308 Adult Flashcards

Question

Multiple sclerosis (MS) Corticosteroids (eg, methylprednisolone)

Answer 1

a chronic autoimmune disorder that typically presents in young adults, especially women of childbearing age autoimmune destruction of the myelin-sheath in the central nervous system (ie, brain, spinal cord) causes abnormal and slowed conduction through the nerves MS causes motor and sensory loss below the level of the lesion. S/s: muscle weakness spastic paralysis with hyperreflexia, and paresthesia (eg, pins-and-needles sensation). the optic nerve is an extension of brain tissue=demyelination results in eye pain and visual disturbances (eg, blurry vision).

Answer 2

ensuring that a responsible adult will check on the client as the level of consciousness can change abstain from alcohol check before taking medications that can affect level of consciousness (eg, muscle relaxants, opioids) avoid driving or operating heavy machinery return to the emergency department or notify the primary care provider if any of the following signs/symptoms are present in the next 2-3 days: Change in level of consciousness (eg, increased drowsiness, difficulty arousing, confusion) Worsening headache or stiff neck, especially if unrelieved by over-the-counter analgesics Visual changes (eg, blurring) Motor problems (eg, difficulty walking, slurred speech) Sensory disturbances Seizures Nausea/vomiting or bradycardia (indicates IICP)

Answer 3

usually asymptomatic unless they rupture; they are often called "silent killers" S/s: abrupt onset of "the worst headache of my life" changes in or loss of consciousness neurologic deficits diplopia seizures vomiting stiff neck

Answer 4

Decreased level of consciousness (ie, client is now disoriented) Agitation and confusion Projectile (forceful) vomiting Severe hypertension—SBP >180 and/or DBP >120 If ICH is suspected, a repeat CT scan of the head is the priority action to identify bleeding. Once ICH is confirmed, prompt treatment (eg, reverse anticoagulation [eg, tranexamic acid], blood pressure management [eg, nicardipine], surgery) is required to prevent life-threatening complications

Answer 5

used to lyse (ie, break apart) thrombi (eg, clots) Ask the client's caretaker about history of recent surgery or trauma: Recent (ie, within 2 weeks) major surgery is an exclusion to thrombolytic therapy because tPA dissolves all clots in the body and may therefore disrupt the surgical site and cause bleeding Maintain BP ≤185/110: BP >185/110 mm Hg is an exclusion to thrombolytic therapy due to the risk for intracerebral hemorrhage Review the client's current home medication list: for any additional anticoagulants Verify the exact time the stroke symptoms started: Thrombolytics are time sensitive and must be administered within 3 to 4.5 hours from onset of symptoms

Answer 6

12-lead ECG to detect atrial fibrillation fall risk precautions frequent neurological assessments Ensuring tissue plasminogen activator (tPA) is available Applying sequential compression devices (SCDs) to bilateral lower extremities NPO

Answer 7

obtain a capillary blood glucose level to rule out hypoglycemia prepare the client for CT scan of the head to determine if the client is experiencing a stroke and the type and location of the stroke use a standardized stroke assessment tool to determine the likelihood, location, and severity of an acute stroke.

Answer 8

skin traction to immobilize a fractured hip, maintain proper alignment, and reduce pain and muscle spasms by applying a continuous pulling force until the client has surgery (eg, hip arthroplasty). A traction boot is applied to the affected extremity. The weight (5-10 lb [2.26-4.5 kg]), connected by a rope passing through a pulley, is attached to the boot. Weights should be free-hanging at all times and should never touch the floor or be placed on the bed A fracture pan, which is smaller than a bedpan, should be provided for elimination needs to minimize client movement and provide comfort. maintain the foot in a neutral position

Answer 9

Ecchymosis and tenderness over the thigh and hip Groin and hip pain with weight bearing Muscle spasm in the injured area – occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area Shortening of the affected extremity – occurs because the fracture can reduce the length of the bone and the muscles above the fracture line pull the extremity upward Abduction or adduction of the affected extremity depending on location and mechanism of injury.

Answer 10

when an intervertebral disc ruptures and herniates (bulges), most often between L4-L5 after lifting heavy weights or using improper body mechanics S/s: low back pain paresthesia that radiates to the lower extremities different lower extremity reflexes (eg, Achilles) become diminished a positive straight-leg raising test due to nerve root compression lumbar strain - pain that does not radiate

Answer 11

a medical emergency marked by compression of multiple spinal nerve roots of the cauda equina (ie, tail-like extension of nerve roots from termination of the spinal cord caused by central lumbar disc herniation at L4-S1 (ie, lumbar and sacral) requires surgical decompression within 24-48 hours to prevent irreversible neurological damage S/s: Motor deficits in the lower extremities (eg, flaccid paralysis, absent/diminished reflexes) Patchy sensory loss in corresponding dermatomes Autonomic (eg, bowel, bladder, sexual) dysfunction

Answer 12

because articular bone may compress surrounding vasculature, causing limb-threatening distal ischemia

Answer 13

rare, life-threatening complication related to bone fractures, typically of the pelvis or long bones no specific treatment at globules travel through the bloodstream and obstruct small blood vessels, causing impaired circulation and ischemia. The lungs, brain, and skin are most often affected, leading to acute respiratory distress and neurologic impairment. S/s: Respiratory distress syndrome (eg, dyspnea, tachycardia, sudden and worsening chest pain, hypoxemia, restlessness, anxiety) Altered mental status (eg, confusion, memory loss) Petechial hemorrhages in the arms, chest, and/or neck

Answer 14

stabilizes a cervical or high thoracic fracture when there is insignificant damage to the ligaments or spinal cord Cleaning pin sites with sterile solution (eg, chlorhexidine, water) to prevent infection Keeping the vest liner clean and dry (eg, changing weekly or when soiled, using a cool blow-dryer to dry) to protect the skin Placing foam inserts under pressure points to prevent pressure injury Placing a small pillow under the client's head when supine to reduce pressure on the device Keeping the correct-sized wrench available at all times in case of emergency do not grab the device while log rolling

Answer 15

priority nursing action: neurovascular assessment (eg, pulse, temperature, color, capillary refill, sensation, movement Administering analgesia to promote comfort Applying an ice pack to the wrist to help reduce edema and inflammation Elevating the extremity on a pillow above heart level to reduce edema Instructing the client to move the fingers to reduce edema, increase venous return, and help improve range of motion.

Answer 16

at risk for hip dislocation until the surrounding soft tissues heal Applying sequential compression devices bilaterally to the lower extremities to promote blood flow and reduce the risk for venous thromboembolism related to immobility Assessing the client's pain level and administering pain medications as prescribed. Monitoring the surgical dressing for drainage, which may indicate hemorrhage Placing an abductor pillow between the client's legs to maintain the hip in a neutral position while in bed because adduction (ie, moving the leg medially) can cause dislocation

Answer 17

client should be fully weight bearing by discharge

Answer 18

life-threatening condition triggered by certain medications used for general anesthesia (eg, succinylcholine). S/s tachypnea, tachycardia, generalized muscle rigidity, and hyperthermia The triggering agent causes excessive calcium release from the muscles, leading to sustained muscle contraction.

Answer 19

do not elevate leg after the first 24 hours because this can cause flexion contractures. Instead, the client should wear a figure eight compression bandage at all times to control edema Hip flexion contractures can also be avoided by placing the client in the prone position with the hip in extension for 30 minutes 3 or 4 times daily. (Option 1) A plaster cast may take up to 72 hours to dry following application. Exposing the cast to circulating air promotes even drying and may speed the drying process.

