia Tachypnea Severe attacks: Use of accessory muscles Wheezing during inspiration and expiration Pulsus paradoxus Dyspneic at rest Speaks in words, not sentences Sits forward Tachypneic (> 30/min) Tachycardic (>120/min) PEFR < 40% of personal best or < 200 L/min JVD

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which common complication?

Arterial dysrhythmias *rationale* Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days after CABG surgery. Although the other complications could occur, they are not common complications.

When assessing a 55-year old patient who is in the clinic for a *routine physical*, the nurse instructs the patient about the need to obtain a stool specimen for *guaiac fecal occult blood testing*

As part of a routine examination for colon cancer *rationale* This is used as a diagnostic screening tool for colon cancer as recommended by the American Cancer Society.

The nurse would assess a patient with complaints of chest pain for which of the following clinical manifestations associated with a myocardial infarction (MI) (select all that apply)?

Ashen skin CorrectDiaphoresis CorrectNausea and vomiting CorrectS3 or S4 heart sounds <div>During the initial phase of an MI, catechola

Before collecting a stool sample for occult blood, the nurse instructs the nursing assistive personnel to:

Ask the patient to void *rationale* Emptying the urinary bladder before collecting the stool sample prevents contamination of the specimen.

A nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which of the following assessments are appropriate for this patient (select all that apply)?

Assess for return of gag reflex. Monitor vital signs and oxygen saturation.

The pt is incontinent, and a condom catheter is placed. The nurse should take which action?

Assess patient for skin irritation *rationale* skin irritation can occur when the condom is twisted at the drainage tube attachment and obstructs urine drainage

The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which of the following nursing interventions is most appropriate at this time?

Assessing the incision for any redness, swelling, or discharge

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which of the following common complications?

Atrial dysrhythmias

The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets that this rhythm is which of the following?

Atrial fibrillation

Which of the following assessments do you perform routinely when an OLDER adult is receiving IV 0.9% NaCl

Auscultate dependent portions of lungs

The nurse has taught a patient admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes which of the following statements? A. "I should only walk barefoot in nice dry weather." B. "I should look at the condition of my feet every day." C. "I am lucky my shoes fit so nice and tight because they give me firm support." D. "When I am allowed up out of bed, I should check the shower water with my toes."

B. "I should look at the condition of my feet every day."

A 54-year-old patient admitted with type 2 diabetes, asks the nurse what "type 2" means. Which of the following is the most appropriate response by the nurse? A. "With type 2 diabetes, the body of the pancreas becomes inflamed." B. "With type 2 diabetes, insulin secretion is decreased and insulin resistance is increased." C. "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." D. "With type 2 diabetes, the body produces autoantibodies that destroy -cells in the pancreas."

B. "With type 2 diabetes, insulin secretion is decreased and insulin resistance is increased."

The patient received regular insulin 10 units subcutaneously at 8:30 pm for a blood glucose level of 253 mg/dl. The nurse plans to monitor this patient for signs of hypoglycemia at which of the following peak action times? A. 9:00 pm to 10:30 pm B. 10:30 pm to 11:30 pm C. 12:30 am to 1:30 am D. 2:30 am to 4:30 am

B. 10:30 pm to 11:30 pm

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia unit. Which of the following should be the nurse's initial action upon the patient's arrival? A. Assess the patient's pain. B. Assess the patient's vital signs. C. Check the rate of the IV infusion. D. Check the physician's postoperative orders.

B. Assess the patient's vital signs.

The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets that this rhythm is which of the following? A. Sinus tachycardia B. Atrial fibrillation C. Ventricular fibrillation D. Ventricular tachycardia

B. Atrial fibrillation

A patient with a history of end-stage renal disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for his scheduled hemodialysis. Which of the following assessments should the nurse prioritize before, during, and after his treatment? A. Level of consciousness B. Blood pressure and fluid balance C. Temperature, heart rate, and blood pressure D. Assessment for signs and symptoms of infection

B. Blood pressure and fluid balance

The nurse is admitting a patient with the diagnosis of advanced renal carcinoma. Based upon this diagnosis, the nurse will expect to find which of the following as the "classic triad" of presenting symptoms occurring in patients with renal cancer? A. Fever, chills, flank pain B. Hematuria, flank pain, palpable mass C. Hematuria, proteinuria, palpable mass D. Flank pain, palpable abdominal mass, and proteinuria

B. Hematuria, flank pain, palpable mass

Which of the following assessment findings is a consequence of the oliguric phase of acute kidney injury (AKI)? A. Hypovolemia B. Hyperkalemia C. Hypernatremia D. Thrombocytopenia

B. Hyperkalemia

The nurse is admitting a patient to the same-day surgery unit. The patient tells the nurse that he was so nervous he had to take kava last evening to help him sleep. Which of the following nursing actions would be most appropriate? A. Tell the patient that using kava to help sleep is often helpful. B. Inform the anesthesiologist of the patient's recent use of kava. C. Tell the patient that the kava should continue to help him relax before surgery. D. Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.

B. Inform the anesthesiologist of the patient's recent use of kava.

Which of the following intraoperative nursing responsibilities would be performed by the scrub nurse (select all that apply)? A. Documenting intraoperative care B. Keeping track of irrigation solutions for monitoring of blood loss C. Passing instruments and supplies to the surgeon by anticipating his or her needs D. Coordinating the flow and activities of members of the surgical team in the surgical suite E. Performing the count of sponges, needles, and instruments used during the surgical procedure

B. Keeping track of irrigation solutions for monitoring of blood loss C. Passing instruments and supplies to the surgeon by anticipating his or her needs E. Performing the count of sponges, needles, and instruments used during the surgical procedure

The perioperative nurse would recognize the need to monitor the patient for hallucinations and agitation when which of the following anesthetic agents is administered? A. Nitrous oxide B. Ketamine (Ketalar) C. Thiopental (Pentathal) D. Halothane (Fluothane)

B. Ketamine (Ketalar)

Unless contraindicated by the surgical procedure, which of the following positions is preferred for the unconscious patient immediately postoperative? A. Supine B. Lateral C. Semi-Fowler's D. High-Fowler's

B. Lateral

The nurse is beginning to teach a diabetic patient about vascular complications of diabetes. Which of the following information would be appropriate for the nurse to include? A. Macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease. B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. C. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control. D. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes.

B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin.

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates A. Hypocapnia. B. Muscle rigidity. C. Decreased body temperature. D. Confusion upon arousal from anesthesia.

B. Muscle rigidity.

Before admitting a patient to the operating room, the nurse recognizes that which of the following must be in the chart of all patients (select all that apply)? A. Electrocardiogram B. Signed consent form C. Functional status evaluation D. Renal and liver function tests E. physical examination report

B. Signed consent form E. physical examination report

Which of the following nursing interventions is appropriate in providing care for an adult patient with newly diagnosed adult onset polycystic kidney disease (PKD)? A. Help the patient cope with the rapid progression of the disease. B. Suggest genetic counseling resources for the children of the patient. C. Expect the patient to have polyuria and poor concentration ability of the kidneys. D. Implement appropriate measures for the patient's deafness and blindness in addition to the renal problems.

B. Suggest genetic counseling resources for the children of the patient.

The nurse obtains a 6-second rhythm strip and charts the following analysis: atrial rate 70, regular; ventricular rate 40, regular; QRS 0.04 sec; no relationship between P waves and QRS complexes; atria and ventricles beating independently of each other. Which of the following would be a correct interpretation of this rhythm strip? A. Sinus dysrhythmias B. Third-degree heart block C. Wenckebach phenomenon D. Premature ventricular contractions

B. Third-degree heart block

Major buffer system in the ECF

Bicarbonate -a base -which buffers metabolic acids or in other worse

How do diuretics work? What are common side effects? What are some important things to watch for?

Block Na+ reabsorption in nephron - Na+ follows water and increases water/urine excretion Loop of henle has highest concentration of Na = loop diuretics are the most potent Side Effects: F&E imbalances, CNS effects, GI effects Nursing Considerations: Monitor for orthostatic hypotension Dehydration Hypokalemia Loop & B- blockers are recommended for initial drug therapy of uncomplicated HTN Thiazides first and most commonly used due to more gentle diuresis

Oxygenated Blood

Blood high in oxygen and low in carbon dioxide

The priority nursing assessment of a patient receiving IV nesiritide (Natrecor) to treat HF would be

Blood pressure

Cyanosis

Blue discoloration of the skin and mucous membranes. A LATE sign of hypoxia

What is collateral circluation?

Body's defense mechanism to prevent ischemia If given enough time, vessels will grow around the blockage and blood supply will continue

Asthma - pathophysiology/what happens?

Bronchoconstriction Airway hyper-responsiveness Airway edema Increased mucus production Airway obstruction = ↑ airway resistance, ↓ flow rates = hypoxemia, hyperventilation (↓ PaCO2) = ↑Airway obstruction, ↑Air trapping = lungs hyper-expanded, respiratory muscles work harder, CO2 retained = respiratory acidosis = respiratory failure

The nurse is caring for a patient admitted with emphysema, angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which of the following adverse effects is this patient at risk for given the patient's health history?

Bronchospasm

Beth enters Mr. Kelter's room after lunch to perform straight catheterization. List in order the steps Beth takes to perform straight catheterization on Mr. Kelter. A. Lubricate the catheter. B. Clean penis with dominant hand. C. Apply sterile gloves. D. Advance catheter into penis. E. Apply fenestrated drape. F. Hold penis with nondominant hand. G. Ask patient to bear down. H. Coil catheter in dominant hand.

C - Apply Sterile Gloves E - Apply fenestrated drape A - Lubricate the Catheter F - Hold penis with nondominant hand B - Clean penis with dominant hand H - Coil/hold catheter in dominant Hand G - Ask patient to Bear down D - Advance catheter into penis

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be which of the following? A. 60 Beats/min B. 75 Beats/min C. 100 Beats/min D. 150 Beats/min

C. 100 Beats/min

Which of the following preoperative patients likely faces the greatest risk of bleeding as a result of their medication? A. A woman who takes metoprolol (Lopressor) for the treatment of hypertension B. A man whose type 1 diabetes is controlled with insulin injections four times daily C. A man who is taking clopidogrel (Plavix) after the placement of a coronary artery stent D. A man who recently started taking finasteride (Proscar) for the treatment of benign prostatic hyperplasia

C. A man who is taking clopidogrel (Plavix) after the placement of a coronary artery stent

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, the nurse should do which of the following? A. Recheck in 1 hour for increased drainage. B. Notify the surgeon of a potential hemorrhage. C. Assess the patient's blood pressure and heart rate. D. Remove the dressing and assess the surgical incision.

C. Assess the patient's blood pressure and heart rate.

The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which of the following nursing interventions is most appropriate at this time? A. Reinforcing the pressure dressing as needed B. Encouraging range-of-motion exercises of the involved arm C. Assessing the incision for any redness, swelling, or discharge D. Applying wet-to-dry dressings every 4 hours to the insertion site

C. Assessing the incision for any redness, swelling, or discharge

An elderly male patient visits his primary care provider because of burning on urination and production of urine that he describes as "foul smelling." The health care provider should assess the patient for which of the following factors that may dispose him to urinary tract infections (UTIs)? A. High-purine diet B. Sedentary lifestyle C. Benign prostatic hyperplasia (BPH) D. Recent use of broad-spectrum antibiotics

C. Benign prostatic hyperplasia (BPH)

A patient is admitted with diabetes mellitus, has a glucose level of 380 mg/dl, and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which of the following respiratory patterns would the nurse expect to find? A. Central apnea B. Hypoventilation C. Kussmaul respirations D. Cheyne-Stokes respirations

C. Kussmaul respirations

A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. Which of the following is an expected assessment finding for this patient during this early stage of recovery? A. Hypokalemia B. Hyponatremia C. Large urine output D. Leukocytosis with cloudy urine output

C. Large urine output

A 54-year-old patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 am. The nurse instructs the patient to only drink water after what time? A. 6:00 pm on the evening before the test B. 4:00 am on the day of the test C. Midnight before the test D. 7:00 am on the day of the test

C. Midnight before the test

The nurse is teaching a 54-year-old patient with diabetes about proper composition of the daily diet. The nurse explains that the guideline for carbohydrate intake is which of the following? A. 80% of daily intake B. Minimum of 80 g/day C. Minimum of 130 g/day D. Maximum of 130 g/day

C. Minimum of 130 g/day

Which of the following ECG characteristics is consistent with a diagnosis of ventricular tachycardia (VT)? A. Unmeasurable rate and rhythm B. Rate 150 beats/min; inverted P wave C. Rate 200 beats/min; P wave not visible D. Rate 125 beats/min; normal QRS complex

C. Rate 200 beats/min; P wave not visible

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that A. She must be NPO after breakfast. B. She needs to be NPO after midnight. C. She can drink clear liquids up to 2 hours before surgery. D. She can drink clear liquids up until she is moved to the OR.

C. She can drink clear liquids up to 2 hours before surgery.

Which of the following is the primary reason for accurately recording the patient's current medications during a preoperative assessment? A. Some medications may alter the patient's perceptions about surgery. B. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. C. Some medications may interact with anesthetics, altering the potency and effect of the drugs. D. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.

