ATI Flashcards
1
Q
What is the definition of electrolytes?
A
Minerals in the body able to conduct electrical charges.
2
Q
What are electrolytes?
A
K+
NA+
Calcium
Magnesium
3
Q
T/F: are electrolytes necessary to sustain life?
A
True
4
Q
How can you evaluate electrolytes?
A
BMP (basic metabolic panel)
CMP (complete metabolic panel)
5
Q
What is BUN?
A
Blood urea nitrogen
6
Q
What is the indication for BUN?
A
Kidney function
7
Q
What is CO2?
A
Carbon dioxide
8
Q
What is the indication for checking CO2?
A
Blood bicarbonate level
Hint: mrs. CO needs to check her BBL
9
Q
What is CR?
A
Creatinine
10
Q
What is the indication for checking creatinine?
A
Kidney function
11
Q
What is glucose?
A
Blood sugar
12
Q
What is CL—?
A
Chloride
13
Q
What is K+?
A
Potassium
14
Q
What is NA+?
A
Sodium
15
Q
What is CA+?
A
Calcium
16
Q
What is the indication for checking CA+?
A
Liver function
17
Q
What are electrolytes responsible for?
A
Water balance
pH Balance
Moving nutrients
Removing wastes
Maintain function of:
muscle
heart
nerve
brain
18
Q
What is 2/3 of a persons weight?
A
Water
19
Q
Water balance prevents?
A
Hypovolemia (low blood volume from blood/fluid loss)
Dehydration
Tachycardia
Tachypnea
Confusion
Headache
Kidney stones
20
Q
Where does water loss occur?
A
Kidneys
21
Q
What is the definition of homeostasis?
A
State of equilibrium
22
Q
How do you measure homeostasis?
A
Serum osmolality (measurement of solutes w/in a solution)
23
Q
What does serum osmolality indicate?
A
Status of body fluids
24
Q
What is the expected range of serum osmolality?
A
285-295
25
What does urine osmolality indicate?
Determining renal function and osmolality
26
What is the expected range for urine osmolality?
50-1,200
27
What is the intracellular space?
Space inside cells
Hints:
The largest fluid compartment
Holds 67% of body’s water
28
What is the extracellular space?
Space outside of cells
Hints:
The other 2 fluid compartments
Comprised of the interstitial space (25% body’s water) & the intravascular space (8% of body’s water)
29
What is osmosis?
Movement of water through a semipermeable membrane
30
Does osmosis move to a higher or lower concentration?
Lower concentration
31
What is one homeostatic mechanism the body uses to maintain homeostasis?
Thirst response
32
What part of the brain determines thirst response?
Lamina terminalis (edge of hypothalamus; senses water balance by osmolality in brain ventricles)
33
What does the thirst response do?
Promotes drinking water
34
What another homeostatic mechanism?
Increase in serum osmolality causes the hypothalamus to stimulate the posterior pituitary to release ADH
35
What is ADH?
Antidiuretic hormone (maintains BP & fluid volume)
AKA vasopressin
36
How does the ADH interact in the kidneys
Collects in the ducts of the nephrons, increasing water absorption, decreasing urine excretion, increasing fluid volume
37
What is the last homeostatic mechanism?
Osmosis, allows passive water flow to maintain equilibrium
Hint: maintains homeOstasis
38
What is the expected range for K+?
3.5-5
39
What is the expected range for NA+?
135-145
40
What is the expected range for Calcium?
9-10.5
Hint: I see CA 9-10.5 over there!
41
What is the expected range for magnesium?
1.3-2.1
Hint:
Magne sees yUM apples for only 1.3- 2.1 dollars
42
What is diffusion?
Movement of solutes from high to low concentration
43
What is active transport?
Movement of electrolytes/molecules across cell membrane w/ energy use in the form of enzymes
44
T/F: diffusion uses energy in the movement of solutes in and out of a cell.
False.
