Exam 2 Practice Questions

Right lung is __% of activity; left lung is __% of activity

55 / 45

A potassium level about ____ is critical

6.4

Which is a better indicator of nutritional/protein status over the last 6 months: pre-albumin or albumin?

Albumin

Which finding would the nurse expect during the assessment of a patient with a serum potassium level of 6.8 mEq/L? Select all that apply. One, some, or all responses may be correct. 1 Bradycardia 2 Muscle twitching 3 Extremity numbness 4 Cardiac dysrhythmias 5 Hyperactive bowel sounds

All of the above!

Dobutamine

Beta 1 agonist / vasopressor

Which finding would the nurse expect to notice during an assessment of a patient admitted with hypocalcemia secondary to chronic kidney disease? 1 Circumoral tingling 2 Lethargy and seizures 3 Negative Trousseau sign 4 Hypoactive bowel sounds

Circumoral tingling

_____ disease associated with HYPOkalemia; ______ disease (adrenal insufficiency) assoc. with HYPERkalemia

Cushing's / Addison's Why? Addison's causes ADRENAL insufficiency, which is where aldosterone is produced. Aldosterone holds in Na and excretes K+.

How do cardioglycosides work?

Have a positive inotropic effect; >HR, > CO Tx. afib and HF Ex. digoxin

Insulin pushes ___ INTO the Cell

K (INsulin pushes K IN)

PAD vs DVT pain

PAD pain is IC; DVT pain is soreness/cramping

resurfacing

Regrowth of new skin cells across the open area of a wound as it heals.

Contact precautions (don't come into CONTACT with anything in this SEWER)

S kin infections E enteric (c. diff.) W wound infection E ye infection R rotavirus

Which pressure stage involves a blister and shallow crater?

Stage 2

_ cells secrete lymphokines that stimulate macrophages

T

Most common HAI

UTI

Dakin's solution

bleach solution that debrides tissue

Tetany is caused by hypo_______.

calcemia

Mannitol

osmotic diuretic used to treat hyponatremia

Homan's sign

pain in *calf upon dorsiflexion* of foot and may indicated thrombophlebitis

prodromal stage

person is most infectious, vague and nonspecific signs of disease (from nonspecific sx. to specific sx.)

Tx for C. diff

*METRONIDAZOLE* *FIDAXOMICIN* (macrolide that targets RNA pol), *VANCOMYCIN* Fecal microbiota transplant (FMT)

Shearing vs Friction

*Shear: sliding movement of skin and sub-q tissue while the underlying muscle & bone are stationary *Friction: force of 2 surfaces moving across one another (like skin dragged over linen)

convalescence

*days-months *acute s/s disappear

Which rational supports administering the medication pregabalin to a client with acquired immunodeficiency syndrome (AIDS)? 1 To reduce neuropathic pain 2 To reduce cognitive difficulty 3 To reduce swallowing difficulty 4 To reduce muscle and joint pain

1 To reduce neuropathic pain

Incentive spirometry goal

1500 mL / 10X per hour, with breaks in between

When is the greatest risk of hemorrhage after surgery?

1st 24 - 48 hrs

1 L of body fluid weighs _ lb

2.2

Normal HCO3 range

22-26 mEq/L

Qualification for c diff dx.

3+ liquid stools in 24 hours

Which is the minimum safe urine output per hour for a 1.5-year-old child who weighs 22 lb (11 kg)? 1 61 to 80 mL 2 41 to 60 mL 3 21 to 40 mL 4 10 to 20 mL

4 10 to 20 mL

2+ score of edema

4 mm indentation

Signs of MILD hypocalcemia 1. seizures 2.Hand spasms 3 severe muscle cramps 4 perioral numbness

4 perioral numbness

Which cells in the dermis are responsible for collagen formation?

Fibroblasts

Which stage of wound healing involves the creation of a fibrin mesh?

Inflammatory phase (full-thickness wound repair)

examples of contact precautions

MRSA, VRE, cdiff, scabies, lice

How does electrical stimulation heal wounds?

Promotes vessel growth / granulation

Pseudoephedrine

Sudafed; nasal decongestant

Treatment for MRSA

Vancomycin, linezolid, ceftaroline

Tx for rhinosinusitis

Vitamin C, zinc

How to remember normal protein levels?

When I get a steak, I want it to be 6-8 oz.

Which vitamin can interfere with copper absorption?

Zinc

SSI's occur when?

within 30 days after surgery

Which symptom is caused by respiratory acidosis? 1 Headache 2 Muscle cramps 3 Abdominal pain 4 Numbness and tingling of fingers

1 Headache

You have a pt. with pulmonary disease, such as COPD. Do NOT give them O2 over _ L. 1. 1 2. 2 3. 3 4. 4

3 L

How does HBOT heal wounds?

> WBC action

When would you use sharp/surgical debridement?

For a draining, necrotic injury

Good sources of zinc

Veggies, meats, legumes

Which vitamin is key in epithelialization?