Answer 20

inflammatory disease affecting the spine S/s stiffness and fusion of the axial joints (eg, spine, sacroiliac), leading to restricted spinal mobility. Low back pain and morning stiffness that improve with activity are the classic findings. Involvement of the thoracic spine (costovertebral) and costosternal junctions can limit chest wall expansion, leading to hypoventilation. Promote extension of the spine with proper posture, daily stretching, and spine-stretching exercises (eg, swimming, racquet sports) Stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications Manage pain with moist heat and NSAIDs. Take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility. rest during flare-ups. sleep on their backs on a firm mattress to prevent spinal flexion and the resulting deformity. Ibuprofen and other NSAIDs should be taken with a meal or snack to avoid gastric upset.

Answer 21

occurs when muscle fibers are released into the blood causes: an intense muscle injury from exercise, heat stroke, or physical trauma S/s: dark, oftentimes bloody urine, oliguria, and fatigue. Acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidneys' filtration ability priority: prevent kidney damage using rapid IV fluid resuscitation to flush the damaging myoglobin pigment from the body.

Answer 22

Paresthesia (early sign) Tingling, numbness, burning Pain Out of proportion to injury, unrelieved by medication Pressure Taut skin, cast fits too tightly Pallor Pale skin tone, decreased color, white, gray Pulselessness (uncommon) Possibly weakened or lost Poikilothermy Cool skin temperature, matches room temperature Paralysis (late sign) Weakness, loss of motor activity

Answer 23

Report foul odors or hot areas (hot spots) in the cast, which may indicate infection Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection Elevate the affected extremity above heart level for the first 48 hours to reduce edema Regularly perform isometric and range of motion exercises to prevent muscle atrophy. Directing air inside the cast with a hair dryer on the cool setting may help relieve itching. contact the health care provider about symptoms of impaired circulation in the affected extremity, including numbness or tingling, pallor, coolness, loss of pulse distal to the cast, or pain that is unrelieved by ice, elevation, and pain medication. Swelling within the cast may result in compartment syndrome, a condition that involves limb-threatening tissue ischemia due to compression of blood vessels and nerves within the extremity's internal compartments.

Answer 24

If wired shut and is choking on spit= suction along gum line if ineffective and the client develops respiratory distress, cutting the wires may be necessary. A tracheostomy or endotracheal tray should be kept readily available in case the client's airway becomes obstructed and intubation is necessary.

Answer 25

device used to stabilize broken bones metal pins are placed through the tissue into the bone and connect to a frame outside the skin. Monitor: neurovascular compromise pin site infection, can lead to osteomyelitis Assess pin sites for new, increased, and/or purulent drainage and check the skin surrounding the pins for erythema, warmth, pain, or breakdown Assess for signs of compartment syndrome decreased pulses, coolness, pain, numbness pin site care with a sterile cleaning solution (eg, chlorhexidine, sterile normal saline) and gauze Monitoring pins and device for loosening and reporting to the health care provider (HCP) if they are loose promote early mobilization the day after sx

Answer 26

internal hemorrhage abdominal distension, vital signs, hematocrit, hemoglobin paralytic ileus absent bowel sounds neurovascular deficits extremity circulation, sensation, movement abdominal and genitourinary organ injuries hematuria, urine output <0.5 mL/kg/hr

Answer 27

inhibit bone resorption by osteoclasts = reducing the risk for osteoporosis-related bone fractures teaching: full glass of water (8 oz [240 mL]) remain upright for 30 to 60 minutes don't take it with Calcium empty stomach

Answer 28

serious postoperative complication caused by decreased blood flow to the tissue distal to the injury restrictive dressings, splints, or casts bleeding, inflammation, and edema Earliest symptoms pain or numbness that is unrelieved by medication. diminished/absent pulses pallor coolness swelling decreased movement cyanosis the extremity should be positioned at the level of the heart.

Answer 29

Asymmetry Border irregularity (eg, edges are notched or irregular) Color changes and variation (eg, different brown or black pigmentation) Diameter of 6 mm or larger (about the size of a pencil eraser) Evolving (eg, appearance is changing in shape, size, color)

Answer 30

stay with the client. Have a staff member notify the surgeon immediately tell pt not to cough Cover the area with sterile, saline-moistened gauze to protect the exposed organs and reduce the risk for infection Obtain vital signs to detect signs of potential shock (eg, hypotension, tachycardia) low Fowler position (ie, head of bed at 15-20 degrees) with the knees slightly flexed to decrease intraabdominal pressure and avoid further evisceration Document interventions and the appearance of the wound and eviscerated organ (eg, color, drainage). If circulation is interrupted, the protruding organs can become ischemic (dusky) or necrotic (black).

Answer 31

fungal infection person-person scaly, pruritic patch that is circular highly contagious treated with topical antifungals (eg, tolnaftate, haloprogin, miconazole, clotrimazole).

Answer 32

4 mL×body weight (kg)×% TBSA=infusion volume (mL)

Answer 33

Cleanse wound with normal saline Cover wound with a hydrophilic (ie, "water-loving") dressing that absorbs moisture Frequently reposition pt and off-load the affected area

Answer 34

thoroughly wash the area to remove the oily resin (which is responsible for causing the rash that follows in 12-48 hours)

Answer 35

Lactated Ringer's

Answer 36

common med triggers Allopurinol Antibiotics (eg, sulfonamides) Anticonvulsants (eg, carbamazepine, lamotrigine, phenytoin) NSAIDs Sulfasalazine

Answer 37

Heat the client's room to 85 F (29.4 C) sterile premedicate allergies

Answer 38

causes transient pain due to hemorrhagic inflammation of the sensory nerve. skin lesions resolve and the pain typically fades; however, persistent pain (ie, >3 months) indicates postherpetic neuralgia stabbing, tingling, or burning sensation. Pain is triggered or worsened by light touch (eg, washing the affected area)

Answer 39

opportunistic fungal infection that most commonly occurs in clients with compromised immunity from inhaling Histoplasma capsulatum spores that are typically found in soil that contains bird or bat droppings.

Answer 40

Low-grade fever Night sweats Anorexia and weight loss Fatigue Additional symptoms depend on the location of the infection. Pulmonary tuberculosis typically includes: Cough Purulent or blood-tinged sputum Shortness of breath Back pain indicates spinal TB. Dysuria is a symptom of extrapulmonary genitourinary TB. Jaundice can be present in disseminated TB with liver involvement. It can also be a side effect associated with drugs used to treat pulmonary TB (eg, isoniazid).

Answer 41

infection of the lower urinary tract and involves inflammation of the bladder mucosa, leading to hyperemia, tissue hemorrhage, and pus formation S/s: -burning with urination (dysuria), -urinary frequency and urgency, ----------hematuria, -suprapubic discomfort if the infection extends to the kidneys (pyelonephritis), clients become seriously ill with nausea, vomiting, fever with chills, and flank pain.

Answer 42

AFB sputum culture is the standard three sputum cultures should be collected at 8- to 24-hour intervals least one of the sputum cultures collected in the early morning.

