Intro to Clinical Study Guide #4
Nurse manager is implementing a change to evening care. She wants to include back rubs to promote sleep. She convinces other units to support this change. Which component of Kotter's eight step model is involved in this scenario?
Performing a powerful coalition
A nurse is teaching a group of parents about the sleep patterns of their children, who range in age 18-36 months. What info is the nurse likely to provide? (2 answers)
1.) Total sleep averages 12 hours a day 2.) During this period, the toddler may be unwilling to go to bed at night
Which order would the nurse follow for the assessment of the pharynx in a client with a respiratory disorder?
1.) inspect the mouth 2.) Observe the rise and fall of soft palate 3.) Assess the symmetry of enlarged tonsils, if present 4.) Inspect the neck symmetry 5.) Palpate the lymph nodes
Which strategies promote sleep? (3 answers)
1.) leaving the bedroom when unable to sleep 2.) Exercising in the afternoon rather than the evening 3.) Counting backward from 100 to 0 when mind is racing
Stage 3 NREM
- Deep sleep - 15-30 min in length - Vital signs continue to decrease - Difficult to awaken -Relaxation with little movement
Stage 2 NREM
- Deeper sleep - 10 to 20 min in length - Vital signs & metabolism continuing to diminish - Requires more stimulation to awaken - Increased relaxation
Stage 5 REM
- Vivid dreaming - 90 min after falling asleep - Longer w/ each sleep cycle - Average length 20 min - Varying vital signs - Very difficult to awaken - Cognitive restoration
Stage 4 NREM
-Called delta sleep - Deepest sleep - 15-30 min in length - Vital signs low - Very difficult to awaken - Physiological rest & restoration - Enuresis (bedwetting), sleeping, sleeptalking -Repair & renewal of tissue
Stage 1 NREM
-In transitional stage between wakefullness and sleep -Light sleep -Only lasts a few minutes -Vital signs & metabolism begin to diminish -Awakens easily -Feels relaxed and drowsy
Nonrebreather FiO2
60% - 100% flow 10-15 L/min Keep reservoir bag 2/3 full during inspiration and expiration.
Nurse is teaching a client about sleeping positions to prevent pressure ulcers. Which statement made by the client indicates effective learning? (3 answers)
1.) "I should use pressure-relieving pads" 2.) "I should place pillows between two bony surfaces" 3.) "I should keep my heels off the bed surface using a bed pillow under the ankles"
Types of Insomnia
1.) Acute insomnia: Lasts a few days and may be related to stressors 2.) Chronic insomnia: Lasts a month or more 3.) Intermittent insomnia: Sleep well for a few days and have insomnia for a few days
A nurse is suctioning a clients tracheostomy. What is the correct order of performing this procedure?
1.) Auscultate the lungs & check the heart rate 2.) turn suction on to between 80 & 120 mm Hg pressure 3.) Hyperoxygenate using 100% oxygen 4.) Don sterile gloves 5.) Guide the catheter into the tracheostomy tube using a sterile gloved hand
What are the 2 disorders of sleep apnea?
1.) Central: CNS dysfunction that fail to trigger breathing during sleep. 2.) Obstructive: Structure in mouth or throat that obstruct breathing.
Which hormone levels peak during the client's sleep? (3 answers)
1.) Cortisol 2.) Thyrotropin 3.) Growth hormone
What 3 tools are used to prevent malpractice?
1.) Documentation, communication & reporting 2.) Risk management/ Quality Assurance 3.) Malpractice insurance
What activities should a nurse recommend to promote better sleep? (2 answers)
1.) Follow the same bedtime routine each night 2.) perform deep-breathing exercises
What are the 2 functions of a properly functioning alveolar system in the lungs?
1.) Oxygenates venous blood 2.) Removes carbon dioxide from blood
Nasal Cannula FiO2
24% - 38% flow 1-2 L 30% - 35% flow 2-4 L 38% - 44% flow 5-6 L
Causes of fluid volume excess:
Chronic stimulus to the kidney to conserve sodium and water, abnormal kidney function, kidney failure, excessive sodium intake, inappropriate use of antidiuretic, barbiturates, anesthetics
A client is receiving PCA after surgery. What does the nurse identify as the primary benefit with this type if therapy?
Client is able to self-administer pain-relieving drugs as necessary.
Simple face mask FiO2
40% - 60% flow 5-8 L/min
Stable angina
A temporary imbalance between the amount of oxygen needed by the heart and the amount delivered to the heart muscles
Oral-pharyngeal Suctioning Complications
Excessive coughing, decreased oxygen saturation, trauma or edema to oral mucosa, hypoxemia.
Assertive behavior
Ability to stand up for oneself and others using open, honest and direct communication. -Express feeling and beliefs in a non-offensive way.