C. Some medications may interact with anesthetics, altering the potency and effect of the drugs.

As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring. Which of the following is the most appropriate action by the nurse? A. Insist the patient remove the ring for safety purposes. B. Explain that the hospital will not be responsible for the ring. C. Tape the ring securely to the finger and document this on the preoperative checklist. D. Note the presence of the ring in the nurse's notes of the chart and on the preoperative checklist.

C. Tape the ring securely to the finger and document this on the preoperative checklist.

Which of the following statements best describes the electrical activity of the heart represented by measuring the PR interval on the ECG? A. The length of time it takes to depolarize the atrium B. The length of time it takes for the atria to depolarize and repolarize C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers D. The length of time it takes for the electrical impulse to travel from the SA node to the AV node

C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers

Diagnostic studies used to assess respiratory fxn:

CBC, ABGs, Oximetry, IGRA Skin Tests Sputum C&S/Gram stain Acid-fast Cytology Most common = CXR Pulmonary angiogram = gold standard Bronchoscopy Thoracentesis (tripod position)

What happens in the event pH rises too high?

CNS depression will result. -deep rapid breathing -decreased BP -coma or death

Coronary Artery Disease - stats

CV is #1 cause of death in US Def: heart disease from impaired coronary blood flow by atherosclerosis Mortality rate decreasing

Diagnostic studies for lung cancer

CXR CT scan (most effective non-invasive technique) PET (for metastases) Sputum cytology - only 20-30% positive Biopsy - definitive diagnosis Fine needle aspiration Bronchoscopy Thoracoscopy Thoracentesis

Describe cardiovascular changes associated with aging

Calcification in valves Pacemaker cells decrease in number Conduction time lengthens Left ventricle size increases (dilates) Aorta and large vessels thicken and become stiffer Baroreceptors less sensitive

Where does the exchange of respiratory gases occur?

Capillary level where the tissues are oxygenated.

patient was admitted to the emergency department 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). Which of the following complications of MI should the nurse anticipate

Cardiac dysrhythmias

A patient who started smoking in adolescence and continues to smoke 40 year laters comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder?

Cardiopulmonary disease and lung cancer *rationale* Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer.

Care and complications of a trach tube

Care: assess airway, breath sounds,warmed & humidified air via vent or trach collar, elevate HOB >30 degrees after eating or tube feeding Complications: obstruction, dislodgement, pneumothorax, bleeding, infection Prevention of tissue damage: cuff pressure less < 20, stabilize tube, suction only when needed

Hemoglobin

Carries 02 and C02 deoxyhemoglobin can dissociate free oxygen to enter tissues

he nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed?

Cerebral or pulmonary emboli

Following the transfusion of one unit of packed RBC, the nurse prepares to administer another unit. Which action is MOST appropriate for the nurse to take initially?

Check the type and cross-match with another nurse rationale: prior to giving blood, 2 RN's must check the HCP order, clients identity, hospital ID band name and number, blood component tag and number, blood type and Rh, and the expiratioin date

Positive lab findings for pneumonia:

Chest X-ray: lobe infiltrate/atelectasis, pulmonary infiltrate or consolidation PO2 decreased Purulent sputum WBC elevation Assess: H & P, CXR, CBC, Sputum C&S/Gram stain, Blood cultures, ABGs/O2 sat

Which assessment do you interpret as a transfusion reaction?

Chills, tachycardia, and flushing *rationale* A transfusion reaction occurs when the immune system reacts against the blood that is being transfused. Chills, tachycardia, and flushing are common manifestations.

A male patient with a long-standing history of HF has recently qualified for hospice care. Which of the following measures should the nurse now prioritize when providing care for this patient?

Choosing interventions to promote comfort and prevent suffering

COPD

Chronic Obstructive Pulmonary Disease is the loss of elastic recoil of the lungs and thorax. This results in increasing of breathing. They have decreased surfactant and sometimes develop atelectasis Rationale: use of accessory muscles. this can cause fatigue. Assess for elevation of patient's clavicles during inspiration which can indicate ventilatory fatigue, air hunger or decreased lung expansion.

Describe COPD

Chronic airflow limitation, progressive, systemic effects COPD includes: Chronic bronchitis Chronic cough for 3 mos in 2 consecutive yrs Emphysema Abnormal, permanent enlargement of air spaces Bronchospasm

Asthma - what is it

Chronic airway inflammation w/recurrent: Wheezing Dyspnea Chest tightness Cough Obstruction

COPD risk factors

Cigarette smoking Occupational chemicals & dust Air pollution Infection Genetics Aging

Compliance 1. decreased compliance 2. increased compliance

Compliance is a measure of lung distensibility 1. lungs harder to inflate, seen in increased fluid (pneumonia, pulmonary edema, ARDS), decreased elasticity (fibrosis, sarcoidosis), and restrictions (pleural effusion) 2. lungs easier to inflate, seen in COPD

The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which of the following medications?

Vitamin K

Stroke Volume

Volume of blood ejected from the ventricles during systole

What are some lifestyle modifications for HTN?

Weight loss DASH diet - less fat, sat fat, cholesterol, salt, sugar. More fruits, vegetables, dairy, fiber, whole grain Increase activity Less booze Stress reduction

Hypoventilation

When oxygen demands is inadequate to remove carbon dioxide -Atelctasis prevents this normal exchange of oxygen and carbon dioxide. hypoventilation occurs -COPD results in barrel chested because the amount of air trapped in lungs

A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these?

While you're still lying in bed in the morning, put on your stockings."

he community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which of the following ethnic groups would the nurse select as the highest priority for this intervention?

White male

COPD - complications

Cor pulmonale RHF COPD exacerbations Acute respiratory failure *DC bronchodilators/corticosteroids

What are the complications of primary HTN?

Coronary Artery Disease Atherosclerosis Left Ventricular Hypertrophy Increases cardiac workload & oxygen consumption Heart Failure Pump failure Cerebral/Peripheral Vascular Disease #1 Risk Factor for Stroke Retinal Damage Hemorrhage; blurring/loss of vision Nephrosclerosis Chronic and End-Stage Renal Disease

The nurse is preparing to administer digoxin to a patient with HF. In preparation, lab results are reviewed with the following findings: sodium 139 mEq/L, potassium 3.0 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dl. The nurse should do which of the following at this time?

Withhold the dose and report the potassium level

A patient is jaundiced and her stools are clay colored (gray). This is most likely related to a. decreased bile flow into the intestine. b. increased production of urobilinogen. c. increased production of cholecystokinin. d. increased bile and bilirubin in the blood

Correct answer: a Rationale: Bile is produced by the hepatocytes and is stored and concentrated in the gallbladder. When bile is released from the common bile duct, it enters the duodenum. In the intestines, bilirubin is reduced to stercobilinogen and urobilinogen by bacterial action. Stercobilinogen accounts for the brown color of stool. Stools may be clay-colored if bile is not released from the common bile duct into the duodenum. Jaundice may result if the bilirubin level in the blood is elevated.

A patient has an elevated blood level of indirect (unconjugated) bilirubin. One cause of this finding is that a. the gallbladder is unable to contract to release stored bile. b. bilirubin is not being conjugated and excreted into the bile by the liver. c. the Kupffer cells in the liver are unable to remove bilirubin from the blood. d. there is an obstruction in the biliary tract preventing flow of bile into the small intestine.

Correct answer: b Rationale: Bilirubin is a pigment derived from the breakdown of hemoglobin and is insoluble in water. Bilirubin is bound to albumin for transport to the liver and is referred to as unconjugated. An indirect bilirubin determination is a measurement of unconjugated bilirubin, and the level may be elevated in hepatocellular and hemolytic conditions.

An 80-year-old man states that, although he adds a lot of salt to his food, it still does not have much taste. The nurse's response is based on the knowledge that the older adult a. should not experience changes in taste. b. has a loss of taste buds, especially for sweet and salt. c. has some loss of taste but no difficulty chewing food. d. loses the sense of taste because the ability to smell is decreased.

Correct answer: b Rationale: Older adults have decreased numbers of taste buds and a decreased sense of smell. These age-related changes diminish the sense of taste (especially of salty and sweet substances).

In preparing a patient for a colonoscopy, the nurse explains that a. a signed permit is not necessary. b. sedation may be used during the procedure. c. only one cleansing enema is necessary for preparation. d. a light meal should be eaten the day before the procedure.

Correct answer: b Rationale: Sedation is induced during a colonoscopy. A signed consent form is necessary for a colonoscopy. A cathartic or enema is administered the night before the procedure, and more than one enema may be necessary. Patients may need to be kept on clear liquids 1 to 2 days before the procedure.

As gastric contents move into the small intestine, the bowel is normally protected from the acidity of gastric contents by the a. inhibition of secretin release. b. release of bicarbonate by the pancreas. c. release of pancreatic digestive enzymes. d. release of gastrin by the duodenal mucosa

Correct answer: b Rationale: The hormone secretin stimulates the pancreas to secrete fluid with a high concentration of bicarbonate. This alkaline secretion enters the duodenum and neutralizes acid in the chyme.

During an examination of the abdomen the nurse should a. position the patient in the supine position with the bed flat and knees straight. b. listen in the epigastrium and all four quadrants for 2 minutes for bowel sounds. c. use the following order of techniques: inspection, palpation, percussion, auscultation. d. describe bowel sounds as absent if no sound is heard in the lower right quadrant after 2 minutes.

Correct answer: b Rationale: The nurse should listen in the epigastrium and all four quadrants for bowel sounds for at least 2 minutes. The patient should be in the supine position and should slightly flex the knees; the head of the bed should be raised slightly. During examination of the abdomen, the nurse auscultates before performing percussion and palpation because the latter procedures may alter the bowel sounds. Bowel sounds cannot be described as absent until no sound is heard for 5 minutes in each quadrant.

When the nurse is assessing the health perception-health maintenance pattern as related to GI function, an appropriate question to ask is a. "What is your usual bowel elimination pattern?" b. "What percentage of your income is spent on food?" c. "Have you traveled to a foreign country in the last year?" d. "Do you have diarrhea when you are under a lot of stress?"

Correct answer: c Rationale: When assessing gastrointestinal function in relation to the health perception-health management pattern, the nurse should ask the patient about recent foreign travel with possible exposure to hepatitis, parasitic infestation, or bacterial infection.

A patient is admitted to the hospital with a diagnosis of diarrhea with dehydration. The nurse recognized that increased peristalsis resulting in diarrhea can be related to a. sympathetic inhibition b. mixing and propulsion c. sympathetic stimulation d. parasympathetic stimulation

Correct answer: d Rationale: Peristalsis is increased by parasympathetic stimulation.

A normal physical assessment finding of the GI system is/are (select all that apply) a. nonpalpable liver and spleen. b. borborygmi in upper right quadrant. c. tympany on percussion of the abdomen. d. liver edge 2 to 4 cm below the costal margin. e. finding of a firm, nodular edge on the rectal examination.

Correct answers: a, c Rationale: Normal assessment findings for the gastrointestinal system include a nonpalpable liver and spleen and generalized tympany on percussion. Normally, bowel sounds are high pitched and gurgling; loud gurgles indicate hyperperistalsis and are called borborygmi (stomach growling). If the patient has chronic obstructive pulmonary disease, large lungs, or a low-set diaphragm, the liver may be palpated 0.4 to 0.8 inch (1 to 2 cm) below the right costal margin. On palpation, the rectal wall should be soft and smooth and should have no nodules.

Isotonic Solutions IV

Crystalloids - equal to body fluid, keeps fluid in intravascular body volume without causing a fluid shift -replacement or maintainence of fluids -NS - does not enter cells just expands ECV -D5W-aka glucose, enters cell rapidly leaving free water which dilutes ECF -Lacted Ringers- Na+, K+ Ca2+, Cl- and lactate which the liver metabolizes to HC03-

A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is:

Cystitis *rationale* urine is cloudy in cystitis because of bacteria and white cells

A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor. The nurse notes that the patient has an order for D5½ NS to infuse at 125 ml/hr. Until an IV pump is available, the nurse regulates the IV flow rate at which of the following drops (gtts)/min, noting that the tubing has a drop factor of 10 drops/ml? A. 13 gtts/min B. 31 gtts/min C. 25 gtts/min D. 21 gtts/min

D. 21 gtts/min

The nurse is preparing to administer cefazolin (Ancef) 2 gm in 100 ml of normal saline to a postoperative patient. Which of the following IV rates will infuse this medication over 20 minutes? A. 100 ml/hr B. 150 ml/hr C. 200 ml/hr D. 300 ml/hr

D. 300 ml/hr

The nurse is providing care for a patient who has been admitted to the hospital for the treatment of nephrotic syndrome. Which of the following is a priority nursing assessment in the care of this patient? A. Assessment of pain and level of consciousness B. Assessment of serum calcium and phosphorus levels C. Blood pressure and assessment for orthostatic hypotension D. Daily weights and measurement of the patient's abdominal girth

D. Daily weights and measurement of the patient's abdominal girth

The nurse caring for a 54-year-old patient hospitalized with diabetes mellitus would look for which of the following laboratory test results to obtain information on the patient's past glucose control? A. Prealbumin level B. Urine ketone level C. Fasting glucose level D. Glycosylated hemoglobin level

D. Glycosylated hemoglobin level

A 70-year-old woman has been admitted prior to a bilateral mastectomy and breast reconstruction. Which of the following elements should the nurse include in the patient's preoperative teaching (select all that apply)? A. Information about various options for reconstructive surgery B. Information about the risks and benefits of her particular surgery C. Information about risk factors for breast cancer and the role of screening D. Information about where in the hospital she will be taken postoperatively E. Information about performing postoperative deep breathing and coughing exercises

D. Information about where in the hospital she will be taken postoperatively E. Information about performing postoperative deep breathing and coughing exercise

A 71-year-old male patient who is currently undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which of the following drugs? A. Midazolam (Versed) B. Fentanyl (Sublimaze) C. Meperidine (Demerol) D. Ondansetron (Zofran)

D. Ondansetron (Zofran)

The nurse preparing to administer a dose of PhosLo to a patient with chronic kidney disease would interpret that this medication should have a beneficial effect on which of the following laboratory values of the patient? A. Sodium B. Potassium C. Magnesium D. Phosphorus

D. Phosphorus

When caring for a patient during the oliguric phase of acute kidney injury, which of the following would be an appropriate nursing intervention? A. Weigh patient three times weekly. B. Increase dietary sodium and potassium. C. Provide a low-protein, high-carbohydrate diet. D. Restrict fluids according to previous daily loss.