Zinc

________ drugs can >BP and glucose

alpha adrenergic

Most causative HAI agents? a. H. Pylori & CRE b. E. coli & s. auereus c. Influenza & MRSA

b. E. coli & s. auereus

Neutrophils are elevated with ______, while eosinophils & basophils are elevated with _________ infections

bacteria / parasitic

Formulation of a granuloma (macrophages, fibroblasts, & collagen) is assoc. with acute/chronic inflammation

chronic

Sjorgen's disease

-progressive autoimmune disorder that attacks moisture producing glands that that often impacts women after the age of 40; causes DRY EYES

1+ score of edema

2 mm

________ causes deep skin loss / ______ causes superficial skin loss

Shearing / friction (epidermis only)

Nasal cannula

1-6 L/min 24-44% *LOW FLOW

Braden scale categories

1. sensory perception 2. moisture 3. activity 4. mobility 5. nutrition 6. friction/shear

Inserting the vascular access device at a __-__ degree angle reduces the risk of puncturing the posterior wall of the vein.

10 / 30

Someone scoring under a __ on the Braden scale is at high risk for PIs

12

Which is the primary fluid shift that occurs with diabetes mellitus? 1 Intravascular to interstitial because of glycosuria 2 Interstitial to extracellular because of hypoproteinemia 3 Intracellular to intravascular because of hyperosmolarity 4 Intercellular to intravascular because of increased hydrostatic pressure

3 Intracellular to intravascular because of hyperosmolarity

Which sexually transmitted infection is caused by human papillomavirus? 1 Gonorrhea 2 Genital herpes 3 Chlamydia infection 4 Condylomata acuminata

4 Condylomata acuminata Condylomata acuminata is a sexually transmitted infection caused by the human papillomavirus. Gonorrhea is caused by Neisseria gonorrhoeae. Genital herpes is causes by the herpes simplex virus. Chlamydia infection is caused by Chlamydia trachomatis.

Which clinical indicator would the nurse monitor with ESRD? 1 Polyuria 2 Jaundice 3 Azotemia 4 Hypotension

Azotemia

A patient is admitted with pneumonia. When auscultating the patient's chest, you hear low-pitched, continuous sounds over the bronchi. A. Crackles. B. Rhonchi. C. Wheezes. D. Pleural rub.

B. Rhonchi.

Why are tertiary wounds not closed?

Because there is severe contamination and it needs time to heal first

THE NURSE UNDERSTANDS THAT WHICH OF THE FOLLOWING IS THE MOST COMMON SYMPTOM OF PNEUMONIA IN THE OLDER ADULT PATIENT? A. FEVER B. COUGH C. CONFUSION D. WEAKNESS

C. CONFUSION

Which nerves innervate the diaphragm?

C3, C4, C5

What part of the brain regulates VOLUNTARY resp. control?

Cerebral cortex

When preparing to teach a patient with diabetes about a common side effect of metformin, the nurse would include which symptom of lactic acidosis? 1 Diarrhea 2 Restlessness 3 Blurred vision 4 Increased appetite

Diarrhea

________ is a normally passive process

Expiration

T/F: A simple face mask is for long term use

False: A Simple face mask provides a minimum of 5-6 L/min. at 40% - 60% and is for SHORT-TERM use

mucosal membrane pressure injury

Found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these ulcers cannot be staged.

Reorganize the stages of full-thickness healing: Proliferation Hemostasis Maturation Inflammation

Hemostasis Inflammation Proliferation Maturation

What is reestablishment of the epidermis?

Last stage of partial-thickness wound repair *epidermal cells only migrate across a MOIST surface

The shift of body fluids associated with the intravenous administration of albumin occurs by which process? 1 Osmosis 2 Diffusion 3 Active transport 4 Hydrostatic pressure

Osmosis

Which condition is the major cause of death in patients with hypokalemia? 1 Stroke 2 Renal failure 3 Cardiac arrest 4 Respiratory insufficiency

Respiratory insufficiency

Which PI stage has an exposed DERMIS?

Stage 2 (partial-thickness skin loss_

Why can PIs cause osteomyelitis?

Stage IV ulcers can extend into muscle and/or supporting structures

azotemia

accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood

Risks for VRE

age, surgery, extended stay in hospital, enteral nutrition

MOST SERIOUS TRACHEOSTOMY COMPLICATION

airway obstruction, which can result in cardiac arrest

Which finding is a sign of ECV DEFICIT? a. flat neck veins when upright b. flat neck veins when supine

b. flat neck veins when supine (neck veins should normally be flat when upright)

Which type of dressing is used for stage II-IV, has antibacterial activity, and should be changed 3X/day? a. Hydrogel b. Hydrocolloid c. Moist saline gauze d. alginate

c. Moist saline gauze

Which medication do you need to use caution when use with NPWT (negative-pressure wound therapy)? a. ACE inhibitors b. antihistamines c. anticoagulants

c. anticoagulants

candidiasis, tines capitis, and histoplasmosis are caused by a a. bacteria b. parasite c. fungi

c. fungi

_______________________ breathing helps pts. with COPD to breathe deeply

diaphragmatic

What is stable eschar?

dry, adherent, intact with erythema

Increased intestinal peristalsis occurs with hypocalcemia/ hypercalcemia.

hypocalcemia

Muscle tremors occur with hypocalcemia/hypercalcemia.

hypocalcemia

________ is inadequate tissue oxygenation at the cellular level

hypoxia

Signs of infection and local inflammation are ________

identical

internal vs external inflammation

internal is caused by RA

Which type of swabs are good for suture care?

