Exam #2
To cure:
-Ectomy (Remove an infected organ)
Nasal canula flow rates
1-6 LPM, above 4 needs humidification
Non-rebreather mask
10-15 LPM
A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?
15-mm induration
How many pounds is one liter of water?
2.2
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? a. A client who is receiving acetaminophen (Tylenol) for pain b. A client who ambulates in the hallway every 4 hours c. A client with a nasogastric tube d. A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago
A client with a nasogastric tube
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?
Dyspnea
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?
Elevated hematocrit level
A fractured skull would be classified under which category of surgery based on urgency? a) Required b)Elective c) Emergent d) Urgent
Emergent
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? a. Opioid overdose b. Extreme anxiety c. Myasthenia gravis d. Type 1 diabetes mellitus
Extreme anxiety
Is the following statement true or false? For patients with chronic bronchitis, the nurse expects to see the major clinical symptoms of tachypnea and tachycardia
False For patients with chronic bronchitis, the nurse expects to see the major clinical symptoms of sputum and productive cough
Medications Management for Asthma
Quick-relief medications Beta2-adrenergic agonists Anticholinergics Long-acting medications Corticosteroids Long-acting beta2-adrenergic agonists Leukotriene modifiers
Circulating nurse-
RN who preps for the operation and documents
Hyperphosphatemia
Serum level above 4.5 mg/dL
Hypophosphatemia
Serum level below 2.7 mg/dL
Hypercalcemia
Serum level greater than 10.2 mg/dL
The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? a. Stabbing pain during respiratory movement b. Dullness or flatness on percussion over areas of collected fluid c. Fever and chills d. Dyspnea and coughing
Stabbing pain during respiratory movement
Electrolytes Cations
sodium, potassium, calcium, magnesium
Partial rebreather mask
6-10 L
A client experiencing an asthmatic attack is prescribed methylprednisolone intravenously. What action should the nurse take? A. Encourages the client to decrease caloric intake due to increased appetite b. Aspirates for blood return before injecting the medication c. Informs the client to limit fluid intake due to fluid retention d. Assesses fasting blood glucose levels
Assesses fasting blood glucose levels
Asthma
Chronic inflammatory disease of the airways that causes hyperresponsiveness, mucosal edema, and mucus production Inflammation leads to cough, chest tightness, wheezing, and dyspnea (Fig. 24-6) Asthma is largely reversible; spontaneously or with treatment Allergy is the strongest predisposing factor
Electrolytes Anions
Cl-, PO4 2-, SO4 2-, HCO3 ( Cloride, Phosphate, Sulfate, Bicarbonate)
Emphysema
Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli Decreased alveolar surface area increases in "dead space," impaired oxygen diffusion Hypoxemia results Increased pulmonary artery pressure may cause right-sided heart failure (cor pulmonale)
What flow rate needs humidification?
Above 4L nasal canula
The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?
Acute respiratory distress syndrome
A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?
An inhaled beta2-adrenergic agonist
INTRAOPERATIVE COMPLICATIONS
Anesthesia awareness Nausea, vomiting Anaphylaxis Hypoxia, respiratory complications Hypothermia Malignant hyperthermia Infection
You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate? a. Aspiration b. Direct lung damage c. Chemical irritation d. Drug ingestion
Chemical irritation
Wound Healing
First-intention wound healing Second-intention wound healing Third-intention wound healing
Which measure may increase complications for a client with COPD?
Increased oxygen supply
Nursing Management of CF
Strategies that promote removal of pulmonary secretions CPT and breathing exercises Remind patient to reduce risk factors for resp infection Adequate fluid and electrolyte intake Palliative care Discuss end-of-life issues and concerns
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member? a.Circulating nurse b. Anesthetist c. Surgeon d.Scrub nurse
Surgeon
The nurse is assigned to care for a patient in the ICU who is diagnosed with status asthmaticus. Why does the nurse include fluid intake as being an important aspect of the plan of care? (Select all that apply.) a. To loosen secretions b. To facilitate expectoration c. To relieve bronchospasm d. To combat dehydration e. To assist with the effectiveness of the corticosteroids
To combat dehydration To loosen secretions To facilitate expectoration
When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period? a) Up to 72 hours after alcohol withdrawal b) Immediately upon admission c) Up to 24 hours after alcohol withdrawal d)Upon awakening in the postanesthesia care unit
Up to 72 hours after alcohol withdrawal
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?
Using strict hand hygiene
Extracellular space (fluid outside the cells):
approximately 1/3 is in the ECF.
Interstitial space:
contains the fluid that surrounds the cell and total about 11-12 L in an adult
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as A)emergency. B) required. C)urgent. D)elective.
emergency.
Early signs of hypervolemia include
increased breathing effort and weight gain.