Non-verbal communication
Appearance, posture, gait, facial expression, eye contact, gestures, sounds, territoriality, personal space and silence.
Aggressive behavior
Asserting one's rights in a negative manner that violates the rights of others.
Nasal Cannula nursing interventions
Assess patency of nares, prongs fit nares, use water soluble gel, provide humidification for flow rates 4 L/min & above.
Simple face mask nursing interventions
Assess proper fit for secure seal, client must wear during meals, use w/caution for clients who have high risk of aspiration or airway obstruction.
What to teach patients with narcolepsy
Exercise regularly, eat small meals high in protein, avoid activities that increase sleepiness, avoid activities that would cause injury should the client fall sleep, take naps when feeling drowsy, take stimulants provider prescribes.
What 2 systems carry nutrients & waste to & from cells?
Cardiovascular system and hematologic system
A client reports disturbed sleep due to itching caused by an allergy. Which medication would be prescribed to help the client sleep well and treat the allergic symptoms?
Chlorpheniramine
Factors that influence hygiene
Culture/Religion, socioeconomic class, developmental level, health state and personal preference
The nursing team is involved in effective pain management. Which task would be performed by an RN in this case?
Developing a treatment plan for client's pain
CPAP
Device to help client's with sleep apnea (continuous positive airway pressure)
Insomnia
Difficulty in falling asleep, intermittent sleep or early awakening from sleep.
Which central nervous system manifestation observed in a client with a respiratory disorder indicates inadequate oxygenation?
Early unexplained restlessness
Who is prone to fluid volume deficits?
Elderly, young children, obese patients, women and the immunocomprimised
Characteristics of malpractice
Failure to follow standards of care, failure to use equipment in a responsible manner, failure to assess and monitor, failure to communicate, failure to document and failure to act as a patient advocate or follow the chain of command.
FiO2
Fraction of Inspired Oxygen = Fraction of the amount of oxygen a patient is inhaling produced by an oxygen device.
Causes of fluid volume deficit:
GI losses, vomiting, diarrhea, abnormal skin losses, renal losses (diuretics, kidney disease), ascites, hemorrhage, altered intake, dehydration
Postoperative client returned from PACU with a PCA pump, nurses assesses the client's vitals (BP 90/60, HR 96, RR 10 per min. Which action should the nurse take next?
Give naloxone intravenous push med (IVP) per protocol.
Hypertonic
Greater concentration as the solution it is being compared to.
Isotonic
Having the same concentration as the solution it is being compared to.
Client admitted with multiple injuries as a result of an accident. Tracheostomy was performed. While the nurse is caring for the client, the client coughs, expelling tracheostomy tube. What should the nurse's first action be?
Hold the tracheostomy open with a tracheal dilator & call for assistance
Nonrebreather nursing interventions
Perform hourly assess of the valve & flap, proper fit to ensure seal, must wear during meals.
What type of breathing pattern alteration is manifested with hypercarbia?
Hypoventilation
Tracheal Suctioning Complications
Hypoxia, infection, tissue damage, atelectasis (complete or partial collapse of lung)
What factors influence sleep?
Illness, current life events, emotional stress or mental illness, diet, exercise, sleep environment and medications
Atelectasis
Incomplete lung expansion or the collapse of alveoli
A 10-year-old child is receiving oxygen 2 L/min by way of nasal cannula. The healthcare provider asks that pulse oximetry be started. What is the appropriate placement for the oximetry probe in a child this age?
Index finger
What findings indicate Cheyne-Stokes respiration?
Irregular, alternating apnea & hyperventilation
Hypotonic
Lesser concentration than the solution it is being compared to.
Maslow's Hierarchy of Need's
Level 1: Physiological needs Level 2: Safety and security needs Level 3: Love and belonging needs Level 4: Self-esteem needs Level 5: Self-actualization needs
Which medication should be given to a patient suffering from narcolepsy that is feeling drowsy and falls asleep at inappropriate times?
Modafinil
Sleep apnea
More than 5 breathing cessations lasting longer than 10 seconds per hour during sleep, resulting in decreased arterial oxygen saturation levels.
Self-esteem needs
Need for a person to feel good about oneself, feel pride and a sense of accomplishment.
Self-Actualization needs
Need for individual to reach their full potential through development of their unique capabilities.
Nonassertive behavior
Not expressing feelings, needs and ideas and ignoring personal rights.
An obese smoker complains of feeling sleepy during the daytime, waking up tired in the morning and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which condition may the client have?
Obstructive sleep apnea
Suctioning methods
Oral-pharyngeal, Nasal-pharyngeal, Tracheal
What are the 3 phases of helping relationships?
Orientation phase, working phase, termination phase
Physiological needs
Oxygen, water, food, elimination, temp, sexuality, physical activity and rest are examples of?