Answer 43

an overgrowth of Candida albicans (ie, yeast), a component of normal flora (eg, skin, mucous membranes) S/s white patches on the oral mucosa, palate, and tongue (ie, "thrush") Causes: local microbial flora is disrupted (eg, prolonged antibiotic therapy) immune response is impaired (eg, HIV) Inhaled corticosteroids (eg, budesonide, fluticasone),

Answer 44

Rapid lysis of large amounts of bacteria causes the releases of intracellular components into the bloodstream, which triggers a strong immunological response. S/s: fever, myalgia, rigors, sweating, hypotension, and aggravation of preexisting rashes (ie, worsened maculopapular rash). Manifestations are usually self-limited and resolve spontaneously within 48 hours.

Answer 45

highly contagious skin infestation of the Sarcoptes scabiei mite direct person-to-person contact apply the medication from the neck down before going to bed at night avoiding application near the eyes or mouth treating all household members, retreating 1-2 weeks later.

Answer 46

herpes simplex virus type 2 no cure S/s small, painful vesicular lesions on an erythematous (reddened) base

Answer 47

chronic scarring and damage to heart valves caused by recurrent rheumatic fever Heart valve replacement may be necessary for clients who are not responsive to nonsurgical measures Notifying the health care provider of any flu-like symptoms indicate infective endocarditis (IE) Taking prophylactic antibiotics before invasive dental procedures bacteria in the bloodstream can increase the risk for IE Adhering to life-long anticoagulation therapy vitamin K antagonist (eg, warfarin)

Answer 48

develop quickly (20-30 minutes hypotension laryngeal edema (from inflammation) bronchoconstriction (from release of histamine);-> these can lead to cardiac and respiratory arrest. Call for help (activate emergency management systems) – first action Maintain airway and breathing – administer high-flow O2 via non-rebreather mask Epinephrine, intramuscular – the drug of choice and should be given next. Epinephrine stimulates both alpha- and beta-adrenergic receptors, dilates bronchial smooth muscle (beta 2), and provides vasoconstriction (alpha 1). The IM route is better than the subcutaneous route. The dose should be repeated every 5-15 minutes if there is no response. Elevate the legs Volume resuscitation with IV fluids Bronchodilator (albuterol) to dilate the small airways and reverse bronchoconstriction Antihistamine (diphenhydramine) to modify the hypersensitivity reaction and relieve pruritus Corticosteroids (methylprednisolone [Solu-Medrol]) to decrease airway inflammation and swelling associated with the allergic reaction

Answer 49

Immunosuppressants such as corticosteroids (eg, prednisone), increase the risk for conversion of latent TB to active TB

Answer 50

inflammation and damage to synovial joints Progressive fibrosis of joint membranes results in pain, deformity, and stiffness avoid frequent repetitive movements because overuse of the joints can worsen inflammation and accelerate progression of the condition to do: -alternating ice packs and moist heat to reduce inflammation. - Wearing a splint during periods of inflammation can help to reduce the risk for joint malformation.

Answer 51

overproduction of collagen that causes tightening and hardening of the skin and connective tissue Renal crisis - complication =malignant hypertension due to narrowing of the vessels that provide blood to the kidneys.

Answer 52

a chronic autoimmune disorder in which moisture-producing exocrine glands of the body are attacked by white blood cells. dry eyes (xerophthalmia) and dry mouth (xerostomia) Skin - dry skin and rashes Throat and bronchi - chronic dry cough Vagina - vaginal dryness and painful intercourse no cure. tx S/s avoid OTC decongestants as they cause further dryness to the mouth and nasal mucosa. eye drops, sugar-free candy or artificial saliva, vaginal lubricants, frequent dental examinations, lukewarm showers with mild soap, and avoiding decongestants.

Answer 53

receive inactivated vaccinations risk for kidney injury (ie, glomerulonephritis) and should receive routine screening of urine for protein, as well as monitoring of serum creatinine Secondary Raynaud phenomenon can occur

Answer 54

The client should monitor for transplant rejection (eg, hypertension, edema). Immunosuppressant (antirejection) medications require lifelong use. Regular blood specimen collections should be obtained to check medication levels. Immunosuppressants increase the risk for cancer and infection. The client should request an inactivated influenza vaccine during influenza season.

Answer 55

risk factors: Prolonged estrogen exposure without adequate progesterone obesity polycystic ovary syndrome Pregnancy

Answer 56

genetic bleeding disorder caused by a deficiency of von Willebrand factor (vWF), which plays an important role in coagulation Intranasal desmopressin or topical therapies (eg, thrombin) may be prescribed to stop minor bleeding, whereas major bleeding may require the replacement of vWF. Clients with vWD are taught to: Use a humidifier or nasal spray to keep the mucosa moist, reducing the risk for nosebleeds Wear gloves while doing household chores or yard work to prevent abrasions. soft-bristled toothbrush, gentle flossing Report heavy menstrual bleeding (eg, soaking a pad in <3 hr), which can be managed with hormonal therapies and intranasal desmopressin Notify the health care provider of signs of bleeding (eg, severe joint pain or swelling, blood in urine/stool, uncontrollable nosebleed). -avoid medications that can exacerbate bleeding, including aspirin and NSAIDs (eg, ibuprofen, naproxen). - Clients should instead use the mnemonic RICE (Rest, Ice, Compression, Elevation) to help alleviate pain and inflammation

Answer 57

implement neutropenic precautions (eg, placing a face mask on the client)

Answer 58

the accumulation of lymph in soft tissue, often due to lymph node removal or radiation therapy. Interventions to manage lymphedema include: Avoidance of injections (eg, vaccination), venipunctures (eg, IV catheter insertion, blood specimen collection), and blood pressure measurements in the affected arm Elevation of the affected arm to facilitate drainage Isometric arm exercises to improve circulation in the affected arm Compression sleeves or intermittent pneumatic compression sleeves to facilitate lymph drainage and prevent further fluid accumulation Massage therapy by licensed/trained therapists to promote lymph drainage and improve circulation

Answer 59

Radiation therapy damages both healthy and malignant (cancerous) cells. S/s: -inflammation and ulceration of healthy mucosal epithelial -dry mouth, loss of taste, painful swallowing Using water-soluble lubricating agents to moisten mouth tissues Using a soft-bristle toothbrush to decrease gum irritation Cleansing the mouth with saline or baking soda solution after meals and at bedtime Avoiding hot liquids and spicy/acidic foods, which can cause oral discomfort Removing dentures between meals to minimize gum irritation and soaking them in an antimicrobial solution to reduce pathogens Applying prescribed viscous lidocaine hydrochloride to alleviate oral pain

Answer 60

Anaphylactic Within seconds to minutes Recipient anti-IgA antibody response to blood product component Respiratory distress Wheezing Angioedema Hypotension Hives ---------------------\ Acute hemolytic Within 1 hr (usually within first 15 min) ABO incompatibility Fever Flank pain Hypotension Dyspnea Hemoglobinuria ---------------------\ Febrile nonhemolytic (most common reaction) Within 1-6 hr Recipient antibody response to cytokines that accumulate during blood product storage Fever Chills Headache ---------------------\ Urticarial Within 2-3 hr Recipient IgE antibody response to blood product component Hives Itching ---------------------\ Transfusion-related acute lung injury (TRALI) Within 6 hr Donor antileukocyte antibodies reacting with recipient leukocytes Respiratory distress Noncardiogenic pulmonary edema ---------------------\ Transfusion-associated circulatory overload (TACO) Within 12 hr Fluid overload (clients with cardiovascular or renal disease at risk) Respiratory distress Pulmonary edema

Answer 61

Nursing interventions: - Stop transfusion immediately and disconnect tubing at the catheter hub. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse Notify health care provider (HCP) and blood bank. Monitor vital signs. Recheck labels, numbers, and the client's blood type. Treat client's symptoms according to the HCP's prescription. Collect blood and urine specimens to evaluate for hemolysis. Return blood and tubing set to the blood bank for additional testing. Complete necessary facility paperwork to document the reaction.