CPAP (continuous positive airway pressure)
pressurized air delivered to lungs to keep them expanded during exhalation
In respiratory alkalosis, the pH is
↑ and the PaCO2 is ↓
Hypokalemia
Below-normal serum potassium <3.5 mEq/L
To diagnose:
Biopsy-malignant or benign
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: a.Scrub nurse b.Circulating nurse c.Anesthesiologist d.Surgeon
Circulating nurse
To palliate:
Debulk tumors to improve organ function
Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? a.Propofol b.Succinylcholine c.Halothane d.Fentanyl
Halothane
Renin-Angiotensin-Aldosterone system
Helps maintain a balance of sodium and water in the body as well as to maintain a healthy blood volume and blood pressure
In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? a.Decreased level of consciousness (LOC) b.Increased blood pressure c.Increased restlessness d.Decreased heart rate
Increased restlessness
What are ICF & ECF?
Intracellular fluid (fluid in cells) and extracellular fluid (fluid outside cells)
During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following a.Rebound hyperthermia b.Metabolic acidosis c.Hypoxia d.Anaphylaxis
Metabolic acidosis
As status asthmaticus worsens, the nurse would expect which acid-base imbalance? Metabolic alkalosis Respiratory alkalosis Metabolic acidosis Respiratory acidosis
Respiratory acidosis
Hypermagnesemia
Serum level greater than 2.6 mg/dL
Hypomagnesemia
Serum level less than 1.8 mg/dL
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?
The tissues give a crackling sensation when palpated.
The primary objective in the immediate postoperative period is a. monitoring for hypotension. b.controlling nausea and vomiting. c.maintaining pulmonary ventilation. d.relieving pain.
maintaining pulmonary ventilation.
In respiratory acidosis, the pH is
↓ and the PaCO2 is ↑
A client is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which medication is contraindicated in the treatment of asthma exacerbations?
Cromolyn sodium
A nurse plans care for a client and notes that all of the following must be completed for a client being prepared for surgery. Which intervention should the nurse complete first? A.) complete the preoperative checklist. B.) Assess the client's preoperative vital signs. C.) Remove the client's rings, gold chain, and wristwatch D.) Administer 10 mEq KCL IV for serum potassium level of 3.0 mEq/L
D
List reference ranges for sodium, potassium, calcium, phosphate, magnesium:
Na 135-145, Ca 8.6-10.2, K 3.5-5, PO4 2.2-4.4, Mg 1.5-2.5
To prevent:
Polyp removal to prevent cancer (spread of infection)
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? a. Hemoptysis b. Tachypnea c. Cough d. Syncope
Tachypnea
A mediastinal shift occurs in which type of chest disorder? a. Simple pneumothorax b. Tension pneumothorax c. Traumatic pneumothorax d. Cardiac tamponade
Tension pneumothorax
A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue? a. "Drink fluids upon arising from bed." b. "Delay self-care activities for 1 hour." c. "Raise your arms over your head." d. "Sit in a chair whenever doing an activity."
"Delay self-care activities for 1 hour."
A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? a. "It is all right if I have a grilled cheese sandwich with American cheese." b. "It is all right if I drink a glass of red wine with my dinner." c. "It is fine if I eat sushi with a little bit of soy sauce." d. "I am going to have a tuna fish sandwich for lunch."
"It is all right if I have a grilled cheese sandwich with American cheese."
Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? a. Adrenal b. Parathyroid c. Thyroid d. Pituitary
Adrenal
A client with chronic obstructive pulmonary disease (COPD) is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory status, which finding should the nurse anticipate? a.An inspiratory-expiratory (I:E) ratio of 2:1 b.A transverse chest diameter twice that of the anteroposterior diameter c.An oxygen saturation of 99% d.A respiratory rate of 12 breaths/minute
An inspiratory-expiratory (I:E) ratio of 2:1
Bronchiectasis
Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles
Medications to Treat COPD
Bronchodilators, MDIs Beta-adrenergic agonists Muscarinic antagonists (anticholinergics) Combination agents Corticosteroids Antibiotics Mucolytics Antitussives
Chronic Bronchitis
Cough and sputum production for at least 3 months in each of 2 consecutive years Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucous may plug airways Alveoli become damaged, fibrosed, and alveolar macrophage function diminishes The patient is more susceptible to respiratory infections
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? a. Metabolic alkalosis b. Altered blood urea nitrogen (BUN) value c. Respiratory acidosis d. Extracellular fluid volume deficit
Extracellular fluid volume deficit
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?
Flail chest
Bronchiectasis: Nursing Management
Focus is on alleviating symptoms and clearing pulmonary secretions Patient teaching Smoking cessation Postural drainage Early signs and symptoms of respiratory infections Conserving energy
A client diagnosed with asthma is preparing for discharge. The nurse is educating the client on the proper use of a peak flow meter. The nurse instructs the client to complete which action?
If coughing occurs during the procedure, repeat it.
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?
Increases arterial pH
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? a. Administer a large dose of furosemide (Lasix) IVP stat b. Increase oxygen administration c. Schedule the client for pulmonary surgery d. Intubate the client and control breathing with mechanical ventilation
Intubate the client and control breathing with mechanical ventilation
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?
Jugular vein distention
Third-spacing
Loss of ECF into a space that does not contribute to equilibrium between the ICF and the ECF is referred to as a third space fluid shift, or third spacing.