45
What is the largest intracellular electrolyte?
K+
Hint:
My cells need big P
(I’m sorry mom, I can’t un-remember that now)
46
What is the function of K+?
For nerve/muscle function
Especially heart
47
What is the recommended mg intake of K+?
3,400 mg (M)
2,600 mg (F)
48
What is organ is responsible for 90% of K+ excretion?
Kidneys
49
How is the remaining 10% of K+ excreted?
Sweating & digestive tract
50
What is hypoKalemia?
K+ below 3.5
51
What meds are most common cause of hypokalemia?
Potassium wasting diuretics
(Loop, thiazide, osmotic)
52
What other meds have the potential to result in K+ loss?
Amphotericin B, high doses penicillin, theophylline
53
What are diuretics?
Cause increased urination
54
What are common manifestations of hypokalemia?
Muscle weakness
Cardiac arrhythmias
Constipation
Fatigue
55
What are life threatening signs of hypokalemia?
Respiratory paralysis
Paralytic ileus
Hypotension
Tetany
Rhabdomyolysis
Life threading cardiac arrhythmias
56
What might be ordered by the provider to determine K+ levels affect on the heart?
ECG
57
What are potassium-sparing diuretics?
Meds promoting urination while retaining K+
58
What are foods high in K+?
Baked potatoes
Prune juice
Carrot juice
White beans
Plain non-fat yogurt
Sweet potato
Salmon
Banana
Spinach
Avocado
59
What is hyperkalemia?
High K+ levels
60
What is the most common cause of hyperkalemia?
Renal failure
61
What are the meds that mostly cause hyperkalemia?
Potassium-sparing diuretics
NSAIDs
ACE inhibitors
62
What are common manifestations of hyperkalemia?
Nausea/vomiting
Muscle aches/weakness
Decreased deep tendon reflexes
Paralysis
Dysrhythmias/palpations
63
What are life threatening signs of hyperkalemia?
Paralysis
Heart failure
64
How is K+ removed from the blood?
Hemodialysis fr renal failure
Calcium gluconate
Diuretics
Resin meds (removes K+ through BM)
65
What is hypoglycemia?
Blood glucose less then 74
66
What is the most common extracellular electrolyte?
NA+
67
What does NA+ do?
Support nerve/muscle function, maintain normal BP, regulate fluid balance
68
What is hyponatremia?
NA+ below 136
69
What is the most common cause of hyponatremia?
Loss of body water
70
What are foods high in NA+?
Roasted ham
Fresh/frozen shrimp
Frozen pizza
Canned soup
Veggie juice
Cottage cheese
Instant/regular vanilla pudding
71
What is the most abundant mineral in the body?
Calcium, 99% stored in bones & teeth
72
What is the role of calcium?
Bone mineralization, muscle contraction, nerve transmission, blood clotting, hormone secretion, normal heart function
73
What does calcium absorption depend on?
Vitamin D
74
What is the daily intake needed for vitamin D?
600 IU for adults
800 IU for older adults
75
Where is calcium excreted?
Kidneys
76
What is calcium controlled by?
Parathyroid hormone
77
What is hypocalcemia?
Calcium levels below 9
78
What is hypoparathyroidism?
Low PTH levels
79
T/F: can decreased estrogen production inhibit calcium absorption?
True
80
What is osteopenia?
Low bone mass
81
What are the 2 signs to check for hypocalcemia?
Chvostek sign:
+ = twitching when tapped
Trousseau sign:
+ = carpopedal spasm w/ BP (contraction of wrist and hand)
82
What is the ionized calcium levels?
Circulating calcium not attached to proteins
83
What are foods high in calcium?
American cheese
Parm
Plain yogurt
Almond milk
OJ
Soy milk
Low fat milk
Cheddar cheese
Whole milk chocolate
Whole milk
84
What is hypercalcemia?
Calcium higher then 10.5
85
What is the mnemonic for hypercalcemia?
