Exam 2 Fundamentals
Three levels of prevention
1. Primary- wellness education, immunizations, screenings 2. Secondary- screenings, treating early stages 3. Tertiary- disability is permanent, high level of functioning, preventative care
A child with type 1 diabetes is exhibiting deep, rapid respirations; flushed, dry cheeks; abdominal pain with nausea; and increased thirst. Which blood pH and glucose level with the nurse expect the laboratory tests to reveal?
7.20 and 460 mg/dL (25.5 mmol/L)
normal oxygen saturation
95-100%
The nurse should anticipate that which patient will need to be treated with insertion of a chest tube?
A patient experiencing a problem with a pneumothorax
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia?
Arterial blood gas
During the administration of an antibiotic, the client becomes restless and flushed, and begins to wheeze. Which action will the nurse take after stopping the antibiotic infusion?
Assess the client's respiratory status.
spiritual care (FICA)
Faith or belief Importance of spirituality Community Address spiritual needs
When evaluating the concept of gas exchange, how should the nurse best describe the movement of oxygen and carbon dioxide?
Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane.
Which internal variable influences health beliefs and practices?
Intellectual background
cultural competence (LEARN)
Listen to patient's perception Explain your perception Acknowledge differences/similarities Recommendations Negotiate a treatment plan
Blood glucose level chart
Normal •fasting: 80-100 •just ate: 170-200 •3 hours after: 120-140 Pre-Diabetic •fasting: 101-125 •just ate: 190-230 •3 hours after: 140-160 Diabetic •fasting: 126+ •just ate: 220-300 •3 hours after: 200+
ROME
Respiratory Opposite Metabolic Equal
Which complication is the priority for the nurse to assess in a child with smoke inhalation?
Tracheobronchial edema
which arterial blood gas (ABG) Value would indicate diabetic ketoacidosis?
decreased HCO3
On admission to an intensive care unit, a client is diagnosed with compensated metabolic acidosis. The nurse expects which assessment finding?
deep and rapid respirations
Which is a gastrointestinal manifestation of infection in the newborn?
glucose instability
which conditions are cardiovascular manifestations of alkalosis?
increased heart rate and increased digitalis toxicity
Clinical Management: Primary Prevention
infection control smoking cessation immunizations prevent post-op complications
A critically ill five-year-old child exhibits Kussmaul respirations. Which would the nurse suspect may be causing an increasing acid-base imbalance?
metabolic acidosis caused by a concentration of cations in bodily fluids
Which culturally based behavior would the nurse expect to observe in an Asian client who has symptoms of anxiety and panic?
minimal eye contact
Normal respiratory rates
newborns and up to 1 year: 30-40 breaths/min 1-3 years: 23-35 breaths/min 3-6: 20-30 breaths/min 6-12: 18-26 breaths/min Adults and adolescents: 12-20
Adult Arterial Blood Gases
pH (7.35-7.45) PaCO2 (35-45 mmHg) HCO3 (22-26 mEq/L) Base Excess (-2 to 2+)
Maslow's Hierarchy of Needs
physiological needs safety needs love and belonging esteem self-actualization
Stages of behavior change
precontemplation contemplation preparation action maintenance
acid-base balance
resp acid: carbonic acid excess (PaCO2) resp alka: carbonic acid deficit meta acid: bicarbonate deficit ( HCO3) meta alka: bicarbonate excess
The nurse is administering oral glucocorticoids to a patient with asthma. What finding indicates a therapeutic response to the medication?
No observable respiratory difficulty or shortness of breath over the last 24 hours