Answer 62

dt a deficiency in coagulation proteins (eg, factor VIII, factor IX) cause excessive bleeding from minor injuries administering clotting factor replacement therapy RICE avoid using a warm compress Avoiding NSAIDs (eg, ibuprofen, aspirin) and administering alternate analgesics (eg, acetaminophen) is appropriate because the antiplatelet properties of NSAIDs increase the client's risk for bleeding.

Answer 63

C Change in bowel or bladder habits A A sore that does not heal U Unusual bleeding or discharge from a body orifice T Thickening or lump in the breast or elsewhere I Indigestion or difficulty swallowing O Obvious change in a wart or mole N Nagging cough or hoarseness

Answer 64

cancer that begins in the body's lymphatic system (eg, lymph nodes, spleen 2 major subtypes: Hodgkin lymphoma - predictable vs non-Hodgkin lymphoma -unpredictable S/s: painless, enlarged lymph nodes, often in the neck (ie, cervical lymph nodes), underarm, or groin fever, fatigue, weight loss, and night sweats. Treatment includes chemotherapy and external beam radiation therapy to destroy malignant cells. The nurse should monitor for complications, including: Tumor lysis syndrome, which occurs when chemotherapy successfully kills tumor cells, resulting in the systemic release of intracellular components (eg, potassium, phosphate) that leads to life-threatening electrolyte imbalances and acute kidney injury Superior vena cava (SVC) syndrome, which can occur when the SVC becomes obstructed due to malignancy (eg, lymphoma in cervical or mediastinal lymph node chains) (Incorrect) Tuberculosis (TB) is a highly communicable bacterial respiratory infection that can be identified with sputum culture and sensitivity. Symptoms of TB can be very similar to those of lymphoma; clients with TB typically have abnormal lung findings on chest x-ray (eg, upper lobe cavity [gas-filled space]). Hemoptysis is a complication of TB.

Answer 65

an immune reaction to heparin that causes a decrease of ≥50% in platelets from baseline When large changes are noted in laboratory test results = draw specimens again to verify the results because errors in sampling or specimen handling could result in unnecessary intervention notify the HCP immediately perform a neurovascular assessment and report evidence of vascular clots (eg, deep venous thrombosis) to the HCP. The nurse should also obtain a full set of vital signs to assess for pulmonary embolism (eg, tachycardia, tachypnea, decreased capillary oxygen saturation) anticipate stopping heparin therapy and initiating a nonheparin anticoagulant (eg, warfarin, rivaroxaban, argatroban)

Answer 66

hematologic cancer characterized by an unrestricted overproduction of immature leukocytes (ie, blasts) that invade the bone marrow and blood. AML is diagnosed with a bone marrow biopsy Proliferation of blasts in the bone marrow results in depressed bone marrow activity, causing pancytopenia, anemia (decreased number of RBCs), neutropenia (decreased number of WBCs), and thrombocytopenia (decreased number of platelets). Interventions: Implementing neutropenic precautions (eg, placing the client in a private room) to prevent infection Administering blood products (eg, packed RBCs) to help correct anemia Preparing the client for chemotherapy, which targets and eliminates cancer cells Immunization with inactivated vaccines is recommended for clients who are immunocompromised intranasal influenza = live vaccine = contraindicated .

Answer 67

too many RBCs (and often WBCs and platelets) are produced = increased blood viscosity venous stasis increased risk for thrombus formation Reports of possible thrombus require immediate intervention to avoid serious injury (eg, stroke, pulmonary embolism) S/s of thrombus (eg, swelling, redness, or tenderness in one leg)

Answer 68

Meats (eg, beef, lamb, liver, chicken, pork) Shellfish (eg, oysters, clams, shrimp) Eggs, green leafy vegetables, dried fruits, dried beans, brown rice, and oatmeal Eating foods rich in vitamin C (eg, citrus fruits, potatoes, tomatoes, green vegetables) with iron-rich foods will enhance iron absorption

Answer 69

slow-growing malignancy that is highly curable when treated early. -Black men, -first-degree relative with prostate cancer -age >50 lower risk for prostate cancer by: Reducing intake of red meat, animal fat, and high-fat dairy products Decreasing intake of refined carbohydrates Maintaining a healthy weight

Answer 70

monitor for severe abdominal pain (especially radiating to the back/shoulders), tachycardia, restlessness, and oliguria. = a life-threatening anastomotic leak immediately report to HCP

Answer 71

if taking iron, take it on empty stomach

Answer 72

S/s Ventricular dysrhythmias (eg, torsades de pointes) (priority). Neuromuscular excitability: similar to hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, seizures.

Answer 73

potentially lethal complication of nutritional replenishment LOW PPM phosphate, potassium, and/or magnesium hyperglycemia fluid overload, sodium retention, thiamine deficiency.

Answer 74

vit B12 deficiency megaloblastic anemia and neurological symptoms (eg, peripheral neuropathy, neuromotor impairment, memory loss) vitamin B12-fortified foods (eg, cereals, grain products, soy and nut milks, meat substitutes)

Answer 75

or accompanied by fever or bloody stool should see their health care provider for assessment of fluid status, electrolyte levels, and identification of underlying causes.

Answer 76

preserve gut integrity limit movement of bacteria from the intestines into the bloodstream prevent stress ulcers

Answer 77

small intestine stoma bypasses the colon = Functions of the colon (eg, fluid and electrolyte absorption, vitamin K production) do not occur, resulting in liquid stool In the immediate postoperative period of an ileostomy = low-residue diet (low-fiber) After the ileostomy heals, the client reintroduces fibrous foods one at a time Foods to be avoided include: High fiber: popcorn, coconut, brown rice, multigrain bread Stringy vegetables: celery, broccoli, asparagus Seeds or pits: strawberries, raspberries, olives Edible peels: apple slices, cucumber, dried fruit

Answer 78

increased prealbumin indicates a positive nitrogen balance weight gain or maintenance that does not result from fluid retention

Answer 79

Clarifying enteric-coated medications with HCP Identifying foods that cause excess gas and odor (eg, broccoli, cauliflower, dried beans) XIrrigation to promote a bowel regimen may be useful for descending or sigmoid colostomies because the stool is more solid. Because part of the colon is no longer absorbing water, increased fluid intake should be encouraged. Ensuring sufficient fluid intake (ie, at least 3,000 mL/day unless contraindicated)

Answer 80

The client should be placed in the low Fowler position with the knees bent to reduce tension on the open wound. require emergency surgery While waiting for surgery, the area should be covered with sterile, saline-moistened gauze

Answer 81

Prior to the procedure, clients are prescribed a bowel preparation (eg, laxatives) to completely empty the colon watery diarrhea that is clear or light yellow The client will receive sedation for the procedure, but the procedure itself is not painful The client should avoid red-colored liquids prior to the procedure, which could be misinterpreted as blood or tissue discoloration The health care provider may prescribe a clear liquid diet prior to the procedure. complication: perforation and rectal bleeding. Abdominal cramping, flatus, and watery stool are expected findings. Perforation can lead to peritonitis, with positive rebound tenderness, guarding, abdominal distension, tenesmus, and/or boardlike (rigid) abdomen.