D. Restrict fluids according to previous daily loss.

The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission?

Debilitating Joint Paint *rationale* The most common reason for knee arthroplasty is debilitating joint pain despite exercise, weight management, and drug therapy. Recent knee trauma, repeated knee infections, and onset of frozen knee joint are not primary indicators for a knee arthroplasty.

Your older-adult patient is receiving intravenous (IV) 0.9% NaCl. You detect new onset of crackles in the lung bases. What is your priority action?

Decrease IV flow rate *rationale* When an IV fluid is infusing, monitor for excess infusion. Crackles in the lung bases are an indication of *extracellular fluid volume excess*. For patient safety the IV flow rate must be decreased immediately.

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status?

Decreased activity tolerance and increased breathlessness *rationale* *Hypoxia* occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath.

Increased energy expenditure

Decreased lung compliance, increased airway resistance, and the increased use of accessory muscles increase the WOB

The client suffers a full thickness burn injury. The nurse cares for the client during the shock phase. The nurse understands which finding is expected during this phase?

Decreased urine output rationale: has a high specific gravity. output should be 30-50 mL/hour

Triglycerides

Desirable less than 150 mg/dL; males 40-160 mg/dL; females 35-135 mg/dL

Total serum cholesterol

Desirable less than 200 mg/dL (risk for cardiac or stroke event with levels greater than 150 mg/dL)

Steps involved in breathing:

Diaphragm contracts Intrathoracic volume ↑ Abdominal contents pushed ↓ External intercostal and scalene muscles contract Intrathoracic pressure ↓ Air enters lungs

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately?

Do you dribble consistently *rationale* *Incontinence characterized by constant dribbling of urine is associated with incontinence associated with urinary retention* The other options point to stress incontinence, functional incontinence or a UTI.

Status Asthmaticus - s/s

Drowsy/confused Too dyspneic to speak Profuse diaphoresis PEFR < 25% of personal best Distant breath sounds "Silent chest" Bradycardia

A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. This patient should be advised to avoid

Drugs to treat erectile dysfunction

Which of the following defining characterstics is consistent with fluid volume deficit?

Dry mucous membranes, thready pulse, tachycardia (abnormal rapid HR) -neck veins flat when she is supine; has 100 mL of dark yellow urine in 4 hours -*neck vein fullness when supine*

An 85-year-old woman seen in the primary care provider's office for a well check complains of difficulty swallowing. What common effect of aging should the nurse assess for as a possible cause? Anosmia Xerostomia Hypochlorhydria Salivary gland tumor

Xerostomia (decreased saliva production), or dry mouth, affects many older adults and may be associated with difficulty swallowing (dysphagia). Anosmia is loss of sense of smell. Hypochlorhydria, a decrease in stomach acid, does not affect swallowing. Salivary gland tumors are not common.

Describe the clinical manifestations of primary HTN

Early - Elevated BP, asymptomatic (silent killer) Later - Symptoms second to effects on other organs, headache, N/V, fatigue, confusion, dizziness, epistaxis, blurred vision, palpitations, angina, dyspnea, nocturia, dependent edema

Upon admission assessment, the nurse notes clubbing of the patient's fingers. Based on this finding, the nurse will question the patient about which of the following disease processes?

Endocarditis

What happens during the resolution period of pneumonia?

Exudate lysed and processed by macrophages Healing occurs if no complications

Which factor should be considered when caring for a woman with suspected coronary artery disease?

Fatigue *rationale* Fatigue, rather than pain or shortness of breath, may be the first symptom of impaired cardiac circulation. Women may not exhibit the classic signs and symptoms of ischemia such as chest pain which radiates down the left arm. Neck, throat, or back pain may be symptoms experienced by women. Risk for coronary artery disease increases four times after menopause. *Men are more likely to develop collateral circulation.*

A 35-year-old man with a family history of adenomatous polyposis had a colonoscopy with removal of multiple polyps. Which signs and symptoms should the nurse teach the patient to report immediately? Fever and abdominal pain Flatulence and liquid stool Loudly audible bowel sounds Sleepiness and abdominal cramps

Fever and abdominal pain. The patient should be taught to observe for signs of rectal bleeding and peritonitis. Fever, malaise, and abdominal pain and distention could indicate a perforated bowel with peritonitis.

Pneumonia stats:

Fifth leading cause of death in hospitals Nosocomial = 50 % mortality (20 - 30% become septic)

What are the respiratory defense mechanisms?

Filtration of air Mucociliary clearance system Cough reflex Reflex bronchoconstriction Alveolar macrophages

You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid?

Fluid that has sodium in it *rationale* Body fluid losses remove sodium-containing fluid from the body and can cause extracellular fluid volume deficit unless both the sodium and the water are replaced.

FiO2

Fraction of inspired oxygen concentration. This is caused by upper or lower airway obstruction -limits oxygen to alveoli

Which individuals would the nurse identify as having the highest risk for coronary artery disease (CAD)?

a 45 year old man with a high stress job *rationale* Studies demonstrate that depression and stressful states can contribute to the development of CAD.

Which of these patients do you expect will need taching regarding dietary sodium restriction?

a 65 year old recently diagnosed with heart failure *rationale* Heart failure commonly causes extracellular fluid volume (ECV) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na+ and water. Dietary sodium restriction is important with heart failure because Na+ holds water in the extracellular fluid, making the ECV excess worse.

Tuberculosis: - bacteria type - spread via - where found

Gram-positive, acid-fast bacillus Spread via airborne droplets Remains airborne for minutes to hours Not highly infectious Once inhaled, lodges in bronchioles and alveoli Replicates slowly Can be found in lungs, kidneys, bone, cerebral cortex, and adrenal glands Caused by Mycobacterium tuberculosis World's 2nd most common cause of death Occurs disproportionately in poor, under-served, and minorities In US, Native Americans, health care workers with exposure high risk Emergence of MDR strain

What nursing intervention decreases the risk for catheter associated urinary tract infection (CAUTI)?

Hang the urinary drainage bag below the level with the bladder. *rationale* Evidenced based interventions shown to decrease the risk for CAUTI include ensuring that there is a free flow of urine from the catheter to the drainage bag.

Wheezing

a high-pitched muscial sound caused by high-velocity movement of air through a narrowed airway associated with -asthma, acute bronchitis, or pneumonia

What is a Huber needle?

a noncoring needle with a slanted tip used in implanted ports, placement is verified by blood return

The nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver?

Have you experienced frequent, small liquid stools recently? *rationale* Frequent or continuous oozing of liquid stools occurs when liquid fecal matter above the impacted stool seeps around the fecal impaction.

CAD - prevention

Healthy weight Reduce sodium Increase activity Avoid tobacco Limit alcohol Diet - low chol + sat fats. high fruits/veggies/lean meats/poultry/fish Drug therapy - restrict lipoprotein production, removal or absorption

Describe heart rate conduction

Heart muscle generates its own action potentials/impulses SA node is pacemeker, fastest AV node conduction slows thru the Bundle of His Delay allows the atria to completely empty w/atrial kick as they depolarize Bundle branches depolarize in unison Purkinje fibers depolarize ventricles in unison

What affects diastolic filling time?

Heart rate

What carries the majority of oxygen to tissues?

Hemoglobin

AFter having a total knee replacement, the client is anemic and receives a blood transfusion. 10 minutes after the transfusion starts, the client reports chills, chest tightness, LBP, and nausea. Which client condition is sugested to the nurse by these symptoms?

Hemolytic transfusion reaction rationale: most dangerous type of transfusion if patients blood is not compatible with the donor

Nurses discourage patients from straining on defecation primarily because it causes: SATA 1) pain 2) impaction 3) hemorrhoids 4) Dysrhythmias

Hemorrhoids and Dysrythmias *rationale* The Valsalva maneuver requires the patient to hold his or her breath while straining to defecate. This maneuver increases venous pressure from straining. Over time, hemorrhoids result. In addition, this maneuver increases the risk for dysrhythmias, which are often life threatening.

Blood screening checks for...?

Hep C, HIV, West Nile

The nurse is assessing a 50-year-old woman admitted with a possible bowel obstruction. Which assessment finding would be expected in this patient? Tympany to abdominal percussion Aortic pulsation visible in epigastric region High-pitched sounds on abdominal auscultation Liver border palpable 1 cm below the right costal margin

High-pitched sounds on abdominal auscultation The bowel sounds are more high pitched (rushes and tinkling) when the intestines are under tension, as in intestinal obstruction. Bowel sounds may also be diminished or absent with an intestinal obstruction. Normal findings include aortic pulsations on inspection and tympany with percussion, and the liver may be palpable 1 to 2 cm along the right costal margin.

What electrolyte imbalance is connected with; -somnolence (strong desire to sleep) -respiratory and cardiac arrest

Hypermagnesiumia and it is the condition of a strong desire to sleep

The adult client has a history of diabetes insipidus. The nurse identifies which imbalance is MOST likely to develop if this medical problem recurs?

Hypernatremia rationale: diabetes insipidus is a disorder of water metabolism caused by a deficiency of ADH. large amounts of water are lost from the body causing building of sodium in the body, leading to HYPERNATREMIA.

Which imbalance is associated with; -neuromuscular irritability and tetany (hypocalcemia)

Hyperphosphatemia

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which of the following mechanisms?

Hypertension promotes atherosclerosis and damage to the walls of the arteries

Breathing long and rapid

Hyperventilation examples- -COPD lung disease

Two days after a total thyroidectomy, the client reports painful spasms of the hands. The client says, "My muscles tingle and twitch." The nurse identifies the client has developed which electrolyte imbalance?

Hypocalcemia rationale: accidental removal of or damage to one or more parathyroid glands during thyroidectomy can cause tetany due to calcium loss Tetany - twtiches or muscular spasms

The emergency department nurse knows which cause MOST frequently is associated with tetany?

Hypocalcemia rationale: hypocalcemia is the most common underlying cause of tetany, which is a condition with convulsions, cramps, muscle twitching, sharp flexion of ankle and wrist joints, possible respiratory stridor; calcium related tetany is treated with IV calcium or calcium gluconate; if need to dilute calcium, use D5W, not saline because saline promotes calcium loss

The nurse identifies nasogastric drainage, vomiting, diarrhea, and the use of diuretics likely cause which electrolyte imbalance?

Hypokalemia rationale: all involve the loss of ECF which contains potassium

The nurse notices flattened T waves on the ECG of the client diagnosed with acute kidney injury. Based on this finding the nurse checks the laboratory values for which electrolyte imbalance?

Hypokalemia rationale: hypokalemia is associated with T wave changes and presence of a U wave

Which electrolyte imbalance is connected with: -hyperactive DTR -corresponding hypocalcemia and hypokalemia -tremors and seizures

Hypomagnesemia rationale: can take milk of magnesia or malox

Which imbalance is associated with; -CNS depression -cardiomyopathy -dysrhythmias

Hypophophatemia

What are side effects and considerations ass. w/ ace inhibitors?

Hypotension Hyperkalemia...esp w/CHF, CKD, DM Angioedema Facial/laryngeal swelling Nursing considerations Do not use with potassium sparing diuretic! By blocking angiotensin II ace inhibitors decrease BP, lowering peripheral resistence-AFTERLOAD....and decreasing blood volume-PRELOAD

The nurse would recognize that indications for the use of dopamine (Intropin) in the care of a patient with heart failure include

Hypotension and tachycardia.

A patient experienced sudden cardiac death (SCD) and survived. Which preventive treatment should the nurse expect to be implemented?

Implantable cardioverter-defibrillator (ICD) *rationale* An ICD is the most common approach to preventing recurrence of SCD.

COPD What happens?

Inability to expire air Loss of elastic recoil Air trapping Breathing with "over-inflated" lungs Air trapping worsens and alveoli destroyed Hypoxia and hypercarbia Bullae and blebs Excess mucus production Pulmonary hypertension Vasoconstriction from hypoxia Cor pulmonale Right ventricle hypertrophy

Hypoxia

Inadequate tissue oxygenation. It is a life threatening condition that if left untreated can cause fatal cardiac dysrhythmias

The nurse cares for the client receiving a blood transfusion. The nurse observes which symptoms if *fluid overload* occurs during the transfusion?