Chlorohexidine swabs

Which microorganism causes gas gangrene? 1 Escherichia coli 2 Neisseria gonorrhoeae 3 Staphylococcus aureus 4 Clostridium perfringens

Clostridium perfringens

Best position for precordium exam.

Supine, slightly elevated

Tube dislodgment

*emergency during first 72 hrs postop *always have another staff member assist with tract care during 1st 72 hours to prevent dislodgment

Normal ESR

0-20 mm/hr (> 20 indicates general inflammation)

Tamiflu (oseltamivir)

Antiviral; shortens flu, but has MANY RISKS!!

Chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes occur during tertiary syphilis.

Gummas

Nutrition therapy for dyspnea

High-protein, high-cal

________ is used for ulcers with little to no exudate and should be changed 1-4 times/day

Hydrogel

When are edges approximated?

In a healing by primary intention

Which vaccine is recommended for those over 65?

Pneumococcal vaccine

Which electrolyte deficiency would the nurse expect to find when reviewing the laboratory data for a patient who presents with seizure activity, decreased deep tendon reflexes, and diarrhea? a. Sodium b. Calcium c. Potassium d. Magnesium

a. Sodium

examples of exotoxins

botulism, tetanus, diphtheria (produced/released by bacteria into environment)

Phase in wound healing occurs STAT after injury; lasts up to 4 days; blood clot forms fibrin matrix and a scab

inflammatory phase

_______ & _______ are types of phagocytes

neutrophils / monocytes

Becaplermin gel (Regranex)

type of topical growth factor

wet to damp dressing

used on non infected wounds, used to absorb exudate, dressing stays moist and does not debride, usually changed every 4-6 hours

When is serosanguinous drainage normal?

1st 48 hours after surgery

examples of antipyretics

NSAIDS, aspirin, Tylenol

________ are a type of hormone that promote immune response & > autoimmune risk

estrogens

Infection vs. Colonization

An infection results when a pathogen invades tissues and begins growing within a host. Colonization is the presence and growth of microorganisms within a host but without tissue invasion or damage

Which stage of full-thickness healing occurs on days 3-24 and is characterized by epithelialization (wound resurfacing), fibroblasts producing collagen, wound contraction, and reestablishment of vascular bed? a. hemostasis b. inflammation c. proliferation d. maturation

c. proliferation

Which type of intention is healing by the formation of scar tissue?

secondary intention

Chest physiotherapy (CPT)

therapy used to remove bronchial secretions, improve ventilation, and increase the efficiency of the respiratory muscles; types include postural drainage, chest percussion, and vibration

Should you give a loop diuretic to someone with HYPERcalcemia?

Yes; loops promote the excretion of calcium.

colonization

m/o invades a host but DOES NOT INVADE TISSUE/CAUSE INFECTION

MASD

moisture associated skin damage

Signs of hypoxia

*restless* (1st), lack of concentration, dizzy, <LOC

Rhinosinusitis nursing interventions

*ANTIHISTAMINES, LEUKOTRIENE INHIBITORS, MAST CELL STABILIZERS, DECONGESTANTS, ANTIPYRETICS, ANTIBIOTICS *VITAMIN C, ZINC

Normal PaCO2

35-45 mmHg

CDI

C. diff infection

Which clinical manifestation is indicative of the fluid and electrolyte imbalance associated with a parathyroidectomy? 1 Constipation 2 Muscle spasms 3 Hypoactive reflexes 4 Increased specific gravity

2 Muscle spasms

The nurse would assess the respiratory status of the client at 2-hour intervals as a safety priority for which condition affecting the client? 1 Hypokalemia 2 Hyperkalemia 3 Hyponatremia 4 Hypernatremia

1 Hypokalemia

The nurse reviews the serum laboratory values of a client. The nurse suspects hypofunctioning of the adrenal gland based on which results? Select all that apply. One, some, or all responses may be 1 Increased calcium 2 Decreased cortisol 3 Decreased sodium 4 Decreased potassium 5 Increased glucose

1 Increased calcium 2 Decreased cortisol 3 Decreased sodium

1 L of Body Fluid = ? lb or ? kg

1 L of Body Fluid = 2.2lb or 1kg

The nurse instills an antibiotic ophthalmic ointment into a newborn's eyes. The nurse would explain to the mother that the medication prevents which condition? 1 Ophthalmia neonatorum 2 Herpetic ophthalmia 3 Retinopathy of prematurity 4 Hemorrhagic conjunctivitis

1 Ophthalmia neonatorum (caused by gonorrheal and/or chlamydial infections present in the vaginal tract. It is preventable with the prophylactic use of an antibiotic ophthalmic ointment applied to the neonate's eyes.)

Which clinical manifestation would the nurse expect to indicate a local inflammation? Select all that apply. One, some, or all responses may be correct. 1 Swelling 2 Redness 3 Pain 4 Anorexia 5 Vomiting

1 Swelling 2 Redness 3 Pain

Degree of edema - 6-mm deep indentation 1 4+ 2 3+ 3 2+ 4 1+

2 3+ 6 mm: 3+ 8 mm: 4+. 4 mm: 2+. 2 mm: 1+.