Answer 82

should not advance to a regular diet until peristalsis returns (eg, bowel sounds, passage of flatus, bowel movement). Advancing the diet before peristalsis returns could lead to a bowel obstruction.

Answer 83

gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia Teach: Consume meals high in fat, protein, and fiber Avoid fluids with meals Slowly consume small, frequent meals Avoid meals high in simple carbohydrates Avoid sitting up after a meal because gravity increases gastric emptying. lay down after meals

Answer 84

remove excess ascitic fluid from the abdominal cavity or to collect a specimen for diagnostic testing void prior to the procedure to prevent puncturing the bladder Assessing the client's vital signs, abdominal girth, and weight before and after the procedure

Answer 85

Colicky abdominal pain, vomiting Inability to pass flatus or stool if complete Hyperactive bowel sounds Distended & tympanitic abdomen dx Dilated loops of bowel with air-fluid levels on x-ray or CT scan Ischemia/necrosis (strangulation) Bowel perforation Bowel rest, nasogastric tube suction, IV fluids Surgical exploration for complications

Answer 86

central venous access devices only Do not piggyback or add medication to TPN infusions Do not stop TPN abruptly due to its high concentration of dextrose. If TPN is disrupted, dextrose 10% in water is administered at the prescribed rate of the TPN to prevent hypoglycemia Check blood glucose every 4 to 6 hours to maintain appropriate glucose levels daily weights and intake and output

Answer 87

uses fluoroscopy to visualize the colon outlined by contrast (ie, barium) to detect polyps, ulcers, tumors, and diverticula Before the procedure, clients should complete a prescribed bowel preparation to make sure colon is clear of stool Retained barium can cause constipation and fecal impaction. After the procedure, fluids and laxatives or suppositories should be used to help clients expel the barium and avoid fecal impaction Clients may experience chalky white stool for up to 72 hours after the procedure as barium is expelled from the body Instillation of the barium can cause abdominal cramping and an urge to defecate.

Answer 88

inflammation and autodigestion of pancreatic tissue from lipase being around cause: -obstructive biliary tract disease (eg, untreated cholelithiasis [ie, gallstones]) - alcohol use disorder -abdominal trauma -certain medications such as thiazide diuretics (ie, hydrochlorothiazide) -- -------hypertriglyceridemia -medical procedures that can irritate the pancreas (eg, endoscopic retrograde cholangiopancreatography) S/s: -severe epigastric pain after eating, nausea/vomiting -elevated serum lipase and amylase levels NPO IV fluids IV opioid analgesics Insert a nasogastric tube To relieve pain, the client should maintain a position that flexes the trunk and draw the knees up to the abdomen, decreasing tension on the abdomen. A side-lying position with the head elevated to 45 degrees will also help relieve pain.

Answer 89

removing the distal two-thirds of the stomach remain NPO until bowel sounds return Once tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome initiation of thromboembolism prophylaxis sequential compression devices, compression hose turning, coughing, and deep breathing aspiration precautions (eg, elevating the head of the bed DO NOT flush the clogged nasogastric tube. report to surgeon

Answer 90

overproduction of thyroid hormone (ie, hyperthyroidism) and leads to a hypermetabolic state (eg, tachycardia, weight loss, exophthalmos). Treatment includes radioactive iodine (RAI) therapy. Clients must understand contraceptive teaching because RAI is teratogenic.

Answer 91

results from prolonged exposure to excess glucocorticoids. Surgical removal of the pituitary gland (ie, transsphenoidal hypophysectomy) may be indicated if caused by a pituitary tumor. The presence of glucose in nasal drainage indicates a cerebrospinal fluid leak and is a complication of transsphenoidal surgery.

Answer 92

when the adrenal glands do not produce adequate amounts of steroid hormones s/s weight loss, muscle weakness, hypotension, hypoglycemia, and hyperpigmented skin.

Answer 93

chronic adrenal insufficiency lifelong hormone replacement therapy, increasing dietary salt intake, monitoring for orthostatic hypotension. Increased stress can lead to addisonian crisis, requiring emergency administration of IM hydrocortisone injection.

Answer 94

hypersecretion of parathyroid hormone (PTH) PTH increases serum calcium =hypercalcemia s/s muscle weakness, fatigue, constipation, and bone pain.

Answer 95

pH <7.35 and HCO3⁻ <21 mEq/L [21 mmol/L]) low pH and low HCO3⁻

Answer 96

increase in thyroid hormones (T3 and T4) hypermetabolic state SWEATING Sweating excessively Weight loss Exophthalmos Amenorrhea/irregular menstrual cycles Tachycardia/tremor Intolerance to heat Nervousness/insomnia Gastrointestinal (GI) stimulation/goiter --------- leads to an increased metabolic rate satisfy hunger and prevent weight loss and tissue wasting include: Adherence to a high calorie diet (4000-5000 calories per day). Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg, diarrhea). Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks). Avoidance of spicy foods as these can also increase GI stimulation.

Answer 97

Weakness & fatigue Weight gain Bradycardia Delayed deep tendon reflexes Constipation Cognitive slowing Cold intolerance Coarse, dry skin Hoarseness Nonpitting edema (myxedema) Macroglossia Depression Myalgia & arthralgia Hypercholesterolemia

Answer 98

occurs due to insufficient production/suppression of antidiuretic hormone (ADH) polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). Neurogenic DI is caused by impaired ADH secretion, transport, or synthesis. It can result from manipulation of the pituitary gland or other parts of the brain during surgery, brain tumors, or head injury ADH replacement with vasopressin can be used to treat DI

Answer 99

complication of Graves disease exposed cornea is at risk for dryness, injury, and infection Nursing care for a client with exophthalmos includes: Using artificial tears or other similar products to moisten the eyes and prevent corneal drying (which causes abrasions/ulcers) Taping the client's eyelids shut during sleep if they do not close on their own raise HOB facilitate fluid drainage from the periorbital area corticosteroids to reduce periorbital swelling Client teaching includes: Making regular visits to an ophthalmologist to measure eyeball protrusion and evaluate the condition Using dark glasses to decrease glare and prevent external irritants and infection Restricting dietary sodium intake to decrease periorbital edema

Answer 100

an overproduction of growth hormone (GH) due to a pituitary adenoma that releases excessive amounts of the hormone onset in adult clients generally occurs at age 40-45. In an adult, increased GH results in overgrowth of soft tissues of the face, hands, feet, and organs. The high level of GH stimulates an increase secretion of fatty acids into the bloodstream. high [fat] in blood -> atherosclerosis and coronary artery disease. Other complications such as arrhythmias and left ventricular hypertrophy are possible. Additional heart tones (ie, S3, S4) require further assessment by the health care provider for potential cardiac complications (eg, heart failure, cardiomyopath

Answer 101

indicative of diabetic nephropathy, a complication caused by microvascular damage to the kidneys. Diabetic nephropathy can lead to end-stage renal disease.

Answer 102

Tofu Banana Oily fish (eg, sardines, salmon, tuna) Almonds Dairy products (eg, cheese, milk, yogurt) Dark green leafy vegetables Foods high in oxalic acid (eg, rhubarb, spinach) can inhibit calcium absorption and are not appropriate for clients with hypoparathyroidism and hypocalcemia.

Answer 103

rapid-acting insulin with a peak of 30min- 3 hours should be given only if it is certain the client will eat within 15 minutes Scheduled prandial (ie, fixed dosage) given to prevent hyperglycemia with consumption of food. Typically, this would not be held unless the blood sugar is below normal (70 mg/dL [3.9 mmol/L]) or according to facility guidelines. Correctional (ie, sliding-scale dosage) given to correct hyperglycemia. Typically, this would be held when blood glucose is <150 mg/dL (8.3 mmol/L).