Increased pulse rate, increased BP, increased respirations. rationale:If running rapidly HF will be seen

Obstructive pulmonary disease 1. what is it 2. most common s/s

Increased resistance to airflow, need more force/time to exhale Unifying sign/symptom - wheezing/dyspnea, ↑ work of breathing, V/Q mismatch, ↓ FEV1

Why is smoking so bad to heart??

Increases LDL, decreases HDL, nicotine stimulates release of catecholamines which increases HR and BP which increases cardiac workload and demand, When heart needs more O2 supply, O2 extraction is decreased due to carbon monoxide in smoke, stimulates polycythemia = vessel inflammation and thrombosis

What is pneumonia?

Inflammatory alveolar spaces b/c of infection. Cearance mechanism are overwhelmed by secretions, alveoli fill w/ exudate, tissues become ischemic or necrotic

What must the nurse do after starting a blood infusion?

Infuse slowly for first 15 min and assess q 15 min, watch for vitals, and check vitals regularly

Pneumococcal vaccine: When to vaccinate?

Initial pneumococcal vaccine ≥ 65 yrs 2-64 yrs long-term health probs 19-64 yrs smoker, asthma 2-64 yrs for decreased resistance 19-64 yrs in chronic care settings Re-vaccinate: ≥ 65 yrs if > 5 yrs previous and < 65 yrs

The nurse identifies which group of symptoms is indicative of a hemolytic transfusion reaction?

Kidney pain, hematuria, cyanosis rationale: characteristic of a hemolytic reaction in which hemolysis or destruction of blood cells occurs; leads to hematuria (blood in urine), cyanosis, and kidney pain

What are quick short breathes?

Kussmaul Respirations depth and rate increases to decrease C02

During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with:

Lactose intoleranc *rationale* pt may lack the enzyme to digest milk sugar lactase

Latent Tb vs active Tb

Latent: No active disease Not infectious ~10% develop active TB Dormant bacteria can persist for years and reactivate-thus treat latent TB Active: Initial immune response inadequate Bacteria multiply and cause active disease

Describe (TRALI) transfusion-related acute lung injury

Leading cause of transfusion-related deaths; chills, sudden resp. distress, resp. failure;

The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. Which of the following should the nurse do to correctly administer this medication?

Leave the air bubble in the prefilled syringe

The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse?

Left leg externally rotated and shorter than the right leg *rationale* Clinical manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

Urine glucose

Less than 0.5 g/day

Erythrocyte sedimentation rate (ESR)

Less than 20 mm/hr

Give examples of Loop, thiazide, and k sparring diuretics

Loop: Bumetanide (Bumex) Furosemide (Lasix) Thiazides: Chlorothiazide (Diuril) Hydrochlorothiazide (HCTZ) K-Sparing: Spironolactone (aldactone) Triamterene (Dyrenium

he blood pressure of a 71-year-old patient admitted with pneumonia is 160/70 mm Hg. Which of the following is an age-related change that contributes to this finding?

Loss of elasticity in arterial vessel

What are the two acid-secretion systems in the body?

Lungs and kidneys

Hyperventilation

Lungs removing carbon dioxide faster then is being produced -increasing carbon dioxide stimulate respirations

Decrsibe head and neck cancerM MCC S/S -Pharyngeal - laryngeal TX

MCC: ETOH, tobacco, HPV, chronic laryngitis, GERD S/S: painless growth, non healing ulcer, pain later on, hoarseness, change in voice, neck mass, big nodes, tracheal deviation, ulcer, asymmetric tongue, white or red patches in mouth Increased risk >50yr and male Pharyngeal : unilateral sore throat, ear pain Laryngeal : hoarseness, "lump" in throat, change in voice. Later - pain, dysphagia, airway closes TX: Stage I & II -radiation, sx, goal of curing Stage III and IV - poor prognosis

Describe the etiology of lung cancer - mcc

MCC: Smoking! Female smokers greater risk than male smokers Never smokers w/ adenocarcinoma - 2.5 x more female

Describe peritonsillar abcess MCC S/S TX

MCC: acute pharyngitis or tonsillitis S/S: Pus, deviation of uvula, fever, chills, drooling, severe throat pain, difficulty swallowing, stridor, resp. distress TX: Assess airway, antibiotics, aspiration

Pulmonary fungal infections - mcc - causative org's

MCC: spore inhalation Common in seriously ill No isolation req'd Org's: Histoplasmosis ("Valley Fever") Coccidiomycosis Candidiasis Pneumocystis - most common in HIV

1.5-2.5

Magnesium

Electrolyte responsible for the metabolism of carbohydrate and proteins

Magnesium

Creatinine clearance test

Males: 90-139 mL/min Females: 80-125 mL/min

HDL (high-density lipids)

Males: >45 mg/dL Females: >55 mg/dL

What is Starlings Law of the heart?

Maximum efficiency of CO is achieved when the myocardium is stretched 2 ½ X its length Think "rubber band" CO is decreased with too low or too high a preload

Describe MAP

Mean Arterial Pressure (MAP) Average systemic pressure Need MAP > 60 mmHg to adequately perfuse major organs MAP = [SBP + (2xDBP)] 3

Where breathing is controlled

Medulla Oblongata located in the brain stem

what Acid Base imbalance manifests -kidneys excrete hydrogen ions and retain bicarb -normal cardon dioxide labs -fruity breathe -decreased BP -Kussmaul Respirations (increased metabolic acid) -when you remove Bicarbonate, the amount of bicarbonate decreases

Metabolic Acidosis Associated with: -ketoacidosis (diabetes) -Circulatory shock (lactic acidosis)

Patients with kidney disease have difficult excreting what

Metabolic Acids -this is because renal cells promote the excreting H+ ions which in turn allows bicarbonate to be higher concentration in the blood -patients with kidney disease will have lower Hydrogen excreting allows a higher concentration of bicarbonate

what Acid Base imbalance manifests -s/s are less severe here -hypoventilation -tingling fingers and toes -prolonged vomiting -prolonged suctioning

Metabolic Alkalosis associated with: -hypokalemia -Increase of base(bicarbonate) -Decrease of metabolic acid IF GI losses - administer antiemetic, fluids and electrolyte replacements -if Potassium depletion - discontinue causative agents

Complications of Tb

Miliary TB - orgs invade blood and spread t/o body Pleural effusion and empyema Tuberculosis pneumonia

S1

Mitral and tricuspid close -pressure rises -diastole

The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/LVN?

Monitor pain intensity and administer prescribed analgesics. *rationale* -The LPN/LVN can monitor pain intensity and administer analgesics. -cannot *assess* RN's job

Na+

Most Abundant cation(+) in the ECF

Cl-

Most abundant Anion(-) in the ECF

Lung cancer - stats

Most common cancer Leading cause of cancer-related deaths in US Decreasing in men Leading cause of cancer death in women

Delegation of digital removal

NAP can not do this

Describe drug therapy treatments for angina

Nitrates - relieves ischemic pain Venodilators - reduce preload Anti-platelets - first line of defense (ASA, Plavix) β-adrenergic blockers ACE-inhibitors or ARBs Vasodilate - ↓ afterload *Nitroglycerin: Relieves pain, can be used prophylactically. Side Effects - decreased B/P, flushing and throbbing headaches.

Tb S/S

No symptoms in early stages Afternoon temp elevation Weight loss Pleuritic chest pain Positive skin test, Asymptomatic in latent Active TB: Fatigue, malaise Low grade fever, night sweats Anorexia, unexplained weight loss Cough with/without sputum production Usually no dyspnea or hemoptysis

Urine ketones

None (negative)

First Pacing

Normal distribution of fluid of IC and ECF

What do ABG's measure?

O2, CO2, Acid-base

A 74-yr-old man with a history of prostate cancer and hypertension is admitted to the emergency department with substernal chest pain. Which action will the nurse complete before administering sublingual nitroglycerin?

Obtain a 12-lead electrocardiogram (ECG). *rationale* (3) obtain a 12-lead ECG, (4) provide prompt pain relief first with a nitrate followed by an opioid analgesic if needed, and (5) auscultate heart sounds. Obtaining a 12-lead ECG during chest pain aids in the diagnosis.

Describe Printzmetal's angina

Occurs at rest Spasm of the coronary artery Not always associated with documented CAD Precipitated by a sudden increase in myocardial O2 demand due to: Nicotine Histamine release Treated with Calcium-channel blockers

The toddler has nausea, vomiting and diarrhea. Which implementation is BEST for the nurse to use to maintain an adquate fluid intake?

Offer oral rehydration solutions (ORS) to rehydrate rationale: contain--> sodium, potassium, chloride citrate and glucose -dont want to give toddlers fruit juices or soft drinks because they are high in carbs low in electrolytes and have high osmolality (total solution)

The client diagnosed with fluid volume deficit related to nausea and vomiting resumes oral intake. Which nursing action has the highest priority?

Offering 20-30 mL of ginger ale or water every 30 minutes *rationale:* When patient tolerates the amount you can increase by progressing to a clear liquid diet of gelatin, tea, and broth

Describe s/s of silent atypical angina

Often is women and diabetic No chest pain #1 s/s = Fatigue!! Shortness of breath Epigastric burning - "heartburn" Anxiety

The nurse is teaching the patient to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the patient to collect the specimen?

One fecal smear from three separate bowel movements *rationale* Samples from three separate bowel movements decrease the risk of a false-negative or a false-positive result.

When caring for a patient with infective endocarditis, the nurse will assess the patient for which of the following vascular manifestations (select all that apply)?

Osler's nodes CorrectJaneway's lesions CorrectSplinter hemorrhages

The nurse evaluates a clients fluid balance. Which finding MOST likely requires an intervention?

Output is <800 mL than intake rationale: intake and output should be between 200-300 mL of each other. If <800 mL less than intake, indicates client retaining fluid

When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administrating?

Oxygen, nitroglycerin, *aspirin*, and morphine

When planning emergent care for a patient with a suspected MI, the nurse will anticipate administration of

Oxygen, nitroglycerin, aspirin, and morphine.

COPD - diagnostic studies

PFTs - to confirm diagnosis FEV1 - obstruction CXR ABGs - show hypoxemia, hypercarbia, acidosis, ↑ bicarbonate BMI -1/3 of COPD patients are underweight

The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting which of the following during a routine shift assessment

Pain and swelling in lower extremity

The nurse is examining the electrocardiogram (ECG) of a patient just admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion?

Pathologic Q Wave *rationale* The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

he nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which of the following ECG changes is most indicative of prolonged or complete coronary occlusion?

Pathologic Q wave

A nurse is caring for a client who has a cardia monitor. The client's serum potassium level is 5.9 mEq/L. The nurse should check the cardiac monitor for the presence of which altered cardiac tracing related to this client's potassium level?

Peaked T wave Rationale: Peaked T waves are associated with an elevated serum potassium level higher than 5 mEq/L. Peaked T waves occur because of a longer cell membrane actiona potential in myocardial tissue -P waves are flattened not peaked with hyperkalemia -QRS are widened

What is the first symptom most commonly seen in lung cancer?

Persistent pneumonia from obstructed bronchi

2.4-4.4

Phosphate

What are the provoking factors for angina?

Physical exertion Temperature extremes Strong emotions Heavy meal Tobacco use Sexual activity Stimulants

The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. The nurse should do which of the following to administer this medication correctly?

Pinch the skin between the thumb and forefinger before inserting the needle.

The client reports sleepiness, nausea, and vomiting. The nurse notes the client is confused and respirations are deep and labored with respiratory rate of 32 breaths per minute. The arterial blood gas values are PaCO2 30 mmHg, pH 7.30, and HC03 20. which action does the nurse take?

Places the client in Fowler's position and encourages measures to support hyperventilation rationale:Fowler's position will allow full chest expansion and hyperventilation in the respiratory

What are complications of pneumonia?

Pleurisy Pleural effusion Empyema - pus Lung abscess Atelectasis Bacteremia Pericarditis Endocarditis Meningitis

A patient admitted with HF appears very anxious and complains of shortness of breath. Which of the following nursing actions would be appropriate to alleviate this patients anxiety (select all that apply

Position patient in a semi-Fowlers position. Administrate ordered morphine sulfate. Instruct patient on the use of relaxation techniques. CorrectUse a calm, reassuring approach while talking to patient.

A patient has sought care following a syncopal episode of unknown etiology. Which of the following nursing actions should the nurse prioritize in the patient's subsequent diagnostic workup?

Preparing to assist with a head-up tilt-test

What is humidification?

Process of adding water to gas. Use of Nasal Cannula

Cholesterol

Produced in liver. Building block in estrogen, steroidal hormones.

The nurse is caring for a 76-yr-old man who has undergone left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively?

Progressive leg exercises to obtain 90-degree flexion *rationale* The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible; continuous passive motion also may be used based on surgeon preference. Early ambulation is implemented, sometimes the day of surgery, but orders are likely to indicate weight bearing as tolerated rather than full weight bearing. Immobilization and bed rest are not indicated. The patient's knee is unlikely to dislocate.The patient has frostbite on the distal toes of both feet

When removing the transparent dressing on a central port, in which direction do you pull?

Pull away from the insertion site

he nurse is caring for a patient with hypertension who is scheduled to receive a dose of atenolol (Tenormin). The nurse should withhold the dose and consult the prescribing physician for which of the following vital signs taken just before administration?