How many pls of fluids should s/one with a PI drink?

2-3 L

Limit O2 to __ L in s/one with COPD

3

Which oxygen delivery equipment could provide a fraction of inspired oxygen (Fio2) greater than 80%? 1 Simple facemask 2 Venturi mask 3 Nonrebreather mask 4 Partial rebreather mask

3 Nonrebreather mask (Last resort before intubation)

How do the vessels compensate for inflammation?

> permeability causes hypovolemia, which leads to hypotension

Classic signs of hypo K+ 1 Tetany 2 Seizures 3 Confusion 4 Weakness 5 Dysrhythmias

Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause confusion, weakness, and cardiac dysrhythmias.

Which electrolyte imbalance would the nurse anticipate in association with a serum magnesium reading of 1.1 mEq/L? 1 Calcium: 7.8 mg/dL 2 Sodium: 149 mEq/L 3 Potassium: 5.7 mEq/L 4 Phosphorus: 2.6 mg/dL

Calcium: 7.8 mg/dL (LOW MG = LOW CA!!!)

Which assessment parameter is useful for identifying magnesium toxicity during IV magnesium administration? 1 Measuring urine output 2 Monitoring serum calcium levels 3 Checking deep tendon reflexes (DTRs) 4 Asking the patient about mood changes

Checking DTRs (The sheriff is in town with a magnum, so they will be DECREASED!)

Does RSV require contact or airborne precautions?

Contact precautions

Betadine & hydrogen peroxide provide moisture/dry out wounds

Dry out wounds

Dx of C diff

GIP-PCR (GI pathogen panel-polymerase chain rx)

Which nerves innervate the external intercostals?

T1-T11

What does it mean if s/one has a Braden scale score of 18?

They are at no risk for PIs

topical chemical debridement

topical enzyme preparations to loosen necrotic tissue

Which medication reduces the risk for human immunodeficiency virus (HIV) infection in unaffected individuals? 1 Truvada 2 Abacavir 3 Cromolyn 4 Methdilazine

1 Truvada Truvada is the first medication approved to reduce the risk for HIV infection in unaffected individuals who are at a high risk of HIV infection. Abacavir treats HIV infection and is a reverse transcriptase inhibitor. Cromolyn manages allergic rhinitis and asthma. Methdilazine, an antihistamine, treat the skin and provides relief from itching.

How often should you ice a sprain?

10 minutes q 2 or 3 hrs

Which hormone directly influences renal fluid excretion? SATA 1 Renin 2 Aldosterone 3 Angiotensin II 4 ADH 5 ANP

2 Aldosterone 4 ADH 5 ANP

The use of a lift (draw) sheet helps pts. with which electrolyte imbalance?

Hypocalcemia (fragile bones)

Which type of dressing would you put in a wound for debridement and to provide moisture for healing? a. hydrocolloid b. hydrogel c. alginate

b. hydrogel

Which two viruses are vector-borne? a. norovirus & hisoplasmosis b. zika virus and West Nile c. rotavirus & adenovirus

b. zika virus and West Nile *histoplasmosis is caused by a fungi

______ are good for burns/facial trauma, while _____ are good for high humidification. a. NPPV/Venti b. Aeresol mask/face mask c. Face tent/aeresol mask

c. Face tent/aeresol mask

Which PI stage may have a sinus tract and tunneling?

stage 4

When assessing a client who has lost a large amount of blood after an automobile collision, which finding would the nurse expect? 1 Urine output of 50 mL/h 2 BP of 150/90 mm Hg 3 Apical heart rate of 142 beats/minute 4 Respiratory rate of 16 breaths/minute

In hypovolemic shock, tachycardia is a compensatory mechanism in an attempt to increase blood flow to body organs. l.

Which type of otitis media presents NO sx of infection and is caused by URI's/allergies? a. acute (AOM) b. OME (with effusion) c. externa/swimmer's ear

OM with effusion (OME)

Preload, contractility, and afterload are all factors affecting a. Tissue perfusion b. SV c. Ejection fraction

b. SV

Which type of dressing would you use to absorb excess exudate? a. hydrocolloid b. hydrogel c. alginate

c. alginate

Which stage of partial-thickness wound repair involves serous exudate for the first 24 hrs? a. reest. of epidermis b. epithelial proliferation c. inflammatory

c. inflammatory

Damaged cardiac cells release ____________

cardiac enzymes/markers

How is MRSA transmitted?

catheters, VADs, endotracheal tubes

CVCs

central venous catheters

causes of the common cold

coronavirus, rhinovirus, adenovirus

WHICH stage is full thickness skin AND TISSUE loss?

stage 4

Normal fever vs elderly fever

A normal fever is at least 101 / fever in the elderly is at least 99

tunneling wound

A passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound. Open wound.

venous ulcer vs. arterial ulcer

*venous ulcer: in lower extremities somewhere around ankle / shallow, irregular shape, pain r/t edema, minimum hair growth *arterial ulcer: small and at tips of toes or toe web and usually result in gangrene / full-thickness; cool, pale, shiny, taut skin, NO EDEMA

