Adult 1 Finale Flashcards by Maddy Golem

mydriatic medications are for:

dilation of the eye

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cycloplegic medications are for:

paralyzing the eye

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A client has had hydrochloric acid splashed in their eye. Which of the following are steps the nurse should instruct the client to do? (2 answers)

Assess visual acuity
Flush eye with sterile saline

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Primary open-angle glaucoma is less common and can be acute: true or false

false

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main s/s of cataracts

glare

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main s/s of glaucoma

peripheral vision loss

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main s/s of retinal detachment

“curtain” coming across vision

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main s/s of age-related macular degeneration (AMD)

central vision loss (black dot in middle of vision)

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risks of retinal detachment?

age
eye trauma

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for cataracts, the first treatment is surgery: true or false?

false

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Scleral buckling

Band placed around the globe and silicone implant sutured against sclera

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Pneumatic retinopexy

Gas bubble inserted into the eye to form a bubble to close retinal breaks

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Vitrectomy

Removal of vitreous to relieve traction on the retina
Laser photocoagulation

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Laser photocoagulation

For retinal tears or holes without detachment; seals with laser and cryotherapy

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sensorineural hearing loss what is it and what can cause it?

INNER ear hearing loss
Meniere’s disease
Noise exposure

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what is normal intraocular pressure (IOP)?

10-20ish

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cause of Cataract:

Caused by accumulation of water and alterations in the lens fiber structure

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cause of Retinal detachment:

Caused by the separation of the sensory retina and the underlying pigment epithelium

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cause of Glaucoma:

Caused by increased intraocular pressure

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cause of Age-related macular degeneration:

Cause of irreversible central vision loss in older adults

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cause of Meniere’s disease:

Caused by the accumulation of endolymph inside the membraneous labyrinth

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The nurse is caring for a client who is scheduled for surgery with regional anesthesia. The client asks, “Will I be awake during surgery?” Which is the most appropriate statement by the nurse?”

“It will seem like you are awake, however, you will not be aware.”

“During the surgery, you will have a loss of consciousness.”

“You will receive medication that will make you sleepy.”

“There will be a loss of sensation, but you will be awake.”

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A nurse is reviewing the laboratory results of a client who is preoperative knee surgery. The nurse should notify which results to the healthcare provider?

WBC count 20,000/mm3
Potassium 3.9 mEq/L
Hematocrit 40%
Creatinine 0.9 mg/dL

WBC count 20,000/mm3

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The nurse is assessing a client who is postoperative day 5 and notes the client’s oral temperature is 100.9 F. Which action should the nurse take first?

provide the client with a cooling blanket
request a prescription for an antibiotic
assess the surgical wound site
administer prescribed acetaminophen

assess the surgical wound site

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The nurse is collecting the health history from a client who is scheduled for surgery. Which statement by the client would a priority for the nurse to follow up? “My mother had a reaction during a surgery.” “I am concerned about the pain after the surgery.” “My father had an infection after surgery.” “I got very nauseous the last time I had surgery.”

“My mother had a reaction during a surgery.”

The nurse is educating a client about how to prepare for abdominal surgery. Which statement by the client would require follow up by the nurse? “I should bathe with the chlorhexidine gluconate solution the morning of the surgery.” “I need to continue taking my prescribed antiplatelet medication up to the day of surgery.” “I can practice my breathing exercises the day before the surgery.” “I will avoid eating and drinking for 8 hours before the surgery.”

“I need to continue taking my prescribed antiplatelet medication up to the day of surgery.”

The preoperative nurse is witnessing a client sign consents for surgery. The client states, “I am not sure I want to have the surgery.” Which statement would be appropriate for the nurse to make? “This is a hard decision for you to make.” “Tell me more about what makes you think you do not want the surgery.” “I will ask your provider to come back to discuss your concerns." “You should talk to your family about your concerns.”

“I will ask your provider to come back to discuss your concerns."

The nurse is monitoring a client who received prescribed fentanyl during a bronchoscopy. The nurse notes the client’s respiratory rate is 10 breaths per minute. Which is the priority action for the nurse to take? alert the rapid response team administer IV morphine reassess the client in 30 minutes begin rescue breathing with bag-mask-valve

begin rescue breathing with bag-mask-valve

The nurse is teaching a client who had surgery how to cough effectively. Which instructions should the nurse include in the teaching? “Hold a pillow over the incision.” “You should cough when you are not experiencing pain.” “Decrease the amount of fluids you drink before coughing.” “Get up and walk before you try to cough.”