Answer 104

long-acting (basal) insulin given to prevent hyperglycemia for 24 hours. no peak = timing of administration is not dependent on food intake.

Answer 105

To prevent hypoglycemia related to an evening dose of NPH, the client should eat a bedtime snack consisting of protein and complex carbohydrates (eg, cereal with milk, crackers with peanut butter)

Answer 106

a life-threatening complication of hyperthyroidism that occurs in response to stress. Thyroid storm is characterized by severe hypermetabolic symptoms, including altered mentation (eg, agitation, confusion), extreme tachycardia, hyperthermia, and cardiac dysrhythmias.

Answer 107

a skin condition characterized by velvety light brownish to black skin thickening seen in the neck, axillae, or flexures and is indicative of insulin resistance. Clients exhibiting acanthosis nigricans should be referred to the health care provider to be evaluated for diabetes mellitus.

Answer 108

Stridor after a thyroidectomy indicates airway obstruction and requires immediate intervention by the nurse to maintain airway patency. Suctioning devices, oxygen, and a tracheostomy tray should be available for emergency airway intervention. Hypocalcemia is a potential complication of a thyroidectomy. A decreased serum calcium level can be treated with calcium supplementation (eg, calcium gluconate) after intervening for an obstructed airway.

Answer 109

results from prolonged or excessive exercise, insufficient dietary intake, and/or excess insulin administration <3.9 mmol/L (70mg/dL) S/s: shakiness palpitations, tachycardia diaphoresis, clammy skin altered mental status hunger if conscious= 15 g/4 oz/120 mL of a simple carbohydrate unconscious = IV dextrose 50% in water and IM glucagon capillary blood glucose level should be rechecked 15 minutes after the administration of a simple carbohydrate to assess the effectiveness of the treatment

Answer 110

Increasing fluid intake to help clear ketones from the system and prevent dehydration during illness Checking blood glucose levels more frequently (eg, every 4 hr) to monitor for hyperglycemia Monitoring the urine for ketones if blood glucose levels are persistently elevated (>240 mg/dL [13.3 mmol/L]) for early detection of impending DKA Consuming beverages that contain glucose and replacing electrolytes if nausea and vomiting are present Notifying the health care provider of persistently elevated blood glucose levels, ketones in the urine, high fever, nausea, vomiting, or diarrhea

Answer 111

bronze skin pigmentation, hypovolemia, hypotension, hyponatremia, hyperkalemia, and vitiligo. Acute adrenocortical insufficiency (ie, addisonian crisis) is a life-threatening complication of Addison disease that is characterized by fluid and electrolyte disturbances (eg, dehydration, hyponatremia, hyperkalemia, hypoglycemia) and cardiovascular collapse (eg, hypotension, tachycardia). The nurse should immediately report new-onset hypotension because the client requires glucocorticoid supplementation.

Answer 112

complication of hypothyroidism characterized by altered mental status hypothermia hemodynamic instability hypoventilation. Management involves IV levothyroxine warm blankets preparation for intubation cardiac monitoring.

Answer 113

records a client's electrocardiogram rhythm for 24-48 hours Keep a diary of activities and any symptoms experienced while wearing the monitor so that these may later be correlated with any recorded rhythm disturbances Do not bathe or shower during the test period Engage in normal activities to simulate conditions that may produce symptoms that the monitor can record

Answer 114

Report fever or signs of redness, swelling, or drainage at the incision site. Always carry a pacemaker identification card and wear emergency medical identification. Take the pulse daily and report it to the health care provider if it is below the predetermined rate. Avoid carrying a cell phone in a pocket directly over the pacemaker and, when talking on a cell phone, hold it to the ear on the opposite side of the pacemaker Discuss the pacemaker with health care providers before receiving an MRI; not all pacemakers are MRI safe Notify airport security of the pacemaker; a handheld screening wand should not be held directly over the device Avoid standing near antitheft detectors in store entryways; walk through at a normal pace and do not linger near the device. avoid: The client should avoid lifting the arm above the shoulder on the side of the pacemaker until approved by the health care provider because this can dislodge the pacemaker lead wires.

Answer 115

To assess the point of maximal impulse (PMI) the client is positioned supine or with the head of the bed elevated to 45 degrees; the nurse should palpate for a short tap at the midclavicular line of the fourth or fifth ICS (pulsation may or may not be visible). A displaced PMI (eg, below the fifth ICS) may be an indication of an enlarged heart. Educational objective: The nurse should not palpate the carotid arteries simultaneously due to possible vagal stimulation resulting in bradycardia or syncope. Each carotid artery should be palpated separately.

Answer 116

Erb's point is located at the third left intercostal space (ICS) near the sternum and is an appropriate location to auscultate heart sounds for murmurs

Answer 117

torsades de pointes lethal cardiac arrhythmia -> low CO-> develop quickly into ventricular fibrillation tx with IV magnesium sulfate

Answer 118

palpitations, dizziness, and lightheadedness Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. teaching: adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms Reduce stress and avoid alcohol use begin or maintain an exercise program, preferably aerobic exercise

Answer 119

they can increase blood pressure.

Answer 120

decreased ejection fraction results in a narrowed pulse pressure With exertion, the volume of blood pumped to the brain and other parts of the body is insufficient to meet metabolic demands, resulting in exertional dyspnea, anginal chest pain, and syncope

Answer 121

hypertension, bradycardia, severe headache, profuse diaphoresis, and nausea If AD is suspected, the nurse should first elevate the head of the bed to 45 degrees or higher to reduce blood pressure. Then the nurse should assess for noxious stimuli (eg, bladder distension, fecal impactino, constructive clothes) to determine the underlying cause.

Answer 122

NSAIDs increases the risk of thrombotic events (eg, heart attack, stroke) in clients with cardiovascular disease (eg, coronary artery disease [CAD]), especially with long-term use The nurse should investigate the reason a client with cardiovascular disease is taking an NSAID and alert the health care provider of the medication usage

Answer 123

risk for developing syncope and sudden death with exertion

Answer 124

The synchronize ("sync") function on the defibrillator must be turned on when cardioversion is planned because it is programmed to sense the client's rhythm and deliver a shock on the R wave of the QRS complex

Answer 125

could mean obstruction Obstruction (eg, clot) of the chest tube will result in excess fluid buildup in the pericardium, leading to inhibited cardiac contractility and eventual diagnosis of cardiac tamponade muffled heart tones, pulsus paradoxus, hypotension)

Answer 126

incision is at groin monitor groin puncture sites, peripheral pulses, urine output, and kidney function

Answer 127

indicate turbulent blood flow across diseased or malformed cardiac valves musical, blowing, or swooshing sounds that occur between normal heart sounds They may be auscultated at the aortic, pulmonic, tricuspid, or mitral areas

Answer 128

Fibrates (eg, gemfibrozil, fenofibrate) reduce triglyceride levels in clients with hypertriglyceridemia increase levels of HDL ("good") cholesterol HMG-CoA reductase inhibitors ("statins") may be used in combination with fibrates in clients with moderate to severe hypertriglyceridemia. Adverse effects of fibrates and statins: hepatotoxicity and rhabdomyolysis. Clients receiving both medications are at greater risk for adverse effects. monitor liver enzymes and teach the client to report jaundice, muscle pain, or dark-colored urine.