Expected s/s of dehydration 1 Protruding eyeballs 2 Postural hypotension 3 The client reports eating an average of two meals daily. 4 The skin on the client's forehead remains tented after being pinched 5 Within 4 days, the client lost 4 ounces (0.11 kg) of weight

2 Postural hypotension 4 The skin on the client's forehead remains tented after being pinched 3. To assess for dehydration, pinch the skin over a bone with little or no underlying fat, such as the sternum or forehead. 1. The eyeballs may be sunken, not protruding, in the presence of dehydration. (exophthalmos is a sign of hyperthyroidism) 5. A weight loss of 4 ounces (0.11 kilogram) does not indicate dehydration. A weight loss of 1+ KG IN 24 HOURS does, though.

LIMIT THE INTRODUCTION OF THE CATHETER TO _ TIMES WITH EACH SUCTIONING PROCEDURE.

2

Which statement best describes a type IV hypersensitivity reaction? 1 "It is a reaction of immunoglobulin G (IgG) with the host cell membrane or antigen." 2 "The reaction of sensitized T-cells with antigen and release of lymphokines activate macrophages and induce inflammation." 3 "It results in release of mediators, especially histamine, because of the reaction of IgE antibody on mast cells." 4 "An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels."

2 "The reaction of sensitized T-cells with antigen and release of lymphokines activate macrophages and induce inflammation." *Delayed hypersensitivity reaction, as is seen with poison ivy (type IV hypersensitivity)* #1: type II hypersensitivity. #3: type I hypersensitivity reaction. #4: type III hypersensitivity reaction. *Remember ACID Type 1: Allergic Type 2: Cytotoxic Type 3: Immune Complex; IgG or IgM (EX. SLE) Type 4: Delayed/Cell-mediated (poison ivy, chronic graft rejections)

Which antimicrobial medication acts on susceptible pathogens by inhibiting nucleic acid synthesis? 1 Penicillin 2 Actinomycin 3 Erythromycin 4 Cephalosporin

2 Actinomycin Actinomycin is an antimicrobial medication that acts on susceptible pathogens by inhibiting nucleic acid synthesis. Penicillin acts on susceptible pathogens by inhibiting cell wall synthesis. Erythromycin acts on susceptible pathogens by inhibiting biosynthesis and reproduction. Cephalosporin acts on susceptible pathogens by inhibiting cell wall synthesis.

The client's intravenous (IV) site is tender with erythema, warmth, and mild edema. Which action will the nurse take? 1 Irrigate the IV tubing. 2 Change the IV site. 3 Slow the rate of the infusion. 4 Obtain a prescription for an analgesic.

2 Change the IV site.

For which reason would a patient with chronic diarrhea show Chvostek's sign? SATA 1 Hypokalemia 2 Hypocalcemia 3 Hyponatremia 4 Hypomagnesemia 5 Hypophosphatemia

2 Hypocalcemia 4 Hypomagnesemia *Calcium and magnesium imbalances show similar s/s

Which symptom is indicative of the need for dialysis in the child with chronic kidney disease? 1 Hypotension 2 Hypokalemia 3 Hypervolemia 4 Hypercalcemia

3 Hypervolemia

Which laboratory values would the nurse expect to find for a patient who has had chronic diarrhea for 3 months in addition to repeated bouts of vomiting? 1 Serum potassium (K+) levels are more than 5 mEq/L. 2 Total serum calcium (Ca2+) is greater than 10.5 mg/dL. 3 Serum K+ levels are less than 3.5 mEq/L. 4 Serum magnesium (Mg2+) levels are greater than 2.5 mEq/L.

3 Serum K+ levels are less than 3.5 mEq/L.

Minimum urine output

30 mL/hr

Which clinical finding would the nurse associate with hypokalemia? 1 Edema 2 Muscle spasms 3 Kussmaul respirations 4 Muscle weakness

4 Muscle weakness hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. This can result in observable muscle weakness. Edema: associated with electrolyte imbalances, including sodium excess (hypernatremia). Muscle spasms: often c hypocalcemia. Kussmaul respiration: deep and labored breaths in response to metabolic acidosis, especially DKA

Which two vitamins are key in the immune response?

A & D

Signs of Infection in the Elderly

AMS (#1), fatigue, < pain, confusion, incontinence

A client who reports chest pain and difficulty breathing is admitted to the emergency department. A chest x-ray reveals a pneumothorax. Which assessment finding would the nurse expect? 1 Distended neck veins 2 Paradoxical respirations 3 Increasing amounts of purulent sputum 4 Absence of breath sounds over the affected area

Absence of breath sounds over the affected area When the lung is collapsed, air is not moving into and out of the area, and breath sounds are absent.

Which leukocytes would the nurse include when teaching about antibody-mediated immunity? Select all that apply. One, some, or all responses may be correct. 1 Monocyte 2 Memory cell 3 Helper T cell 4 B-lymphocyte 5 Cytotoxic T cell

B-lymphocyte Memory cell

Bottom-Up Damage

DEEP damage; caused by pressure intensity, pressure duration, and tissue tolerance

________ is an example of a skin sealant/film for stage 1 ulcers

Decubitene

Dehiscence vs Evisceration

Dehiscence: Closed wound layers open Evisceration: organs protrude through wound

Is tachycardia associated with fluid overload, dehydration, or both?