Cystic Fibrosis
Most common autosomal recessive disease among the Caucasian population Genetic screening to detect carriers Genetic counseling for couples at risk Genetic mutation changes chloride transport which leads to thick, viscous secretions in the lungs, pancreas, liver, intestines, and reproductive tract Respiratory infections are the leading cause of morbidity and mortality
Which of the following factors contribute to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Select all that apply.
Mucus secretions block airways. Inflamed airways obstruct airflow. Overinflated alveoli impair gas exchange.
Indicators of Hypovolemic Shock/Hemorrhage
Pallor Cool, moist skin Rapid respirations Cyanosis Rapid, weak, thready pulse Decreasing pulse pressure Low blood pressure Concentrated urine
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? A.Foul smell B.Pieces of vomitus C. Pink color D. Copious red blood in the sputum
Pink color
The scrub nurse is responsible for: a. Calling the "time-out" to verify the surgical site and procedure b. Monitoring the operating-room personnel for breaks in sterile technique c. Preparing the sterile instruments for the surgical procedure d.Monitoring the administration of the anesthesia
Preparing the sterile instruments for the surgical procedure
The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment?
Providing sufficient oxygen to improve oxygenation
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? a.Report the infection to an immediate supervisor. b.Request a role change to circulating nurse. c.Ensure the infection is covered with a dressing. d.Return to work after taking antibiotics for 24 hours.
Report the infection to an immediate supervisor.
Hypocalcemia
Serum level less than 8.8 mg/dL, must be considered in conjunction with serum albumin level
Hypochloremia
Serum level less than 96 mEq/L
Hyperchloremia
Serum level more than 107 mEq/L
Hyperkalemia
Serum potassium greater than 5.0 mEq/L
Hypernatremia
Serum sodium greater than 145 mEq/L
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? a. Serum creatinine level of 0.4 mg/dl b. Serum sodium level of 124 mEq/L c. Hematocrit of 52% d. Serum blood urea nitrogen (BUN) level of 8.6 mg/dl
Serum sodium level of 124 mEq/L
A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed is: a. Tachycardia b. Sharp, stabbing chest pain c. A dry, hacking cough d. Dyspnea
Sharp, stabbing chest pain
Active transport
Solutes move from an area of lower concentration to an area of higher concentration.
The most diagnostic clinical symptom of pleurisy is: a. Dyspnea and coughing. b. Stabbing pain during respiratory movements. c. Dullness or flatness on percussion over areas of collected fluid. d. Fever and chills.
Stabbing pain during respiratory movements.
Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall? a. Use a heat or cold application. b. Use a prescribed analgesic. c. Turn onto the affected side. d. Avoid using a pillow while splinting.
Turn onto the affected side.
What is the primary clinical symptom of emphysema? a. Chest pain b. Productive cough c. Sputum d. Wheezing
Wheezing The primary symptom of emphysema is wheezing. Sputum and productive cough are the primary symptoms of chronic bronchitis
A cient with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the pancreatic enzymes that the client has been prescribed?
With meals
List a few causes of respiratory acidosis and alkalosis, and patient management
acidosis from asthma, COPD, severe obesity. Managed by clearing airway obstruction. Alkalosis from hyperventilation, chronic liver disease. Breathe into a paper bag.
Venturi mask
an oxygen-delivery apparatus consisting of a mask with holes on each side that allow exhaled air to escape and color-coded entrainment ports that are adjustable to allow regulation of the concentration of oxygen delivered
Intracellular space (fluid in the cells)
approximately 2/3 of body fluid is in the ICF and is located primarily in the skeletal muscle mass
A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: a. pleural effusion. b. oxygen toxicity. c. atelectasis. d. pulmonary edema.
atelectasis.
Preoperative phase
begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed
Intraoperative phase:
begins when the patient is transferred onto the OR bed and ends with admission to the PACU (post anesthesia care unit)
Postoperative phase:
begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home
BiPAP machine
can be set at a higher pressure for inhaling and a lower pressure for exhaling
Intravascular space (fluid within the blood vessels):
contains plasma, the effective circulating volume. Approximately 3 L of the average 6 L of blood volume in adults is made up of plasma
A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypotension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance?
hypokalemia
List a type of isotonic, hypotonic and hypertonic fluid
hypotonic=5% dextrose in Water, isotonic = 0.9% saline, hypertonic = 5% dextrose in saline
A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the
malignancy is causing the electrolyte imbalance.
Oncotic pressure refers to the a. number of dissolved particles contained in a unit of fluid. b. excretion of substances such as glucose through increased urine output. c. amount of pressure needed to stop the flow of water by osmosis. d. osmotic pressure exerted by proteins.
osmotic pressure exerted by proteins.
Arterial Blood Gas (ABG):
pH: 7.35-7.45; CO2: 35-45; pO2: 80-100; HCO3: 22-26
Transcellular space
the smallest division of the ECF compartment and contains approximately 1 L
Surgical time-out or pause:
• Before the induction of anesthesia, ask the patient to confirm name, birthdate, surgical procedure and site, and consent. • Wrong surgical procedure and surgery performed on the wrong body part or wrong patient are sentinel events (never events) or serious reportable events