Pulse 48

While admitting a patient with pericarditis, the nurse will assess for which of the following signs, symptoms, and complications of this disorder?

Pulsus paradoxus

Which of the following ECG characteristics is consistent with a diagnosis of ventricular tachycardia (VT)?

Rate 200 beats/min; P wave not visible

A patient is admitted for lower GI bleeding. What color stool does the nurse anticipate the patient to have?

Red *rationale* Red-colored stool indicates lower GI bleeding.

Red hepatization vs gray hepatization

Red - organisms, neutrophils, and RBCs Gray -Leukocytes and fibrin consolidate

A patient with a recent diagnosis of HF has been prescribed furosemide (Lasix) in an effort to

Reduce preload.

Describe the RAAS system

Regulates BP and CO 1. In presence of low blood volume, renal perfusion decreases (↓ blood flow to kidney decreases GFR) = secretion of renin from juxtaglomerular cells in kidney. 2. Renin converts angiotensinogen (from liver) to angiotensin I. I is converted to II by ACE = vasoconstriction and aldosterone release. 3. Angiotensin II - ↑ SVR and aldosterone 4. ↑ Aldosterone secretion = more Na and H20 reabsorption = increased BP 5. Ultimately, the extra ECF leads to ↑ preload = ↑ energy expenditure = ↑ workload for the heart = pulmonary congestion.

The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which of the following findings are significan

Regurgitant murmur at the mitral valve area

Assessment of a patient's peripheral intravenous site reveals that phlebitis has developed over the past several hours. Which of the following interventions should the nurse implement first?

Remove the patient's IV catheter

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and HCO3-, 24. You interpret these laboratory values to indicate:

Repiratory acidosis

what Acid Base imbalance manifests -alveolar hypoventilation -Kidneys compensate increasing excretion of metabolic acids in urine which increased blood bicarb -warm and flushed skin

Respiratory Acidosis Associated with: -type B COPD -Pneumonia -Obstructive Sleep Apnea implementation: -oxygen therapy and maintain patient airway. Education patient on positioning of breathing techniques, ventilatory support bronchodilators

what Acid Base imbalance manifests -excretion of too much carbonic acid (CO2) -hyperventilation due to anxiety -deep rapid breathing -stimulation of brainstem respiratory control: head injuries, meningitis -hypoxemia

Respiratory Alkalosis

When teaching a patient about dietary management of stage 1 hypertension, which of the following instructions is most appropriate?

Restrict sodium intake

Hypovolemia

Results in hypoxia in tissue due to no fluid in the extracellular tissues -increases in cardiac output because the body tries to adapt by peripheral vasoconstriction and increase HR

Pneumonic of Hyponatremia

S - Seizures and Stupid A - abdominal cramping and attitude change L - Lethargic T - Tendon Reflexes Diminished L - Loss of urine O - Orthostatic pressure S - Shallow respirations S - Spasms of muscles

WHat is the pathway of depolarization?

SA node to AV node, to AV bundle to Bundle Branches to Perkinje Fibers

In caring for a patient admitted with poorly controlled hypertension, the nurse would understand that which of the following laboratory test results would indicate the presence of target organ damage secondary to the primary diagnosis?

Serum creatinine of 2.6 mg/dl

a patient with a cardiac history is taking furosemide and is seen in the emergency department for muscle weakness. Which lab value do you assess first?

Serum potassium *rationale* Potassium-wasting diuretics such as furosemide increase potassium urinary output and can cause hypokalemia unless potassium intake also increases. Hypokalemia causes muscle weakness.

Diagnostic sudies for Tb

Skin test (PPD) - don't re-test if pos Tw0-step test for health care workers CXR - Not diagnostic alone Acid-fast bacilli Sputum X 3 QFT (QuantiFERON-TB Gold)

which lab finding does the nurse expect if the client is diagnosed with fluid volume deficit?

Specific gravity 1.034 Normal lab = 1.0053-1.030 rationale: greater than 1.030 indicates fluid volume deficit; other symptoms include increased tep, rapid, weak pulse, poor skin turgor, hypotension, dry eye sockets, daily weight

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short term memory and has not been seen toileting independently. What is the best nursing intervention for this patient?

Start a scheduled toileting program. *rationale* *The first nursing intervention for any patient with incontinence, who is able to toilet, is to assist them with toilet access. * This patient is not cognitively intact so a bladder retraining program is not appropriate for her. It is not clear in this case that she has OAB and a catheter is never a good solution for incontinence.

Impaired Valvular(valves) Function

Stenosis (hardening) or regurgitation (impaired closure) of the valves Rationale: when chronic stenosis happen, right or left sided heart failure happens because of the muscle working harder to push blood beyond stenotic valve

Respiratory changes due to aging:

Stiff chest wall ↓ elastic recoil/compliance/alveoli/macrophages ↑ V/Q mismatch ↓ response to hypoxemia and hypercapnia ↓ immunity and antibodies ↓ pharyngeal sensation/cough

During the administration of a warm tap-water enema, the patient complains of cramping abdominal pain that he rates 6 out of 10. What is the first thing the nurse should do?

Stop the instillation *rationale* When a patient complains of pain during an enema, the instillation should be stopped, and an assessment done before discontinuing or resuming the procedure.

A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does the nurse take first?

Stops the instillation and assess vitals *rationale* Bleeding is an unexpected outcome. You should stop the procedure, obtain vital signs, and call the health care provider since this is a medical emergency.

A Male patient returned home from the operating room 5 hours ago with a cast on his right arm. He has not yet voided. Which action woulbe the most beneifical in assisting the patient to void?

Suggest he stand at the bedside *rationale* Men void more easily in the standing position

Circulation of blood through the heart

Superior Vena Cava Inferior Vena Cava Right Atrium Tricuspid Valve Right Ventricle Pulmonic Valve Pulmonary Artery Lungs carbon dioxide and oxygen Pulmonary Vein Left Atrium Mitral valve (bicuspid) Left Ventricle Aortic Valve Aorta Rest of body

Surgical and radioation tx for lung cancer

Surgery: Stage I - 5-yr survival rates ~90% Stage II - 5-yr survival rates ~50% Radiation: Used for SCLC and NSCLC Palliative Treat pain from bone or brain metastases Reduce tumor mass

Describe: Cordectomy Hemilaryngectomy Supraglottic laryngectomy Radical neck dessection

Sx treatments for neck cancer: Cordectomy - one cord Hemilaryngectomy - one vocal cord Supraglottic laryngectomy - false cords and epiglottis Radical neck dissection - excision of nodes, muscles, IJ vein, thyroid and parathyroids

Pneumothorax s/s

Tachycardia Dyspnea O2 desaturation Chest pain Cough No breath sounds Tracheal deviation

Dysrhythmia classification

Tachycardia - >100 beats/min bradycardia - <60 beats/min these both lower cardiac ouput and blood pressure

Which of the following nursing actions should the nurse prioritize during the care of a patient who has recently recovered from rheumatic fever?

Teach the patient about his or her need for continuous antibiotic prophylaxis.

Which of the following is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI

Teaching the patient the correct use of compression stockings

Which assessment finding in the young adult client indicates to the nurse that there is a problem with fluid volume deficit?

Tenting of the skin rationale: use thumb and index finger to gently pinch and then lift skin on the forearm of the client

Hypotonic Solutions

The cell is large because the outside of the cell has less concentration

Hypertonic Solutions

The cell is small and shriveled because the outside has more concentration -think about outside the cell and its environment then inside

Work of breathing

The effort required to expand and contract the lungs Inspiration - active process on inhaling air to lungs Expiration - a passive process that depends on the elastic recoil properties of the lungs require little muscle work

What is afterload?

The force of resistance that the left ventricle must overcome to open the aortic valve.

A male patient who has coronary artery disease (CAD) has serum lipid values of low-density lipoprotein (LDL) cholesterol of 98 mg/dL and high-density lipoprotein (HDL) cholesterol of 47 mg/dL. What should the nurse include in patient teaching?

The lipid levels are normal. *rationale* For men, the recommended *LDL is less than 100 mg/dL* and the recommended level for *HDL is greater than 40mg/dL* His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.

The nurse observes a student nurse begin an IV on an elderly client. The nurse should intervene if which action is observed?

The student nurse marks the time on the IV bad with a permanent marker rationale: can contaminate solution; use time taping Correct possible answers: 1) use smallest gauge needle 24-26 2) 5-15 degrees because of older veins

Jehovah Witness that cant do blood transfusions

They are to be given Iron Dextram

The nurse obtains a 6-second rhythm strip and charts the following analysis: atrial rate 70, regular; ventricular rate 40, regular; QRS 0.04 sec; no relationship between P waves and QRS complexes; atria and ventricles beating independently of each other. Which of the following would be a correct interpretation of this rhythm strip?

Third-degree heart block

When providing nutritional counseling for patients at risk for coronary artery disease (CAD), which foods would the nurse encourage patients to include in their diet (select all that apply.)?

Tofu walnuts and tuna fish *rationale* high in omega-3 fatty acids that can lower CAD risks

Describe complete upper airway obstruction MCC S/S TX

Total airway obstruction, medical emergency MCC: Aspiration/choking, edema, CNS depression, allergic rxn, extubation, abscess S/S: stridor, increased WOB, intercostal retractions, wheezing, restlessness, tachycardia, cyanosis TX: Assess airway, suction, heimlich, cricothyroidotomy, intubation, tracheotomy

A 59-year-old man has presented to the emergency department with chest pain. Which of the following components of his subsequent blood work is most clearly indicative of a myocardial infarction (MI)?

Troponin

What are the serum markers of myocardial damage?

Troponin & Creatine kinase (CK) B-Type Natriuretic Peptides Serum lipids C-reactive protein Electrolytes K+; Mg++ Blood coagulation PTT; PT/INR

Auscultation of a patient's heart reveals the presence of a murmur. This assessment finding is a result of

Turbulent blood flow across a heart valv

CAD - risk factors unmodifiable vs modifiable

Unmodifiable: Age (>65), gender (men), race (white), genetics Modifiable: #1 Hyperlipedemia #1!!!!! #2 Hypertension #3 Tobacco #4 Physical Inactivity

Describe obstructive sleep apnea MCC S/S TX Comps

Upper airway obstruction during sleep MCC: obesity, >65yrs, smoker S/S: snoring, sleep distruptions, daytime somnolence, apneic episodes TX: side sleeping, lose weight, CPAP Comps: HTN, pulmonary disease, heart disease, CVA's. heart failures, and arrhythmias

The nurse assesses the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to:

Use crede's method *rationale* promoted bladder emptying by relaxing the urethral sphincter

Describe stable angina

Usually stable plaque that is about 75% occlusive Chest Pain with exertion - subsides with rest or nitroglycerine Reversible - if perfusion restored no permanent damage Occurs intermittently with same pattern-duration-intensity of symptoms

A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which of the following replies by the nurse is most appropriate?

"This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal."

Describe hypertension

"Vascular Disease" 1 in 4 adults in US Rsk factor for cv disease: stroke, MI, Heart Failure Other Target Organ Damage: -LV hypertrophy -Nephropathy -Vascular Disorders -PVD -Retinopathy

What are non modifiable cardiovascular risk factors?

#1 Age - greatest risk factor for cv disease Gender Ethnicity Family history & genetics

Asthma treatments: 1. corticosteroids 2. IV/oral drugs 3. ICS 4. Leukotriene modifiers 5. monoclonal antibodies 6. bronchodilators

(1-4 are anti infammatory) 1. More effective than any other drugs 2. acute exacerbation 3. few systemic effects 4. prevent bronchoconstriction, not used in acute attacks, Singulair (montelukast), Accolate (zafirlucast) 5. expensive, risk of anaphylaxis, Xolair (omalizumab) 6.β2-adrenergic agonists Methylxanthines - rare Anticholinergics - common

Types of pneumonia: CAP HAP VAP

(H)CAP : Onset in community or w/in 2 days of hospitalization HAP: within 48 hrs or more after admission, common!! VAP: > 48 hrs after intubation *increased morbidity, death, all caused by different organisms

What position the pt should be in when under chest tube

*semi-fowler's* for pneumothorax. This allow air to rise to highest point in chest. In 2nd or 3rd intercostal spaces *High-Fowler's* for hemothorax, effusions.

Large-bore tubes

- 12-Fr and above are used for gastric decompression or removal of gastric secretions

Location and function of respiratory center

- located in medulla, aortic arch, lungs, chest wall, diaphragm - chemoreceptors resond to changes in PaCO2 and pH

Tap Water Enemas

-*hypotonic* as lower than fluid in interstitial spaces -may have *water toxicity or circulatory overload*

Nursing Interventions for Hypocalcemia

-10% calcium gluconate -check for infiltration or phlebitis since its hard on veins -Check if they are for Digoxin because it causes digitoxicity

Myocardial Pump

-2 atria and 2 ventricles -ventricles fill with blood during diastole and empty during systole

Systemic Circulation

-Arteries; deliver nutrients and oxygen to tissues -veins; remove waste from tissue

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented prior to the test?

-Ask the patient about any allergies and reactions. -Ensure that informed consent has been obtained. *rationale* An intravenous pyelogram (IVP) involves intravenous injection of an iodine based contrast media. Patients that have had a previous hypersensitivity reaction to contrast media in the past are at high risk for another reaction. Informed consent is required. There is no need for a full bladder such as with a pelvic ultrasound or to save any urine for testing. There is no instrumentation of the urinary tract such as with a cystoscopy.