Dehydration. Fluid overload is associated with a BOUNDING PULSE but not necessarily a rapid pulse.

A health care provider prescribes mannitol for a client with a head injury. Which mechanism of action is responsible for therapeutic effects of this medication? 1 Decreasing the production of cerebrospinal fluid 2 Limiting the metabolic requirements of the brain 3 Drawing fluid from brain cells into the bloodstream 4 Preventing uncontrolled electrical discharges in the brain

It is an osmotic diuretic; it draws fluid from brain cells into the bloodstream

How should you keep the bed for s/one with a PI?

Keep HOB < 30 degrees

S3 is a sign of left/right sided HF

Left HF

s/s of hyperkalemia: MURDER

M: muscle weakness U: urine oliguria or anuria R: respiratory distress D: decreased cardiac contractility E: EKG chagnes (peaked T waves or small P waves) R: reflexes hyper or hypo

Which stage of full-thickness healing occurs up to 1 year after injury and is assoc. with collagen scar reorganizing?

Maturation phase

Should you remove stable eschar?

NO; it is dry, adherent, and intact, and acts as a natural cover

THE USE OF __ INSTILLATION INTO THE AIRWAY BEFORE SUCTIONING IS NOT RECOMMENDED.

NS

_______ which is 79% of room air, helps prevent alveolar collapse because it doesn't cross over the capillary membranes into the blood.

Nitrogen

Which form of O2 therapy is the last type implemented before intubation?

Non-rebreather; gives 10-15 L/min.

Which clinical manifestation would the nurse associate with a patient's admitting dx. of heart failure and fluid overload? SATA 1 Weight loss 2 Hypotension 3 Clear lung sounds 4. Jugular vein distention 5 Decreased respiratory rate

Only JVD ;

Which is more effective: PAPR or N95?

PAPR (Powered air-purifying respirator)

Droplet precautions

Pertissuis Influenza Mumps Pneumonia DROP it for your PIMP (if anyone sees this card, don't judge me; this is just how I remember, LOL!)

Which information would the nurse include when teaching the patient with a new tracheostomy about preventing aspiration? 1 Raise the head of the bed 30 degrees when eating. 2 Thicken liquids, including water. 3 When swallowing, raise the chin as though looking at the ceiling. 4 If not already inflated, inflate the tube cuff when eating or drinking.

Thicken liquids, including water *The close proximity of the cuffed tube to the esophagus may interfere with the passage of food, so the cuff should be deflated to facilitate swallowing and prevent aspiration.

examples of endotoxins

Typhoid fever and meningococcal meningitis (produced in bacterial cell walls and released via lysis)

What should be used to protect the skin around a wound from Dakin's solution?

Vaseline

Botulism

prevention of nerve impulse transmission

Which phase of infection involves nonspecific s/s

prodromal

Natural chemical debridement

promoting self-digestion of dead tissues by naturally occurring bacterial enzymes

Assay

rapid culture

5 hallmarks of inflammation

redness, heart, swelling, pain, loss of function

Complications of strep

renal problems and heart valve damage

Cholera

rice watery stool

Which of these ARE ratings on the Braden scale? a. sensory perception b. socialization c. nutrition d. medications e. activity f. friction/shear

sensory perception nutrition activity friction/shear

Put the stages of burn healing in order a. acute/healing phase b. rehab/restorative c. emergent/resuscitational phase

a. emergent/resuscitational phase b. acute/healing phase c. rehab/restorative

Convalescence period of infection

acute sx. disappear

Three types of active inflammation

acute, chronic, and repair/restorative

DTPI goes into _____ tissue

adipose

Always suction mouth & nose after/before artificial airway

after

Chlorpheniramine

antihistamine that helps manage allergic symptoms by preventing vasodilation and decreasing allergic sx.

Oseltamivir (Tamiflu) and Zanamivir (Relenza)

antivirals note: best if begun w/n 48 hrs of onset of sx of the flu

What is the rehab phase of burn healing?

from the time of wound closure to the highest level of functioning

_______ tissue is healthy scar tissue that is not quite as strong as collagen

granulation

Elderly have dilated/shrunken alveoli

dilated

fetal hemoglobin (HbF)

has a higher affinity for oxygen than adult hemoglobin (primarily HbA), which also assists in the transfer (and retention) of oxygen into the fetal circulatory system *present in first 5 mths *<RBC life leads to anemia

Normal stimulus to breathe

hypercapnia

Abdominal cramps occur with hypocalcemia/hypercalcemia

hypocalcemia

Dark Skin Assessment

-MOISTEN SKIN to highlight color changes -Color-no blanching evident, but inflammation may be purplish/blue -look for slightly darker skin or is taut and shiny -COMPARE one side of the body to another -Temp - may be warm to touch, but returns to normal -Boggy, maybe edema, may be sensitive around area

Hydrocolloid dressing (DuoDerm)

-stage II -maintains moisture and promotes autolytic debridement -change q. 3-7 days