Safety and Security needs
Physical -proper hand hygiene, administering medications safely, teaching parents about household chemicals Emotional -trusting others, free of fear, anxiety and apprehension
What action should the nurse implement when performing tracheal suctioning?
Preoxygenate the client before suctioning
Malpractice
Professional misconduct in the performance of professional services that results in liability for negligence and damages.
A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperativley, what should the nurse do?
Provide a means for the client to write
What are physiologic symptoms assessed in a client with sleep deprivation? (2 answers)
Ptosis and blurred vision & decreases auditory alertness
A client with a history of heart failure is experiencing dyspnea w/ respiratory rate of 32. Crackles are noted bilaterally. Client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first?
Raise the client to high-Fowler position
Tracheal suctioning indications
Relieves respiratory distress, remove secretions, improve ventilations & oxygenation.
Oral-pharyngeal suctioning indications
Remove secretions, if patient has undergone head and neck surgery, impaired swallow reflex, abnormal mucous production.
Nasal-pharyngeal suctioning indications
Remove secretions, impaired conscious level, decreased oxygen saturation levels, increased respiratory rate and diminished breath sounds.
A laboring client has asked the nurse to help her use a nonpharmacological strategy for pain management. Name the sensory simulation strategy.
Selecting a focal point and beginning breathing techniques
SBAR
Situation, Background, Assessment, Recommendation
What are the stages of sleep?
Stage 1 NREM Stage 2 NREM Stage 3 NREM Stage 4 NREM Stage 5 REM
Narcolepsy
Sudden attacks of sleep during the waking hours.
The oxygen saturation value of an African American client measured through a pulse oximeter is 93%. What does the nurse infer from this reading?
The client has a normal SpO2 value
A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason identified by the nurse for suctioning the client?
The tracheostomy tube interferes with effective coughing
Nasal-pharyngeal Suctioning Complications
Trauma to nasal mucosa, excessive coughing, pain or discomfort, decreased oxygen saturation, hypoxemia, atelectasis (complete or partial collapse of lung) .
Love and Belonging needs
Understanding and acceptance of others in both giving and receiving love and a feeling of belonging.
Nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined using this technique?
Venous oxygen saturation
How does respiration occur
by diffusion of oxygen and CO2 across the membranes
Hyponatremia (sodium) side effects
causes anorexia, n/v, lethargy, confusion, muscle cramps, muscular twitching, seizures, coma, serum na <135 mEq/l
Myocardial infarction
death of heart tissue due to lack of oxygen
myocardial ischemia
decreased oxygen supply to the heart caused by insufficient blood supply
Hypoventilation
decreased rate or depth of air movement into the lungs
Hypokalemia side effects
fatigue, anorexia, n/v, muscle weakness, decreased bowel motility, cardiac arrhythmias, increased sensitivity of digitalis, polyuria, nocturne, dilute urine, postural hypotension, serum k <3.5 mEq/l
hypertonic solution
having a greater concentration than the solution with which it is being compared
hypotonic solution
having a lesser concentration than the solution with which it is being compared
isotonic solution
having about the same concentration as the solution with which it is being compared
Hypercalcemia side effects
muscular weakness, tireless, lethargy, C/N/V, anorexia, decreased memory and attention span, polyuria and polydipsia, renal stones, neurotic behavior, cardiac arrest, serum calcium >10.5 mg/dl
what is the function of the cardiovascular system
pushes blood out to the tissues to conduct internal respiration (the exchange of oxygen and CO2 between the blood and tissue cells)
What are the functions of the alveolar system of the lungs
respiration, it provides a site for gas exchange between alveoli and blood
heart failure
the heart is unable to pump a sufficient blood supply, resulting in inadequate perfusion and oxygenation to tissues
hypoxia
the inadequate amount of oxygen is available to cells resulting in dyspnea, high BP and pulse, pallor, and cyanosis
Hypernatremia (sodium) side effects
thirst, raised temp, dry swollen sticky membranes, if severe: disorientation, hallucinations, lethargy, irritable and hyperactive, seizures, coma serum na >145 mEq/l
Assessment findings for fluid volume deficit:
thirst, weight loss over short period of time, weakness, fatigue, anorexia, dry mucous membranes, poor skin turgor
Hypocalcemia side effects
trousseau and chvostek signs, numbness and tingling of fingers and toes, mental changes, seizures, spasm of laryngeal muscles, ECG changes, cramps in extremity muscles, serum calcemia <8.5 mg/dl
Hyperkalemia side effects
vague muscle weakness, cardiac arrhythmias, paresthesias of extremities, flaccid muscle paralysis, gi symptoms, serum k >5.0 mEq/l
Assessment findings for fluid volume excess:
weight gain over short period of time, peripheral edema, increased BP, SOB, crackles & wheezes in the lungs, bounding pulse, ascites, pleural effusion