“Hold a pillow over the incision.”

The post-anesthesia care nurse is monitoring a client following a surgical procedure. Which findings should the nurse report immediately to the healthcare provider? pain at the incision site cold, clammy skin non-productive cough clear emesis

cold, clammy skin

The perioperative nurse is planning care for a client. Which interventions would be the PRIORITY for the nurse in the operating room? Verify if the client received teaching. Provide updates to the client’s family members. Apply eye patches to client's eyes for longer procedures Ensure safe client position.

ensure safe client position

hyponatremia s/s

Nausea/vomiting, lethargy, confusion, muscle cramps, muscle twitching, seizures, coma

hyponatremia nursing interventions

Monitor fluid loss/gains Assess GI/neuro symptoms Administer isotonic sodium-containing solutions Encourage oral intake Seizure precautions Avoid “free water”

hypernatremia s/s

Thirst, dry mucous membranes, disorientation, hallucinations, lethargy, irritability, seizures, coma

hypernatremia nursing interventions

Monitor fluid loss/gain Restrict dietary sodium Assess neurologic status Administer sufficient water Administer IV fluids without sodium

hypokalemia s/s

Fatigue, N/V, muscle weakness, cardiac arrhythmias, nocturia, postural hypotension, paresthesia or muscle tenderness

hypokalemia nursing interventions

potassium chloride IV a diet high in potassium: beans, bran, squash

hyperkalemia s/s

Muscle weakness, cardiac arrhythmias, paresthesias of face, tongue, feet, and hands, GI symptoms (nausea, colic, diarrhea)

hyperkalemia nursing interventions

Decrease intake (PO and IV) Increase potassium excretion (medications) Life-threatening

hypocalcemia s/s

Trousseau’s and Chvostek’s signs, numbness and tingling of fingers/toes, mental changes, seizures, laryngeal muscle spasms, ECG changes, extremity muscle cramps

hypocalcemia nursing interventions

Diet: milk, yogurt, cheese IV calcium gluconate

hypercalcemia s/s

Muscle weakness, tiredness, constipation, N&V, renal stones, cardiac arrest, neuro changes

hypercalcemia nursing interventions

Increase mobilization Increase oral fluids Fluids for renal stones Medications if severe Dialysis if severe

hypomagnesemia s/s

Neuromuscular irritability, increased reflexes, seizures, tachyarrhythmia, mental changes

hypomagnesemia nursing interventions

Oral supplements dietary intake IV if severe Seizure precautions LOC

hypermagnesemia s/s

Flushing of skin, hypotension, depressed RR, drowsiness, hypoactive reflexes, and muscle weakness

hypermagnesemia nursing interventions

Interventions: Stop and limit dietary intake and Mg containing drugs Assess neuro, BP, RR Prevention

hypertonic

h2o out of cells raisin blood cells

hypotonic

h2o swells cells too firm of a grape kind of cell

what to assess during fluid imbalance

What do you want to measure? Daily weights Intake and output What body systems do we want to assess? How? CV Respiratory Skin

what should be restricted for a client with end-stage renal disease?

sodium fluids

s/s fluid volume overload?

Crackles in the lungs 3+ edema in extremities

AV dialysis fistula

A connection between an artery and vein that ensures increased blood flow for dialysis

what is a lithotripsy procedure

non-invasive procedure to break up kidney stones

types of lithotripsy procedures

Ultrasound Laser Extracorporeal shock wave

Peritoneal dialysis

done nightly at home

A client comes to the emergency department with a potassium of 6.0. Which of the following are possible interventions to anticipate? Place on cardiac monitor Educate client on consuming green leafy vegetables Assess for Chvostek's sign Prepare client for dialysis