Answer 129

adequacy of blood flow to the lower extremities by palpating for the presence of posterior tibial and dorsalis pedis pulses and their quality Dry, scaly skin thin, shiny, and taut skin; hair loss

Answer 130

Defibrillation attempts to convert lethal ventricular dysrhythmias (ie, ventricular fibrillation and pulseless ventricular tachycardia) into an organized rhythm by passing an electric shock through the heart. Defibrillation cannot create an organized rhythm if there is no electrical activity in the heart When treating asystole or PEA, the absolute priority is providing continuous, high-quality CPR and oxygenated ventilation until circulation spontaneously returns or the client enters into a shockable rhythm. Unfortunately, restoration of circulation may not be possible, and clients in asystole often cannot be resuscitated.

Answer 131

priority: Obtain a 12-lead ECG Performing a cardiopulmonary assessment O2, as needed Inserting 2 large-bore IV catheters Administering antianginal medication (eg, nitroglycerin) Obtaining baseline blood work (eg, cardiac markers, serum electrolytes) Obtaining a portable chest x-ray Assessing for contraindications to antiplatelet and anticoagulant therapy Administering aspirin unless contraindicated The defibrillator may be used if ECG or cardiac monitoring shows a lethal and shockable rhythm (eg, pulseless ventricular tachycardia, ventricular fibrillation)

Answer 132

Instead, they can present with "atypical" symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue.

Answer 133

T5 and up causes hemodynamic decompensation due to loss of SNS response leads to bradycardia, systemic vasodilation, and pooling of blood in the extremities, reducing venous return and cardiac output and ultimately causing impaired tissue perfusion IV fluid bolus (eg, 0.9% sodium chloride) along with vasopressors (eg, norepinephrine) to keep the systolic blood pressure >90 mm Hg and mean arterial pressure >60 mm Hg after, Testing for the presence of blood in the urine is important in determining whether kidney damage has occurred A neurological assessment (eg, level of consciousness) Autonomic dysreflexia is a medical emergency, but it does not present for weeks to years after the initial injury. Bladder and stool impaction are etiologies for autonomic dysreflexia and generally occur in a client with a high-level fracture at T5 or above with a stimulation below the fracture.

Answer 134

pus in the pleural cavity due to bacteria spreading from the lung to the pleural space.

Answer 135

alter the renin-angiotensin-aldosterone system by inhibiting conversion of angiotensin I to angiotensin II, thereby preventing the release of aldosterone. Aldosterone, an adrenal steroid hormone, retains sodium and water in addition to promoting vasoconstriction. By reducing circulating aldosterone, ACE inhibitors promote vasodilation and as a result decrease blood pressure. ACE inhibitors also decrease ventricular remodeling, an added benefit for clients with HF.

Answer 136

reduce cardiac workload by inhibiting the action of catecholamines (eg, epinephrine, norepinephrine) on beta-adrenergic receptors in the heart. Beta blockers decrease myocardial oxygen demand by decreasing blood pressure and decreasing heart rate.

Answer 137

smoking cigarettes is permissible while on the medication, sleep disturbances may occur, significant changes in behavior or mood should be reported to the health care provider, and varenicline can be combined with other forms of nicotine replacement if needed.

Answer 138

A drop in systolic BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal

Answer 139

measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects fluid volume problems elevated CVP = right ventricular failure or fluid volume overload. Peripheral edema Increased urine output that is dilute Acute, rapid weight gain Jugular venous distension S3 heart sound in adults Tachypnea, dyspnea, crackles in lungs Bounding peripheral pulses

Answer 140

for lumbar puncture - side-lying fetal position or hunched seated position (to separate the vertebrae) After the procedure- Supine -to minimize the risk for postprocedure headache from loss of cerebrospinal fluid.

Answer 141

HOB ≤30 degrees to prevent hip flexion which could disrupt clot formation at the insertion site and initiate bleeding.

Answer 142

systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg) S/s hypertensive encephalopathy, including severe headache, confusion, nausea/vomiting, and seizure high risk for end-organ damage (eg, hemorrhagic stroke, kidney injury, heart failure, papilledema IV nitrates or antihypertensives (eg, nitroprusside, labetalol, nicardipine) and continuous monitoring (eg, blood pressure, telemetry, urine output) in a critical care setting

Answer 143

a highly potent venous and arterial vasodilator commonly used in hypertensive emergencies and for conditions in which blood pressure (BP) control is essential (eg, aortic dissection, acute decompensated heart failure) exert its effects within 1 minute and can produce a sudden and drastic decrease in BP (symptomatic hypotension [eg, light-headedness; cool, clammy skin]). Therefore, the client's BP should be monitored closely (ie, every 2-5 min)

Answer 144

-apply an occlusive dressing to the site - administer 100% O2 nonrebreather -position the client in left lateral Trendelenburg position -monitor VS and resp effort -immediately notify the health care provider. Air embolism

Answer 145

Several small incisions are made between the ribs so pain during breathing -take pain medication before the pain is too intense. - instructed pt to cough, breathe deeply while splinting the chest with a pillow, -use the incentive spirometer routinely to reduce the incidence of postop complications.

Answer 146

Prosthetic heart valve or prosthetic material used to repair heart valve Previous history of IE Some forms of congenital heart disease Unrepaired cyanotic congenital defect Repaired congenital defect with prosthetic material or device for 6 months after procedure Repaired congenital defect with residual defects at the site or adjacent to the site of a prosthetic patch or device Cardiac transplantation recipients who develop heart valve disease any form of prosthetic material in their heart valves or who have unrepaired cyanotic congenital heart defect or prior history of IE

Answer 147

to diagnose and/or treat conditions such as coronary artery disease and heart failure Contrast dye is injected through a thin, flexible catheter that is inserted through the radial or femoral artery. Images are obtained, and hemodynamic assessments are completed. Complications- associated with the catheter insertion site: arterial thrombosis or embolism frequently assess the affected extremity and report any neurovascular changes (eg, numbness, tingling, decreased pulses, or coolness of the extremity) to the health care provider immediately as blood flow to the extremity may be compromised It is expected for the pt to feel warm or flushed while the contrast dye is injected. With diagnostic studies, the client often goes home the same day. Hospitalization is typically only required if angioplasty or stent placement is performed. General anesthesia is not used during the procedure. Sedatives (eg, midazolam, fentanyl) are administered for client comfort.

Answer 148

widespread activation of the coagulation cascade, causing abnormal clot formation and then hemorrhage due to consumption of clotting factors and platelets causes: sepsis, trauma, malignancy, and obstetric complications (eg, placental abruption). S/s: external bleeding (eg, gums, nose, IV sites), internal bleeding (eg petechiae, ecchymosis), and organ damage from clot formation (ie, respiratory distress, renal insufficiency) decreased platelet count and fibrinogen level with prolonged clotting times (ie, PT, PTT Anticipated interventions include: Initiating vasopressors (ie, norepinephrine infusion) to increase blood pressure and restore tissue perfusion Monitoring coagulation studies (eg, PT/PTT, fibrinogen, platelets) to assess the severity of DIC and evaluate the effectiveness of interventions Transfusing fresh frozen plasma and platelets for clients with severe bleeding to replace clotting factors and reduce blood loss

Answer 149

150-220bpm reduced cardiac output such as hypotension, palpitations, dyspnea, and angina tx; vagal maneuvers such as Valsalva, coughing, and carotid massage Adenosine (anticholinergic) rapidly via IVP over 1-2 sec. followed by 20ml NS bolus may be given twice if ineffective

Answer 150

chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina: Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium

Answer 151

is a colloid that mobilizes fluid from the extravascular tissues into the vascular space. Although it expands intravascular volume, albumin is a second-line therapy in clients with hypotension, low intravascular proteins, and increased fluid in extravascular tissues (eg, cirrhosis with ascites).