Abdominal Moans
Painful bones
Kidney stones
Groans
& neurologic overtones
86
What is the 2nd most common intracellular electrolytes?
Magnesium
87
What does magnesium do?
Regulate nerve/muscle function, BP, glucose levels, making DNA, protein, & bone
88
What is the recommended daily intake for magnesium?
400-420 mg (M)
310-320 mg (F)
89
What are foods high in magnesium?
Cooked spinach
Pumpkin seeds
Black beans
Cooked soybeans
Cashews
Dark chocolate
Avocados
Tofu
Salmon
Banana
90
What is half life?
Amount of time is takes 50% of drug to be excreted
91
What is hypervolemia?
Fluid overload (too much water)
92
What is apoptosis?
Cellular destruction
93
What does urine specific gravity?
Test that measures of fluid balance from urine sample
94
what is fluid volume deficit?
Condition caused by water loss
AKA hypovolemia
95
What is third spacing?
Movement of fluid from intravascular space (w/in veins) to interstitial space
96
What is hypovolemic shock?
Body 1/5 (20%) of blood supply
97
What is creatinine?
Reflection of renal function
Byproduct of skeletal muscle contractions
Excreted through urine
98
What is hemoglobin?
RBC component that carries O2 & CO2 to/from cell
99
What is a colloidal solution?
IV solution containing large molecules unable to pass through capillary membranes
100
What is a hypotonic solution?
Has fewer solutes than cell components & results in fluid moving into cell
101
What is an isotonic solution?
Same # of solutes than cell components & results in no fluid movement into cells
102
What is a hypertonic solution?
Has more solutes than are present w/in the cell & results in fluid movement out of cell
103
What is a tonicity solution?
Ability to make water move in/out of cells; includes isotonic, hypotonic, hypertonic solutions
104
What is flow rate?
IV fluid infusion rate
105
What is whole blood?
Combo of RBCs, WBCs, & platelets in plasma
106
What do RBCs contain?
Contains hemoglobin; responsible for O2/CO2 transport in body
107
What does hematocrit measure?
RBCs in total blood volume
108
What are the expected values of a CBC?
RBC= 4.7-6.1 (M), 4.2-5.4 (F)
Hemoglobin= 14-18 (M), 12-16 (F)
Hematocrit= 42-52% (M), 37-47% (F)
WBC= 5,000-10,000 (M & F)
Platelet=150,000-400,000 (M & F)
109
What are granulocytes?
Type of WBC responsible for immune response during infections/allergic reactions
Compromised of:
Neutrophils
Eosinophils
Basophils
110
What is plasma?
Straw colored liquid portion of blood containing water, proteins, salt, & antibodies
111
What is fractionation?
Removing components of plasma use
112
What are antigens?
Trigger immune response
113
What is the universal blood donor?
O-
114
what is the universal blood recipient?
AB+
115
What is peripheral IV catheter?
Single lumen plastic cannulas inserted into a peripheral vein
AKA peripheral IV
116
What is CVADs? (Central venous access devices)
Device inserted into body via central vein
Ex: subclavian/jugular
117
What are PICCs?
Peripherally inserted central catheters; inserted through vein, w/ tip centrally located
118
What is heparin?
Anticoagulant agent
119
What os phlebitis?
Vein inflammation
120
What is vesicants?
IV fluid that damages surrounding tissue outside of vein
121
What is infusate?
Solution infused through IV access
122
What is circulatory overload?
IV therapy complication; too much fluid too fast
123
What is Infiltration?
Inadvertent admin of fluid into tissue surrounding IV due to displacement of catheter tip
124
What is extravasation?
Inadvertent admin of vesicant fluid into tissue surrounding IV cannula
125
What is an air embolism?
Vessel obstruction by air
126
What is scope of practice?
Services/activities licensed professionals are competent to perform
127
What is acid-base balance?