Which result would the nurse expect to find when reviewing the serum screening tests of a client with acquired immunodeficiency syndrome (AIDS)? 1 A decrease in CD4 T cells 2 An increase in thymic hormones 3 An increase in immunoglobulin E 4 A decrease in the serum level of glucose-6-phosphate dehydrogenase

1 A decrease in CD4 T cells

Which medication is a leukotriene modifier used to manage and prevent allergic rhinitis? 1 Zileuton 2 Ephedrine 3 Scopolamine 4 Cromolyn sodium

1 Zileuton

Which value in a client with urinary problems increases risk of muscle weakness and arrhythmias? 1 Calcium of 9.5 mg/dL (2.375 mmol/L) 2 Potassium of 7.02 mEq/L (7.02 mmol/L) 3 Bicarbonate of 22.8 mEq/L (22.8 mmol/L) 4 Phosphorus of 4.1 mg/dL (1.3243 mmol/L)

2 Potassium of 7.02 mEq/L (7.02 mmol/L) (K+ should be 3.5 - 5.0)

Which function is the responsibility of the immune system and lymph nodes? Select all that apply. One, some, or all responses may be correct. 1. Secrete hormones 2 Protect the body from foreign antigens 3 Remove damaged cells from circulation 4 Provide a partial barrier to malignant cell growth 5 Manufacture protein

2 Protect the body from foreign antigens 3 Remove damaged cells from circulation 4 Provide a partial barrier to malignant cell growth

The nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. Which assessment will provide the nurse with the most significant data? 1 Weights every day 2 Urinary output every hour 3 Blood pressure every 15 minutes 4 Extent of peripheral edema every 4 hours

2 Urinary output every hour

Which initial electrolyte imbalance would the nurse anticipate in a patient experiencing hyperglycemia secondary to a lack of insulin? 1 Hypokalemia 2 Hyperkalemia 3 Hyponatremia 4 Hypernatremia

Hypokalemia The initial electrolyte imbalance the nurse should anticipate for in a patient experiencing hyperglycemia is hypokalemia secondary to osmotic diuresis caused by excess glucose in the urine. With the increased fluid loss from hyperglycemia, the kidneys excrete excessive potassium in the urine, leading to low serum potassium levels.

Azotemia

Increase in nitrogenous waste (particularly urea) in the blood, which is common with ESRD

Which nutrients are most important for wound healing? SATA a. zinc b. Vitamin A c. Vit. B d. copper e. protein f. vitamin K

a. zinc b. Vitamin A d. copper e. protein

Which are low-flow O2 systems? a. venti b. cannula c. face tent d. partial rebreather

b. cannula d. partial rebreather

What is an ileus?

loss of peristalsis w/o structural obstruction; typically post-op

CO2 narcosis

loss of sensitivity to high levels of CO2

Which O2 therapy provides O2 > 90%

non-rebreather

Which electrolyte, found on UA, would indicate AKI? *Protein *Calcium *Potassium *Phosphate

Protein is usually not excreted in urine because it is a large molecule. When found, it indicates kidney disease. Excess calcium and phosphate are excreted in urine. Potassium is excreted by the kidneys to maintain electrolyte balance.

exogenous vs endogenous infection

exogenous - not in normal flora endogenous - normal flora malfunction

S/S of infant heart disease

fatigue, poor wt. gain, >RR, sweating with feeding

Who is at increased risk for sickle-cell? a. AAs b. White/caucasian c. Hispanic d. Indian

a. AAs c. Hispanic d. Indian

Which pt. is not at a candidate for beta-blockers? a. asthma b. angina c. migraines d. Hx. of 2 MIs

a. asthma (shouldn't be on a NON-SELECTIVE beta blocker bc it can cause bronchospasm)

Which infections are NOT caused by bacteria? a. candidiasis b. impetigo c. gastritis d. histoplasmosis e. STI's

a. candidiasis d. histoplasmosis *Both are caused by fungi

S/S of systemic infection

fever, > HR and RR, N&V, lymphadenopathy

which virus causes gastroenteritis? a. adenovirus b. norovirus c. rhinovirus

b. norovirus

A patient is admitted with hypokalemia and skeletal muscle weakness. Which assessment would the nurse perform first? a. Pulse b. Respirations c. Temperature d. BP

b. respirations Respiratory changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness results in shallow respirations. Thus respiratory status should be assessed first in any patient who might have hypokalemia. Blood pressure and pulse will be altered in this patient, but they are not the priority assessment.

What is the purpose of the inflammatory phase of full-thickness wound healing? a. to cause a systemic reaction b. to clean the wound c. to lay down granulation tissue d. to create a fibrin mesh

b. to clean the wound

How long is sterile water good after opening? a. 6 hrs b. 12 hours c. 24 hours d. 48 hours

c. 24 hours

A patient with chronic obstructive pulmonary disorder (COPD) who has been receiving oxygen via nasal cannula is becoming increasingly dyspneic with increased use of accessory muscles to breathe. The nurse auscultates markedly diminished breath sounds in all lung fields. Which oxygen delivery method would the nurse recommend that the provider prescribe? a. Venturi mask b. Transtracheal oxygen catheter c. Noninvasive positive-pressure ventilation (NPPV) d. Face tent

c. Noninvasive positive-pressure ventilation (NPPV) The patient is experiencing atelectasis, as evidenced by diminished breath sounds, and may benefit from NPPV, which helps open alveoli, improve gas exchange, and relieve dyspnea. A Venturi mask helps deliver a precise amount of oxygen but does not help open alveoli. Transtracheal oxygen is used to provide oxygen without the discomfort of a mask or nasal cannula.