Answer 152

can sense life-threatening arrhythmia and discharge electrical shocks directly into the cardiac muscle to correct the arrhythmia Clients typically receive ICDs after a history of sustained or recurrent ventricular tachycardia (VT) monitor for ICD firings (eg, client report, observation on cardiac monitors). After firings, the nurse should monitor for resolution of the arrythmia, indications of hemodynamic compromise (eg, hypotension, chest pain, altered mentation), and additional ICD discharges. Occasionally, an ICD may be unable to convert the arrythmia to a hemodynamically stable rhythm and will repeatedly shock the client. If the client experiences repeated ICD shocks without dysrhythmia resolution, the nurse should promptly obtain a manual external defibrillator and initiate measures to prevent hemodynamic instability and cardiac arrest teaching: refrain from lifting the affected arm above the shoulder (until approved by the health care provider) to prevent dislodgement of the lead wire on the endocardium Driving may be approved by the health care provider after healing has occurred The ICD may set off the metal detector in security areas but. flying is not restricted Firing of the ICD may be painful. Clients have described the feeling as a blow to the chest.

Answer 153

HOB 30-45 degrees observe for distension and prominent pulsation of the neck veins The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid overload.

Answer 154

are prescribed in clients with benign prostatic hyperplasia and work by relaxing the smooth muscle in the prostate, thereby reducing urinary hesitancy, urgency, and nocturia.

Answer 155

block renal reabsorption of sodium, chloride, and potassium, which increases fluid excretion in the urine (ie, diuresis). fluid volume decreases, pulmonary congestion improves,

Answer 156

a vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress women age 15-40 Vasospasms-> color change in the appendages (eg, fingers, toes, ears, nose initially turns white from decreased perfusion, followed by a bluish-purple appearance due to cyanosis, numb, cool When blood flow is restored, the affected area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling teaching regarding prevention of vasospasms includes: Wear gloves when handling cold objects (Option 5). Dress in warm layers, particularly in cold weather. Avoid extremes and abrupt changes in temperature. Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). Avoid excessive caffeine intake Refrain from use of tobacco products Implement stress management strategies (eg, yoga, tai chi) If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole smooth muscle and prevent recurrent episodes.

Answer 157

infection of the innermost layer (ie, endocardium) of the heart +valves Bacteria adhere to the inner surfaces of the heart and grow into vegetations that can calcify and break off (ie, embolize) to various parts of the body, placing the client at risk for life-threatening complications (eg, pulmonary embolism, stroke). Splinter hemorrhages (ie, dark, longitudinal streaks under the fingernails) and Janeway lesions (ie, flat, small red spots) on the fingertips, palms, soles, and toes, are common findings in clients with IE due to microemboli in the end-capillaries blocking blood flow. Microemboli should not be prioritized before macroemboli (eg, stroke, ischemic limb).

Answer 158

prolonged (>0.20 seconds), regular PR interval

Answer 159

absent P waves and fine, fibrillatory waves, indicating disorganized atrial electrical activity. The ventricular rate is usually irregular.

Answer 160

The internal jugular and subclavian veins are preferred sites for CVADs The basilic vein is a preferred site for a peripherally inserted central catheter (PICC).

Answer 161

potentially life-threatening dysrhythmia characterized by a ventricular rate of 100-250/min QRS complexes are wider than 0.12 seconds and the P wave is usually buried in the QRS complex, making a PR interval unmeasurable Pulseless VT is treated with cardiopulmonary resuscitation (CPR) and defibrillation.

Answer 162

a protein made by the ventricles in response to stretching caused by increased blood volume and higher levels of extracellular fluid (ie, fluid overload) in HF

Answer 163

performed to restore coronary artery perfusion and prevent or treat myocardial infarction (MI) a catheter is inserted into a large artery (eg, femoral, radial) and threaded into the coronary vessels A balloon and stent on the catheter are positioned near the plaque and expanded. Stent remains permanently preparing the client: Assess client for iodine allergy NPO Review most recent creatinine level (kidney damage risk) verify consent hold beta blockers for the client with bradycardia

Answer 164

pt with symptoms of AAA should be transported to an emergency medical care facility for confirmatory diagnosis (eg, CT scan, abdominal ultrasound) and treatment because surgical repair is urgently required.

Answer 165

should display a pacemaker spike before the P wave

Answer 166

P wave = atrial depolarization QRS complex = ventricular depolarization

Answer 167

participate in a cardiac rehabilitation program abstain from sexual activity until approved Wound care generally involves washing the incisions gently with mild soap and water and patting dry. (no bath or creams) blankets for hypothermia initiate continuous blood pressure monitoring via an arterial line report excessive chest tube drainage (ie, >100 mL/hr) to the health care provider

Answer 168

Treatment of symptomatic sinus bradycardia may include a temporary (eg, transcutaneous or transvenous) or permanent pacemaker.

Answer 169

lower the head of the bed (HOB) supine elevate legs/feet -IV fluids -> maintain fluid volume -monitor hgb, hct -> blood transfusion -continuous cardiac monitoring dt risk of dysrythmias dt shock

Answer 170

an intermittent block usually occurring at the level of the AV node characterized by a progressively lengthening PR interval until a QRS complex is dropped dt myocardial ischemia (eg, coronary artery disease) or certain medications (eg, beta blockers, digoxin) First, take VS to check for symptoms of the rhythm report dizziness, hypotension, SOB If no symptoms are present, closely monitor the client. If symptoms are present, anticipate using atropine or temporary pacing.

Answer 171

pacemaker is firing but the myocardium is not responding with a contraction It is identified on telemetry by the absence of a P wave or QRS complex following a pacer spike. Causes include lead dislodgement, battery failure, and inadequate voltage. A malfunctioning pacemaker can cause asystole or serious bradycardia. If pt is hemodynamically unstable (eg, hypotension, dizzy, short of breath), transcutaneous pacing should be initiated to normalize the heart rate, stabilize blood pressure, and maintain adequate perfusion (temporary until pacemaker is fixed)

Answer 172

uses vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone Preprocedure instructions: Avoid smoking cigarettes on the day of the test because nicotine is a stimulant no coffee,not even decaf Expect to feel transient nausea and/or flushing as vasodilators are injected report symptoms such as chest pain and/or dyspnea during the test. hold beta blockers to ensure accuracy of the test. A peripheral venous access device will be inserted to administer medications

Answer 173

a device that is inserted percutaneously, usually via the femoral vein to trap blood clots from lower extremity vessels used when clients have recurrent emboli or anticoagulation is contraindicated. - Physical activity should be promoted, - avoid crossing their legs to promote venous return from the legs - Leg pain, numbness, or swelling may indicate impaired neurovascular status distal to the insertion site and should be reported immediately -S/s of PE (eg, chest pain, shortness of breath) and vascular injury (bleeding causing back pain) are not expected findings after the procedure and should be reported immediately.

Answer 174

stabilizes cell membranes: IV calcium gluconate excretes k: IV furosemide moves K into cells: albuterol nebulizer IV insulin with dextrose

308 Adult Flashcards

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