Place on cardiac monitor Prepare client for dialysis

risks during peritoneal dialysis

hernias

symptoms of hypoglycemia

sweating blurred vision confusion

diabetic ketoacidosis s/s

thirst fruity breath Kussmaul respirations

Which of the following blood gases would be expected from a client in diabetic ketoacidosis (DKA)? pH 7.48, PaCO2 42, HCO3 30, O2 88 pH 7.28, PaCO2 38, HCO3 18, O2 88 pH 7.30, PaCO2 55, HCO3 26, O2 88 pH 7.50, PaCO2 30, HCO3 24, O2 8

pH 7.28, PaCO2 38, HCO3 18, O2 88

what is the only type of insulin that can be administered intravenously.

insulin regular

A nurse is counseling a patient with type 2 diabetes mellitus about nutritional therapy. Which dietary recommendation best aligns with the principles of managing blood glucose levels in this patient? Consuming simple sugars when experiencing hypoglycemia for rapid energy restoration. Increasing saturated fat intake to promote satiety and reduce carbohydrate cravings. Eliminating all fruits due to their natural sugar content to maintain blood sugar control Choosing whole grains, vegetables, and lean proteins as part of a balanced diet.

Choosing whole grains, vegetables, and lean proteins as part of a balanced diet.

Which of the following should be included in client teaching for administration of insulin? Sites include the abdomen, arm, and thigh Insulin should be stored in the fridge until opened Roll insulin lispro in hands before administering Administer at a 60 degree angle for smaller patients

Sites include the abdomen, arm, and thigh Insulin should be stored in the fridge until opene

With diabetic ketoacidosis (DKA), the client typically presents with higher blood glucoses than hyperglycemia hyperosmolar state (HHS): true or false

false

dawn phenomenon

A condition where morning hyperglycemia is caused by the natural release of growth hormone and cortisol in the early morning hours.

cor pulmonale

Cor pulmonale occurs due to the high pressure in the pulmonary vessels, causing the heart to work harder leading to right-sided heart failure.

The nurse is caring for a client with a cor pulmonale due to COPD. Which of the following are priority assessment techniques?

capillary refill auscultation of the heart auscultation of the lungs

diagnostic studies for COPD?

spirometry 6 minute walk test

appropriate amount of hydration for a client with pneumonia?

2500 ml/day

exercise that would help a pt. wit pneumonia

A hand patting technique used to help clear mucus from the airways

how are telemetry leads attached?

White on the right Smoke over fire Brown- chocolate to the heart green is last one left (bottom right)

how to read an EKG

every 5 squares = 1 second

right-sided heart failure

JVD dependant edema ascites portal hypertension

left-sided heart failure

dyspnea/cough crackles S3 heart sound decreased perfussion

cardiomyopathy

Dyspnea, fatigue, angina, syncope (LOC), dysrhythmias, S3/S4

clinical manifestations of cardiomyopathy

anorexia S3/S4 Hepatomegaly

femoral-popliteal bypass surgery

treat blockages in the arteries of the lower extremities by providing collateral blood flow

diagnostic studies to diagnose a deep vein thrombosis

D-dimer fibrin monomer complex venous duplex ultrasound

hypertensive crisis priority interventions

obtain base vitals continuous BP monitoring assess Heart and chest sounds IV insertion Administer IV antihypertensives

4 stages of a seizure

prodromal aural ictal postictal

Which foods are best for a client with iron deficiency anemia?

chicken whole grains kale

You are caring for a client with a port. Which of the following are the best ways to best prevent infection? Hand hygiene Ensuring only you wear a mask when changing the dressing Change the dressing everyday Scrub each clave/hub for at least 15 seconds Ensure the client bathes each day

Hand hygiene Scrub each clave/hub for at least 15 seconds Ensure the client bathes each day

Which of the following lab values would decrease in a plastic anemia client?

hemoglobin platelet count WBC count

Thalassemia minor may go unrecognized or undetected because it only causes mild to moderate anemia: true or false

true

A client is undergoing chemotherapy and was identified at risk for tumor lysis syndrome. Which of the following actions is appropriate for the nurse to take? Restrict fluid intake to 1500mL/day Ensure the client remains on bedrest. Administer IV fluids prior to treatment Hold chemotherapy until lab values return to normal limits

Administer IV fluids prior to treatment

muffled heart sounds, low bp, and distention of jugular veins =

cardiac tamponade

Adult 1 Finale Flashcards

(87 cards)