What are the recovery methods when a patient seizes? and What do do after?

-Assess patients LOC -Check patients Airways and suction if needed -place patient in a position where they are turned on their right side, with legs over hip and arm behind neck -semi flowlers position

Smoking

-Associated with heart disease, COPD and lung cancer -10x greater for a person who smokes vs who does not

What are the manifestations of Hypernatremia?

-Coma -seizures -swollen tongue -sticky mucous membranes -excessive IV solutions -tachycardia -LOC -thirsty due to: -diabetes insipidus

What are the types of risks for patients that are hypercalcemic?

-Falls due to lethargy -Sepsis due to contaminated blood by lack of mobility Rationale: Give patients adequate fluid intake to prevent renal damage.

What are the manifestations of Hypercalcemia

-Flank pain due to renal calculi -digoxin toxicity if taking digoxin -lethargy -diminished reflexes due to -prolonged immobilization -hyperparathyroidism -bone tumors

What are the manifestations of Hypokalemia

-Flattened T waves and elevated U waves -Decreased DTR -weak, irregular pulse -decreased muscle tone -rhabdomyolysis -muscle spasms

Positioning pt on Bedpan that are immobile

-HOB flat -patients roll onto one side, backside toward the nurse -apply powder to back and buttocks to prevent skin from sticking to pan -Raise HOB to *30 degrees* -place a rolled towel on pt lumbar curve

What are the types of disease that can be transmitted through blood transfusions?

-Hepatitis B -Heptatitis C -HIV (however they are screened now) -AIDS -Cytomegalovirus infection

What are some siezure precautions?

-Must remove all clutter in room - in case patient is seizing in floor -Keep close to nursing station -keep lights low (no flashing) -Padded side rails - in case patient is seizing in bed -bed in low position -do not use tongue blade -have 02 equipment and suction at bedside -do not have a pillow

Which of the following skills can be delegated to nursing assistive personnel (NAP)?

-Oropharyngeal suctioning of a stable patient -Permanent tracheostomy tube suctioning *rationale* Oropharyngeal suctioning of a stable patient and permanent tracheostomy tube suctioning may be safely delegated to a NAP. The other skills require nursing assessment and clinical decision making as the skill progresses.

What are the manifestations of Hyperkalemia

-Peaked T waves, flattened P waves prolonged PR and widen QRS -increase GI --> Abdominal cramps, diarrhea and increased bowel sounds -flaccid paralysis

What are the manifestations of Hypocalcemia

-Positive chvostek sign and trousseau -tetany -tingling of fingers -cramping -stridor(harsh grating sound on auscultation) due to -Vitamin D deficiency C - Confusing R - hyperactive DTR A - Arrhthmia, prolonged QT intervals M - Muscle spasms, calve and feet P - Positive trousseau S - Sign of Chvosteks

Conduction system order

-SA Node Right Atrium -AV Node which activates when the atria empties blood into ventricles -Bundle of His -Purkinje Fibers

Enema Administration

-Sterile Technique used -*enemas until clear* - means enema is repeated until the patient passes fluid that is clear and contains no fecal material -give enema has they are positioned on bedpan -Left side-lying (Sims')

Result of excretion or exhalation? inspiration?

-The body removes bicarb in the form of C02. This results in faster breathing -for inspiration the less you breathe, the more C02 is in the body will be left in the both producing an acidic state.

Hypertonic solutions IV

-Thicker than body fluid and will shift fluid into the blood plasma by moving fluid from the tissue cells -cells shrink -for hyponatremia -3% NS -D5 1/2 NS -D10W D5NS

Ways to improve airway maintenance

-adequate hydration Rationale: to prevent thick, tenacious secretions -proper coughing Rationale: to remove secretions and keep the airway open

Which nursing interventions should the nurse implement when removing an indwelling urinary catheter in an adult patient?

-allow the syringe by gravity -have a void/diary to monitor *rationale* By allowing the balloon to drain by gravity the development of creases or ridges in the balloon may be avoided and thus minimize trauma to the urethra during withdrawal. All patients who have a catheter removed should have their voiding monitored. The best way to do this is with a voiding record or bladder diary. The size syringe used to deflate the balloon is dictated by the size of the balloon. In the adult patient balloon sizes are either 10 mLs or 30 mLs. Catheters should be pulled out slowly and smoothly. There is no evidence to support clamping catheters prior to removal.

S/S of Left Sided Heart Failure

-angina - chest pain radiating to left or both arms, the jaw, neck and back fatigue -breathlessness -dizziness -confusion due to tissue hypoxia from diminished cardiac output -crackles at the base of lungs

What drugs are prepared to be administered when a transfusion reactions occurs?

-antihistamines -vasopressors -fluids -corticosteroids

Administration of KCl

-assess patients kidney function and urine output -never do IV push, will cause death rationale: -kidneys continue to excrete potassium even when the plasma level falls.

Myocardial Blood Flow

-blood flow through heart is forward and this keeps it that way -During Diastole; atrioventricular (mitral and tricuspid) valves open where blood flows from high to low (ventricles) -During systole; mitral and tricuspid valves close making first heart sounds S1 -S2 when ventricles empty, pressure decreases and closure of the aortic and pulmonic valves

Hemoptysis

-bloody sputum

IVP Special nursing considerations

-bowel cleaning for test -only clear liquids after test completed -encourage to dilute and flush dye from pt

Myocardial Ishcemia

-coronary does not supply the myocardium with enough blood

Carbon Dioxide Transport

-diffuses in RBC -rapidly hydrated into carbonic acid -dissociates into H and Bicarbonate ions -Hemoglobin buffers the hydrogen ion and bicarb then diffuses into the plasma -this in turn goes to the lungs to be exhaled

What are the manifestations of Hypomagnesemia

-diplopia double vision -hyperactive DTR -also positive for Chvostek and Trousseau sign (hypocalcemia) -aldosterone excess due to: -malabsorption -use of thiazide or loop diuretics -decreased intake of mg L - Limited Intake of Mg O - Other -> Hypokalemia and Hypocalcemia W -Wasting Mg through Kidneys M - Malabsorption in the small intestine

S/S of extracellular fluid volume excess

-dyspnea -cough -crackles in lungs -engorged neck vessels -bounding pulse -increased BP -edema -wt gain -I&O -lethargy, confusion, HA -lab values (low Na, BUN and creatinine)

Substance Abuse

-excessive use of alcohol and other drugs impairs tissue oxygenation

What are the manifestations of Hypermagnesemia

-flushed warm skin -lethargy -bradypnea (abnormal slow breathing) -flaccid muscle paralysis due to -use of laxative and antacids -end stage renal disease

What is whole blood given for and how is it transfused?

-for shock, low blood volume, low Hgb, low Hct, hemorrhage -500 mls over 2-4 hrs

causes of Extracellular fluid volume excess

-heart failure -liver damage -renal disorders -excessive IV fluid intake

What are the manifestations of ECF volume deficit?

-hypovolemic shock -sudden weight loss -thready pulse and neck veins flat or collapsing with inhalation -cold clammy skin

Orthopnea

-inability to lie flat -needs to sit forward or multiple pillows when reclining to breathe easier

What should the nurse teach a young woman with a history of urinary tract infections about UTI prevention?

-keep the bowels regular -wear cotton underwear -clean perineal front to back *rationale* All are interventions that lead to healthy bladder habits. Adequate hydration will ensure that the bladder is regularly flushed out and will help prevent a UTI. *Pelvic muscle exercises promote pelvic health but not necessarily prevent UTI.*

Soap Suds

-may cause electrolyte imbalance or damage to the intestinal mucosa

S/S of Hypoventilation

-mental status changes -dysrhythmias -potential cardiac arrest

Positioning on Bedpan

-never lift a pt onto a bedpan, this is discomforts the pt -Raise HOB *30-45 degrees* then have patients raise the hips by bending the knees and lifts hips upward

Atrial Fibrilation

-often seen in older adults -chaotic impulse and originates in multiple sites -QRS is normal but occurs in irregular intervals

Positive guaiac

-or presence of fecal occult blood -wait 60 seconds indicates blue color

Stress

-or severe anxiety increases the metabolic rate and oxygen demand of the body -rapid shallow breathing

Hypertonic Solutions

-osmotic pressure that pulls fluids out of the interstitial spaces -what happens is the colon fills with fluid and promotes defecation -120-180mL is *effective* -*feel enema most common*

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply).

-pleuritic pain that worsens on inspiration -Worsening dyspnea -Absent lung sounds to auscultation on affected side *rationale* When the lung collapses, as with a pneumothorax, the thoracic space fills with air, which irritates the parietal pleura causing inspiratory pain. Because of the collapsed lung there is reduced gas exchange in the affected area, reduced oxygenation and dyspnea result. When an area of the lung collapses, breath sounds over affected area are absent.

Conditions affecting chest wall movement

-pregnancy -obesity -neuromuscular disease -musculosketal abnormalities -trauma -CNS alterations

Increased Metabolic Rate demand examples

-pregnancy -wound healing -exercise rationale: body is using energy or building tissue. Fever increases as well for tissues to gain oxygen, this in turn increase C02 production due to increase hyperventilation

Enemas

-promote defecation by stimulating peristalsis -placed in rectum and sigmoid

What are the manifestations of ECF volume excess

-pulmonary edema -sudden weight gain overnight -neck vens full -bounding pulse

S/S of Hyperventilation

-rapid respirations -sighing breaths -numbness and tingling of hands/fee -light headedness -loss of consciousness

Nursing assessment

-respiratory pattern -thoracic inspection -palpation -auscultation for deviations from normal

What are the manifestations of Hyponatremia

-seizures -lethargy -crave salt -confusion -tired due to: -loss of more salt than water or gain of relatively more water than salt -tap-water enemas -excessive IV administration of 5% dextrose in water -excessive ADH

Cathartic

-short-term action of emptying the bowel -prescribed for bowel evacuation for patients going into *GI tests and abdominal surgery* -much stronger than laxatives -*medication used* Dulcolax, act within 30 minutes

What do do if an adverse reaction occurs during a blood transfusion?

-stop the transfusion immediately -Keep the IV line open by replacing a clean tube and running 0.9% NS -do not just simply turn off the blood transfusion and give normal saline because the remainder of the blood is still in the IV -Immediately notify HCP or Emergency response team -remain with patient and observe signs -take Vitals LOC

Left Side-lying (sims) position

-the last portion of colol is on pt left side, must have it travel up the colon to create irritation -have pt lie on left side with Right knee flexed. -For children; they can be in dorsal recumbent position

Salem Sump

-tube preferred for *stomach decompression* -2 lumina one for air vent and other to remove gastric content -*"blue pigtail"*

Drugs that can be given before a transfusion to prevent confused readings

-tylenol this would help lower the temperature -benadryl to prevent itching

NG Tubes

-very uncomfortable and patient may feel like vomiting due to irritation of nasal mucosa -using lubricant minimizes effect of discomfort -may experience sore throat = give pt ice bag externally -patients stomach may be distended because the amount of air

Nursing interventions for extracellular fluid volume deficit

-vital signs every 2- 4 hrs -orthostatic BP -give oral fluids (sm. amounts freq.) -monitor IV fluids -check urine specific gravity -daily wts -I&O -protect skin -oral care -monitor lab values -monitor mental status

Nursing interventions for extracellular fluid volume excess

-vital signs every 4 hrs (or more freq) -listen to lung sounds -monitor O2 saturation -assess for neck vein distention -daily wts -I&O -protect skin -asses for edema -instruct on fluid and/or Na+ restriction -oral care -monitor lab values for changes -give ordered meds (ie: diuretics)

Cleansing enemas

-vs enemas, they *promote complete evacuation of feces fro the colon* -use of large volumes; tap water, normal saline, soapsuds solution and low-volume hypertonic saline -each has different osmotic effect

S/S of Right Sided Heart Failure

-weight gain -distended neck veins -hepatomegaly (abnormal enlargement of liver) -splenomegaly (abnormal enlargement of spleen) -Dependent peripheral edema

Ch 35

...

Ch 36

...

Ch 37

...

Ch 38

...

What is the universal blood donor?

0-

Urine protein

0-8 mg/dL

Total bilirubin

0.1 to 1.0 mg/dL

Lithium therapeutic range

0.4 to 1.4 mEq/L

Serum creatinine for female

0.5-1.1mg/dL

Serum Creatinine for male

0.6-1.2mg/dL

Normal INR

0.7-1.8

Digoxin therapeutic range

0.8 to 2.0 ng/mL

What is the only solution that can be used when giving blood?

0.9% normal saline

The patient is to hav an IVP. which of the following apply to this procedure? SATA 1) note any allergies 2) monitor intake and output 3) provide for prineal hygiene 4) Assess vital signs 5) encourage fluids after the procedure

1 & 5 *rationale* The dye use din the procedure is *iodine* based. Assessing for history of any allergies can predict allergy to the dye used. Fluid intake dilutes and flushes the dye from the patient

Which of the following assessments do you perform routinely when an older adult patient is receiving IV 0.9% NaCl? 1) Auscultate depended portion of the lungs 2) Check color of urine 3) assess muscle strength 4) check skin turgor over sternum or shin

1) Auscultate depended portion of the lungs

Since removal of the patient's foley catheter, the patient has voided 50-100 mL every 2-3 hours. Which action should the nurse take first?