COX inhibitor drugs

for SEVERE inflammation

How do you irrigate a wound?

from clean to dirty

Suprainfection

develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection

Dysguesia

distorted taste

transient microbes

do not normally reside, just passing through most are harmless, some pathogens

Tx for CA-MRSA

doxycycline & minocycline

S/S of O2 toxicity

dyspnea, angina, crackles, GI upset

Gram-positive bacteria release ___ toxins; gram-negative bacteria release ____toxins

exo / endo

Tx for evisceration

place sterile gauze soaked in sterile saline

Polyps

potential cause of rhino sinusitis

S/S of dehiscence

serosanguinous drainage 1st few days post-op

Top-down damage (superficial)

shear/friction / stage 1

_____ infections can be viral, bacterial, or fungal

sinus

Low ______ triggers renin secretion

sodium

Moisture retentive dressings

spontaneous separation of necrotic tissue is promoted by autolysis

Systemic Inflammatory Response Syndrome (SIRS)

stage 1: > cytokines, leukocyte migration, vasodilation stage 2: > macrophages & platelets stage 3: systemic rx./organ failure

When can slough and eschar first appear?

stage 3

Which cytokine would the nurse teach a client is treatment for multiple sclerosis? 1 β-Interferon 2 Interleukin-2 3 Erythropoietin 4 Colony-stimulating factor (CSF)

β-Interferon

Symptoms of hepatitis

•Nausea/Vomiting •Abdominal pain •Loss of appetite •Fever •Diarrhea •Light (clay) colored stools •Dark urine •Jaundice

_____ is also known as EDV

Preload

Which respiratory device can be used to provide a patient with an 80% fraction of inspired oxygen (Fio2)? Select all that apply. One, some, or all responses may be correct. 1 Face tent 2 Aerosol mask 3 T-piece 4 Venturi mask 5 Simple mask

1 Face tent 2 Aerosol mask 3 T-piece An aerosol mask or face tent could deliver the ordered 80% Fio2 with a flow rate of at least 10 L/min. A patient with an endotracheal tube could use a T-piece to receive 80%. A Venturi mask can deliver 24% to 50% oxygen. A simple mask can deliver 40% to 60% oxygen.

A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates administering which intravenous (IV) solution? 1 3% sodium chloride 2 0.9% sodium chloride 3 5% dextrose and 0.9% sodium chloride 4 5% dextrose and lactated Ringer solution

2 0.9% sodium chloride

Signs of hypercalcemia 1 Muscle tremors 2 Abdominal cramps 3 Increased peristalsis 4 Cardiac dysrhythmias 5 Hypoactive bowel sounds

3 Increased peristalsis 4 Cardiac dysrhythmias 5 Hypoactive bowel sounds > calcium initially causes tachycardia; as it progresses, it depresses electrical conduction in the heart, causing bradycardia. Hypercalcemia causes decreased peristalsis identified by constipation and hypoactive or absent bowel sounds. Muscle tremors occur with hypocalcemia, not hypercalcemia. Abdominal cramps occur with hypocalcemia, not hypercalcemia. Increased intestinal peristalsis occurs with hypocalcemia, not hypercalcemia.

Normal PaO2 levels

80-100 mmHg

How does estrogen effect the immune and cardiac systems?

> risk of HTN & autoimmune conditions

Left shift in WBC differential

># of immature neutrophils

Lymphedema causes bilateral/unilateral edema

unilateral

Which 2 types of dressings are used for exudating stage II ulcers or deep stage III-IV ulcers?

Alginate and foam

Coombs' test

used to detect antibodies that act against the surface of your RBCs / can diagnose hemolytic anemia

simple mask

Flow: 6-12 L/min (*must be at least 6 liters to flush out exhaled CO2)

Which stage of full-thickness wound repair occurs in the first 2 days, in which collagen forms scar tissue and works to est. a clean wound bed?

Inflammatory phase

Examples of airborne diseases

TB, measles, chicken pox

iceberg concept of infection

The tip of the iceberg, which corresponds to active clinical disease accounts for only a small proportion of host's infections and exposures to disease agents.

Which type of incontinence is most likely to be associated with a urinary tract infection? 1 Transient incontinence 2 Functional incontinence 3 Stress urinary incontinence 4 Overflow urinary incontinence

Transient incontinence

The primary health care provider prescribes IV administration of 100 mL of 20% glucose along with 20 units of insulin. Which condition would the nurse expect the patient to have? a. Hyperkalemia b. Hyperglycemia c. Hypernatremia d. Hypercalcemia

a. Hyperkalemia (insulin and glucose move potassium INTO the cell)

Seizures caused by electrolyte imbalances are associated with low ____ or _____ levels.

calcium or sodium