1) Check for bladder distention *rationale* -assess first -pt may experience retention after catheter removal. -if patient is dribbling or having small amounts, nurse must assess

A nurse is assessing a client for excess fluid volume. What questions should the nurse ask the client to obtain information specific to this problem? SATA

1) Do your rings feel tighter lately? Rationale: Excess fluid volume results in an increase in interstitial fluid; swelling in the hands and feet can result in rings and shoes feeling tighter 2) Did you gain weight in the last few days?" Rationale; one liter of fluid is equal to 2.2 lbs. Retained fluid will cause weight gain

Assessment findings consistent with IV fluid infiltration include: SATA

1) Edema and Pain 4) pallor and coolness

A nurse is caring for a client with a serum calcium level of 7.5 mEq/L. What nursing intervention is important when caring for this client? SATA

1) Give the client the prescribed calcium supplement Rationale; client is currently in hypocalcemia. Normal ranges for Calcium is 8.5-10.5 2) Protect the client from injury. Rationale: The client must be protected from injury because of parasthesia, hyperactive reflexes, muscle spasms/cramps and the potential for seizures associated with hypocalcemia 3) Assess the client for tetany Rationale: results from low calcium levels

A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for: SATA

1) Infection and 4) Reflux *rationale* -urine in the bag and tubing becomes a medium for bacteria, and infection is likely to develop if urine flows back into the bladder -must have the cath *below* waist

A nurse is caring for a client who reports having severe diarrhea and vomiting for the last few days. Other than these problems the client does not have a concurrent medical diagnosis. The client's laboratory results indicate that the client has a serum sodium level of 147 mEq/L. For which clinical indicator unique to this serum sodium levle should the nurse assess the client?

1) Thirst Rationale; sensation of thirst is triggered when plasma osmolarity increases due to inadequate fluid intake in the presence of excessive fluid loss and no other concurrent medical diagnosis

A nurse in the emergency department is caring for a variety of clients. Which clients should the nurse identify are at risk for a deficient fluid volume? SATA

1) older adult with perfuse diaphoresis Rationale; Older adults do not drink so therefore they become more dehydrated. Altered thirst mechanism 2) Adolescent experiencing ketoacidosis Rationale; polyuria, deep rapid respirations are associated with ketoacidosis. This results in volume deficiency 3) Infant experiencing diarrhea for 12 hours Rationale; a lot of fluid can be lost during watery stools.

3 methods to secure condom catheter

1) tape around the ring 2) self adhesive sheath 3) inflatable ring insdie the cath to keep in place

A nurse is caring for a client who is receiving a low-potassium diet. Which food should the nurse teach the client to avoid? SATA

1) tomato soup 2) lima beans 3) spinach

A nurse is caring for a client admitted to the hospital with a diagnosis of HF and is retaining fluid. For what clinical indicators should the nurse assess the client that supports the presence of this condition?

1) weight gain Rationale; HF is associated with excess fluid volume (hypervolemia) 2) hemodilution Rationale; decreased in the concentration of formed elements in the blood because of the increase fluid content of the blod 3) bounding pulse rationale; resulting

Elimination changes that result from inability of the bladder to empty properly may cause which of the following? SATA 1) incontinence 2)frequency 3)urgency 4)urinary retention

1, 2, 3, 4, 5 *rationale* -any condition in urinary retention increase the risk for urinary track infection. -as retention progresses, retention with overflow develops -urethral sphincters is unable to hold back urine due to *pressure in the bladder*

Assessment findings consistent with IV fluid infiltration include: 1) Edema and pain 2) streak formation 3) Pain and erythema 4) Pallor and coolness 5) Numbness and pain

1, 4 Rationale: -occurs when an IV catheter becomes dislodged or vein ruptures and IV fluids go in the subq tissue around the venipuncture site. -extravasation causes "coolness, paleness, and swelling of the area"

Classes of pneumonia:

1. Aspiration - from↓LOC, dysphagia, NG tubes, bacteria 2. Opportunistic - from ↓immune response ex. Pneumocystis jiroveci - HIV disease ex. Cytomegalovirus - transplant pts

Describe the chambers of a "pleur-evac" 1. collection chamber 2. water seal chamber 3. suction control chamber

1. Collection chamber: Receives fluid and air Air vents to outside 2. Water-seal chamber: One way valve Bubbling and tidaling 3. Suction control chamber: Water or dry Usually 20 cm H2O

Complications of IV therapy 1. infiltration and sepsis 2. phlebitis 3. extravasations

1. D/C IV, document location and size of catheter, edema, temp. of skin at site, and pain; s/s = swelling and tissue leakage 2. D/C IV, vein is swollen, tender, red 3. when the medication from the IV leaks into the surrounding tissue, can cause tissue necrosis

Lung cancer 1. early s/s 2. late s/s

1. Early Persistent cough with blood-tinged sputum Chest pain Dyspnea Wheezes 2. Later Anorexia - N&V Fatigue Weight loss Diaphragm paralysis Dysphagia node changes in neck or axilla

Decribe lipoproteins - HDL - LDL - Triglycerides

1. LDL "bad" < 130 desirable < 100 mg/dL optimal carry cholesterol to tissue sites 2. HDL "good" > 30 desirable- higher HDL = less CAD > 50 mg/dL (females); > 40 mg/dL (males) optimal carry cholesterol from arteries to the liver for removal 3. Triglycerides: < 150 mg/dL optimal

What are the 3 purposes of IV therapy?

1. Maintenance - replaces insesnible losses, given for 24 hrs, 30ml/kg water replacement 2. Replacement - given for 48 hrs, replaces F&E's lost from hemorrhage, vomiting, diarrhea, clotting probs, and starvation 3. Restoration - ongoing, for fistulas, burns, abd wounds

Types of lung cancer 1. nsmclc 2. sclc

1. Non-small cell lung cancer (NSMCLC) Adenocarcinoma 30-40%) - more women Never smokers No symptoms til metastasis Treat w/ sx Squamous cell carcinoma 30% - more men Sx resection Better life expectancy Large cell (undifferentiated) carcinoma 5-15% Highly metastatic Sx resection - chemo palliative 2. Small cell lung cancer (SCLC) - "Oat cell" 20% Most malignant! Early metastasis Chemotherapy - poor prognosis Radiation - palliative

ABO 1. who gets what? 2. who's the universal donor and recipient?

1. O- doesn't have A, B, or O antigens. AB+ has A, B, and O antigens. 2. O- is universal donor. AB+ is universal recipient.

Primary vs secondary hypertension

1. Primary (Essential/Idiopathic)- no known cause, 90-95% 2. Secondary- identifiable causes renal disease, endocrine disorders, neurological disorders, sleep apnea, medications, pregnancy

Primary vs. piggyback solution

1. Primary - lg. volume, crystalloid 2. Piggyback - small volume med, short term, hangs higher than primary

Leukocyte poor RBC's 1. what are they? 2. who are they given to?

1. a blood product in which the WBC's have been removed to reduce risk of reaction 2. patients w/ known nonhemolytic transfusion reactions and imunosuppressed ppl

Why do patients get blood products?

1. anemic w/ a hgb < 8-10 2. increase their blood volume 3. they have a clotting disorder 4. surgical blood loss > 1200 5. never just b/c

Rh 1. what is it? 2. who gets + or - ?

1. blood factor made of antigens 2. Rh+ gets + or - blood, Rh- gets - blood only

List the two main functions of transfusions

1. increase O2 carrying capacity of the blood 2. reverse tissue hypoxia

Long quote vs. short quote

1. long quote is > 40 words, use block formatting, double spacing, no quotes, begins w/ 1/2" hanging margin, parenthesis follows last quotation mark

Platelets 1. when is it given? 2. are they cross matched? 3. how are they stored?

1. maintain normal coagulability of the blood, given for bleeding disorders and when bone marrow doesn't make enough 2. no 3. room temp w/ agitation, expire after 5-7 days

Ventilation 1. what is it? 2. inhalation vs exhalation

1. mechanical movement of gas into/out of lungs 2. inhalation - active process, intrathoracic pressure decreases exhalation - passive process based on elastic recoil, intrathoracic pressure increases

PRBC's 1. what must you do first? 2. what must you do for Rh neg? 3. how does it affect the blood? 4. 1 unit = how many mls? 5. what's the infusion rate?

1. must be typed and cross matched 2. Rh neg. gets Rh neg. 3. 1 unit increase Hgb by 1g/dL or Hct by 3% 4. 4 unit = 300-350mls 5. 250-300 mls given over 2-3 hrs, completed w/in 4

Short term CVAD's 1. types

1. non-tunneled percutaneous, PICC

Dressing changes for CVAD's

1. original PICC dressing changed after 24 hrs 2. occlusive gauze changed q 24 hrs 3. transparant semiperm membrane dressing changed q week or when damp, loose, or soiled

Mixed venous blood gases normal ranges for: 1. pH 2. PaO2 3. SaO2 4. PaCO2 5. HCO3

1. pH - 7.33 to 7.53 2. PaO2 - 38 to 42 3. SaO2 - 60-80% 4. PaCO2 - 40 to 55 5. HCO3 - 22 to 26

ABG normal ranges for: 1. pH 2. PaO2 3. SaO2 4. PaCO2 5. HCO3

1. pH - 7.35 to 7.45 2. PaO2 - 80 to 100 3. SaO2 - >95% 4. PaCO2 - 35 to 45 5. HCO3 - 22 to 26

Quoting vs paraphrasing?

1. quote when exact words, phrases, or sentences are used 2. paraphrase when a direct quote is too long, overall meaning is more important than exact words, to demonstrate understanding

Describe the drugs used to lower lipid levels

1. restrict lipoprotein production - "Statins" (atorvastatin/Lipitor ), niacin, nicotinic acid (severe flushing/itching common) 2. increase lipoprotein removal - Bile acid sequestrants (cholestyramine/Questran) 3. decrease cholesterol absorption - ezetimibe (Zetia)

Frozen Fresh Plasma 1. how is it seperated? 2. when is it given? 3. are they cross matched? 4. what's in it? 5. how is it infused?

1. seperated via centrifuge 2. to restore plasma volume and treat some bleeding problems 3. no 4. all clotting factors, antithrombin, plasmin protein 5. short half-life means it runs over 30-60 minutes and must be stored frozen, must finish w/in 4 hrs

Osmolarity of parenteral solutions, definitions: 1. osmolarity 2. hypertonic 3. hypotonic 4. isotonic

1. the concentration/tonicity of a solution 2. >375, more concentrated than cell, fluid moves out of cell and it shrinks, D10W, 3%NS 3. <250, fluid moves into cell and it swells, treats cellular dehydration; D5W, 0.45NS 4. 250-375, no movement, treats intravascular dedydration; D5W, 0.9NS, Lactated Ringer's

Cryoprecipitate 1. what is it? 2. what factors are in it? 3. when is it given?

1. the precipitate after FFP thaws 2. factor VII, vonWillebrand, fibrinogen, factor XIII 3. for fibrinogen levels < 100, when there's a factor deficiency that's leading to bleeding

Long term CVAD's 1. types

1. tunneled cathetars and impanted ports

In text citations and reerences

1. when using facts or statements w/out direct quotations: (Last name, year). 2. with direct quotes: (Last name, year, p. ##). 3. with 2 authors: (Last name, Last name, year). 4. with 3-5 authors after 1st citation all others are: (First Last name et al., year). 5. with unknown author use doc title or org name 6. for reference page: not bold, not italicized, not underlined; centered 7. n.d. for no pub date 8. DOI preferred to IRL

he nurse is reviewing the laboratory test results for a 68-year-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which of the following INR (international normalized ratio) results?

1.0

Urine specific gravity

1.005 to 1.030

Therapeutic PT

1.5-2 times normal (11-12.5)

Therapeutic aPTT

1.5-2 times normal (30-40 sec)

Dilantin therapeutic range

10 to 20 mcg/dL

Phenobarbital therapeutic range

10 to 40 mcg/mL

BUN

10-20 mg/dL

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be which of the following?

100 Beats/min nce each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15 in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).

Normal PT

11-12.5 sec

What are diagnostic tests used to determine cv disease?

12 lead ECG 24-Hour Holter monitor (ambulatory ECG) Electrophysiologic (EP) study Exercise Stress test Echocardiography 2D and Color Doppler Pharmacologic echocardiogram Transesophageal echocardiogram Thallium imaging

Hemoglobin for females

12-16g/100mL

The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate do you program into the infusion pump?`

125 mL / Hr *rationale* 500/4 hours

Sodium

136-145 mEq/L

Hemoglobin for males

14-18g/100mL for male

Platelet

150,000-400,000

the nurse is planning to remove a Foley catheter at 1300. The nurse would check if the patient has voided by...

1700 *rationale* check every 4 hours. If 4 hours after Foley removal have elapsed without voiding, it may be necessary to reinsert the Foley

You tach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid? 1) tap water or bottled water 2) fluid that has sodium in it 3) Fluid that has K and HCO3 in it 4) Coffee or tea, whichever they prefer

2) Fluid that has sodium (salt) in it

Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. IV fluids and other treatments have just been started. What shold yo do about this patient's breathing? 1) notify her health care provider that she is hyperventilating 2) provide frequent oral care to keep her mucous membranes moist 3) ask her to breathe slower and help her to calm down and relax 4) Assess her for pain and request an order for a sedative

2) Provide frequent oral car to keep her mucous membranes moist

Perfusion

ability to pump oxygentated blood to the tissues and return deoxygenated blood to the lungs. Blood flow to the lungs and tissues

For which problem is percutaneous coronary intervention (PCI) most clearly indicated?

acute myocardial infarction *rationale* PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and coronary artery disease are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure.

Cardiac Output

amount of blood ejected from the left ventricle each minute -4-6 L/min in health adult at rest -poor ventricular contractiond ecreases the amount of blood ejected

Compliance

amount of energy expended on breathing depends on the rate and depth of breathing, the ease in which the lungs can be expanded. Ability of the lungs to distend or expand to increased pressure. Decreased in diseases such as -pulmonary edema -interstitial and pleural fibrosis

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply.)?

ashen skin, diaphoresis, s3 s4 sounds and vomitting *rationale* During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.

Oximetry

assessed w/ vitals, non-invasive, less accurate w/ O2 < 70%; affected by low perfusion, anemia, cold extremities

What best describes measurement of post-void residual (PVR)?

bladder scan the patient immediately after voiding *rationale* A PVR or post void residual is the measurement of urine in the bladder within 15 minutes of normal voiding. It would not be a true measurement of PVR if the bladder was full, or if after 30 minutes of voiding. A 16 Fr/10 mL catheter and would not be appropriate to use when catheterizing for PVR.

Hematuria

blood in urine

A patient admitted to the emergency department 24 hours ago with complaints of chest pain was diagnosed with a ST-segment-elevation myocardial infarction (STEMI). What complication of myocardial infarction should the nurse anticipate?

cardiac dysrhythmias *rationale* Dysrhythmias are present in 80% to 90% of patients after myocardial infarction (MI). Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

Which of the following symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? 1) change in bowel habits 2) blood in the stool 3) larger-than-normal bowel movement 4) fecal impaction 5) muscle aches 6) incomplete emptying of the colon 7) food particles in the stool 8) unexplained abdominal or back pain

change in bowel habits, blood in the stool, incomplete emptying of the colon, unexplainable abdominal or back pain *Rationale* According to the American Cancer Society current guidelines, anyone with these symptoms should seek medical evaluation because they may have colon cancer. Other conditions may also cause these symptoms; but, if colon cancer is present, early diagnosis is important.

A patient returns after cardiac catheterization. Which nursing care would the registered nurse delegate to the licensed practical nurse?

check for bleeding at the catheter insertion site *rationale* The licensed practical nurse can check for bleeding at the puncture sites. If bleeding is identified, it should be reported to the registered nurse. Vital signs should be delegated to the unlicensed assistive personnel. Preparation of discharge teaching and monitoring for dysrhythmias such as S-T elevation would be registered nurse scope of practice.

What are some other blood volume builders?

crystalloids, artificial crystalloids (dextran)

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?

decreased independent ability to cough *rationale* Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia. The patient does not have a productive cough

Examples of colloids

dextran, albumin, mannitol; pull water toward them, can't cross membrane

Risks of infusion therapy

disease transmission (most likely Hep B), bacterial contamination, transfusion rxn, circulatory overload

What is unintentional plagarism?

don't use citations for info not considered common knowledge, incorrectly paraphrase or summerize

What is an autologous blood donation?

donation to one's self, good for one month

Assessment findings consistent with IV fluid infiltration include SATA

edema and pain, with pallor and coolness *rationale* Inadvertent fluid leakage into the interstitial compartment around an IV site can cause swelling, pain from the pressure, pale color, and coolness of the infiltrated area.

Second spacing

edema-abnormal accumulation of interstitial fluid

The nurse formulates a nursing diagnosis of Impaired physical mobility related to decreased muscle strength for an older adult patient recovering from left total knee arthroplasty. What nursing intervention is appropriate?

encourage exercises 4x/day *rationale* Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures.

Preload (filling)

end diastolic volume -the more stretch on the ventricular muscle, the greater the contraction and the greater the stroke volume Example: patient who is hemorrhaging. Volume needs to be replaced otherwise, preload stroke volume and cardiac output decreases

Your patient has severe hypercalcemia. What are your priority nursing interventions?

fall prevention interventions, encouraging increased fluid intake, monitoring constipation *rationale* Severe *hypercalcemia* causes lethargy, which creates a risk for falling and constipation. Increased fluid intake is important to prevent renal calculi during hypercalcemia.

Your patient has hypokalemia with stable cardiac function. What are your priority nursing interventions?

fall preventions, monitoring constipation, *rationale* *Hypokalemia* causes bilateral skeletal muscle weakness, especially in the quadriceps, which creates a risk for falling. It also causes gastrointestinal smooth muscle weakness, which produces constipation.

A 6 year old boy is admitted to the peds unit with chills and a fever of 104. What physiological process explains why the child is at risk for developing dyspnea

fever increases metabolic demands, requiring increased oxygen need *rationale* When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathing.

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following

forms a strong bond with hemoglobin, creating a functional anemia *rationale* *Carbon monoxide strongly binds to hemoglobin*, making it unavailable for oxygen binding and transport.

The nurse is caring for a patient who has decreased mobility. Which intervention is a smiple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

frequent change in position *rationale* Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.

Which assessment do you use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit?

fullness of neck veins when supine *rationale* ECV deficit involves decreased vascular and interstitial volume. One way to assess vascular volume is to examine the fullness of neck veins when an individual is supine. With normal ECV neck veins are full when the individual is supine. With ECV deficit they are flat.

Non-tunneled percutaneous catheters

good for 7-10 days, placed at bedside, single/double/triple lumen available - distal (blood) - medial (TPN) - proximal (blood components)

When delegating input and output (I&O) measurement to nursing assistive personnel, you instruct them to record what information for ice chips?

half the chip volumes example: 200 mL of chips with 900 mL IV fluid during shift the total intake is 1000mL

Which skills must a patient with a new colostomy be taught before discharge from the hospital? SATA 1) how to change the pouch 2) how to empty the pouch 3) How to open and close the pouch 4) irrigate the colostomy 5) how to determine if the ostomy is healing appropriately

how to change the pouch, how to empty the pouch, how to open and close the pouch, how to determine if the ostomy is healing correctly *rationale* irrigation is done by HCP

Main adverse effect of nesiritide is?

hypotension

The patient states that she "loses urine" every time she laughs or coughs. The . nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states:

i drink two glasses of wine with dinner *rationale* alcohol is a bladder irritant. It increases urine production and causes uncontrolled bladder contractions

Which are key points that the nurse should include in patient education for a person with complaints of chronic constipation?

increase fiber and fluids in the diet, exercise 30 minutes everyday, schedule time to use the toilet at the same time everyday

Extracellular fluid volume excess definition

increased fluid retention in the intravascular and interstitial spaces

Pyelonephritis

infection of kidneys

Phlebitis

inflammation of a vein due to; -Acidic or hypertonic IV solutions -rapid IV rate -poor hand hygiene and lack of asceptic technique Rationale: -without asceptic technique phlebitis can cause blood cloths and causes emboli along the veins

PICC lines 1. insertion location

inserted into basilic vein at ac fossa

*A patient has not had a bowel movement for 4 days.* Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what should the nurse suspect?

intestinal obstruction *rationale* Absence of bowel movement, nausea, cramping, and possibly vomiting are characteristic of an intestinal obstruction.

The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery?

left knee infection *rationale* The patient must be free of infection before total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring more extensive surgery. The nurse must assess the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability are typical of osteoarthritis.

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider?

light pink in the urine *rationale* presence of blood should be notified ASAP Light pink urine indicates the presence of blood in the urine, which is never a normal finding. First voided urine can normally be slightly cloudy and darker in color. Pale yellow urine indicates normal finding.

what transfer oxygen from the atmosphere into the alveioli and carbon dioxide out of the body as a waste product

lungs

Oxygen transport

lungs + CV system

How to maintain thin secretions?

maintain hydration 1500-2500 mL/day

Which of the following activities can you delegate to nursing assistive personnel (NAP)? SATA

measuring oral intake and urine ouput as well as reporting an IV container that is low in fluid

What must nurse do to before giving blood?

positively ID the pt, inspect the blood, 2-nurse verification, verify donor-recipient compatibility, check expiration date, get baseline vitals, start IV w/ 18-20G needle to avoid lysing of cells

Chest physiotherapy in mobilizing pulmonary secretions:

postural drainage, percussion, and vibration

What factors effect cardiac output?

preload, afterload, myocardial contractility, and HR

The nurse understand that, when comparing nasogastric tubes used for gastric decompression, a Salem sump is specifically designed to:

prevent gastric mucosal damage *rationale* A Salem sump tube has a double lumen. The second lumen is the blue pig-tailed portion that is open to air for the purpose of equalizing the pressure outside the body to inside the stomach. This prevents the tip of the Salem sump from becoming attached to the stomach lining, thus preventing mucosal irritation and bleeding.

Ventilation

process of moving gases into and out of the lungs. The MAJOR inspiratory muscle is the diaphragm. Innvervate (supplied with nerves) by the phrenic nerve. oxygen entering the lungs

Afterload (squeezing)

resistance to left ventricular ejection -must over the resistance, so the heart works harder to over come. -patients with hypertension increases the afterload making the heart increase in workload

How to treat hyponatremia?

restriction of water Intravenous fluids. Your doctor may recommend IV sodium solution to raise the sodium levels in your blood. This often requires a stay in the hospital. Medications. You may take medications to manage the signs and symptoms of hyponatremia, such as headache, nausea and seizures. -hypertonic solutions in central line to help shrink cell and pulls fluid down to remove swollen cells -restrict fluids -check if pt taking lithium then take their drugs levels Foods: Canned foods, bacon, butter, cheese, processed foods

Fats - saturated vs monounsaturated vs polyunsaturated

saturated = bad (animal fats, coconut, palm oil, dairy products) monounsaturated = ok (fish oil, advocado, almonds, penuts, pecans, olives, canola and olive oil) polyunsaturated = good (shellfish, walnuts, pumpkin seeds, sunflower seeds, margarin, safflower/soy/cottonseed/flaxseed oils)

The nurse is caring for a patient with a colostomy. Which intervention is most important?

selecting a bag with an appropriate-size stoma opening *rationale* The opening of the appliance should be no larger than 0.15 to 0.3 cm (1/16 to 1/8 inch) surrounding the stoma to ensure that the skin around the stoma is protected from the enzymes present in the effluent without impinging the stoma.

Treatment steps for asthma

step 1: SABA (albuterol) step 2: low dose ICS (flovent 0r singulair) step 3: combo LABA & ICS (serevent) step 4: medium ICS & LABA step 5: high dose ICS & LABA step 6: high dose ICS & LABA & corticosteroid

Coronary Artery Circulation

supplies myocardium with oxygen and nutrients to remove waste. -Fills during diastole -Left coronary artery has the most abundant blood supply to feed the left myocardium (does most of the work for the heart)

Cardiopulmonary Physiology

taking deoxygenated blood to RIGHT side where it is oxygenated and then traveled to left side to the tissues

The postoperative patient has difficutly voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action should the nurse *implement* first?

turn on the bathroom faucet as he tries to void *rationale* the sound of running water helps

What assessment do you make before hanging an intravenous (IV) fluid that contains potassium?

urine output *rationale* Increased potassium intake when potassium output is decreased is a major risk for hyperkalemia. Before increasing IV potassium intake, check to see that urine output is normal.

An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings?

use mirror therapy *rationale* Mirror therapy has been shown to reduce phantom limb pain in some patients. Opioid analgesics, rebandaging the residual limb, and showing the patient that the leg is gone may not decrease phantom limb pain.

Small bore tubes

used frequently for medication administration and enteral feedings

What are the components of parenteral solutions?

water, glucose, amino acids, vit's, electrolytes, ph

Describe the steps involved in the development of artherosclerosis

what is it: deposits of fat lining coronary arteries Fatty streaks start at age 15 By 30, fibrous plaque appears 1. Inflammation or injury occurs (smoking, HTN, DM, high cholesterol) C-reactive protein will be elevtated 2. Immune response to injury. Platelets attach, smooth muscle cells migrate in, lipids accumulate, 3. Fibrous plaque forms, can lead to complicated lesions ( dangerous, unstable and can rupture) Two types of plaque: Stable - obstructs blood flow, angina when lesion >75% Unstable - gel-like lipid rich core covered w/fibrous cap - if ruptures leads to platelet aggregation and acute MI or unstable angina **CAD - lipids (atheromas) and cholesterol deposit in the intimal wall of coronary arteries = localized inflammatory response that develops into a fibrous plaque = endothelial injury as the plaque bulges into the lumen of the artery. Ongoing growth of the fibrous plaque plus continued inflammation = plaque instability, ulceration, and ultimately rupture. Once the endothelial layer is damaged, platelet aggregation leads to thrombus formation from receptor binding of fibrinogen.

Tension Pneumothorax

when chest tubes are clamped, kinked or occluded. Air gets trapped

The nurse is taking a health history of a newly admitted patient with a diagnosis rule/out bowel obstruction. Which of the folloing is the priority question to ask the patient?

when was the last time you moved your bowels? *rationale* Lack of a bowel movement is a sign of a bowel obstruction and is a medical emergency.

What determines CVAD tip location?

x-ray, prior to initiation of therapy