Homeostasis of acidic & alkaline compounds in blood to maintain pH
128
What test is used to measure acid-base balance?
ABG (arterial blood gas)
129
What are the expected ranges for an ABG?
Ph= 7.35-7.45
PaCO2= 35-45
HCO3= 21-28
PaO2= 80-100
O2 sat= 95-100
130
What is acidosis?
Acid in blood are too high
Ph is less than 7.35
131
What is alkalosis?
Blood is too alkaline
Ph is greater than 7.45
132
What is metabolic acidosis?
Blood is too acidic
HCO3= less than 21
Ph= less than 7.35
133
What is metabolic alkalosis?
Blood is too alkaline
HCO3= greater than 28
Ph= greater than 7.45
134
What is respiratory acidosis?
Buildup of CO2 in the lungs & fluids
CO2= greater than 45
Ph= less than 7.35
135
What is respiratory alkalosis?
Low CO2 levels
CO2= less than 35
Ph= greater than 7.45
136
What is hyperventilation?
Increased breathing leading to excessive CO2 loss
137
How long should you admin packed RBCs to a pt w/ HF?
4 hrs; admin slowly to avoid cardiac overload
138
Reviewing ABG values is part of what stage if the nursing process?
Evaluation
139
By the 2nd post op day, a pt hasn’t achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to nursing process?
A. Reassess pt to determine the reasons for inadequate pain relief
B. Wait to see whether pain lessens during next 24 hrs
C. Change plan of care to provide different pain relief intervention
D. Teach pt about plan of care for managing pain
C.
Rationale: collect more data to determine any interference w/ discomfort
; determine why others failed
140
A charge nurse is observing a newly licensed nurse care for a pt reporting pain. Nurse has checked MAR & noted last dose of pain med was 6 hrs ago. Prescription reads every 4 hrs PRN for pain. Nurse administered med & checked w/ pt 40 min later, when pt reported improvement. Newly licensed nurse left out which of the following nursing process steps?
A. Assessment
B. Planning
C. Intervention
D. Evaluation
A.
Rationale: ask about pain severity (pain scale)
141
A charge nurse is reviewing the steps of the nursing process w/ a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply)
A. RR= 22/min w/ even, unlabored RR
B. Client’s partner states “they said they hurt after walking 10 mins”
C. Pts pain rating is 3 out of 10
D. Pts skin is pink, warm, dry
E. AP reports pt walks w/ limp
A, D, E.
Rationale:
Objective= measurable, observable, medically shareable
142
A charge nurse is talking w/ newly licensed nurse & is reviewing nursing interventions that don’t require s provider’s prescription. Which of the following interventions should the charge nurse include? (Select all that apply)
A. Writing prescription for morphine sulfate as needed for pain
B. Inserting NG tube to relieve gastric distention
C. Showing pt how to use progressive muscle relaxation
D. Performing daily bath after the evening meal
E. Repositioning a client every 2 hrs to reduce risk of pressure injury
C, D, E.
Rationale: showing how to use = nursing intervention; bath= normal nursing procedure; repositioning= nursing intervention
143
A nurse is discussing process w/ newly licensed nurse. Which of the following statements by new nurse should nurse identify as appropriate for planning steps of nursing process?
A. “I will determine most important pt problems we need to address”
B. “I will review past medical Hx on pt record to get more info”
C. “I will carry out new prescriptions from provider”
D. “I will ask pt if their nausea has resolved”
A.
Rationale: prioritize pr problems during planning steps
144
A nurse is caring for a pt who is 24 hr post op following hernia repair. Pt is tolerating clear liquids, has active BM sounds, and expressing desire for “real food.” Nurse tells pt “I will call surgeon and ask for diet change.” The surgeon hears the nurse’s report & prescribes full liquid diet. Nurse used which of the following levels of critical thinking?
A. Basic
B. Commitment
C. Complex
D. Integrity
A.
Rationale: thinking is concrete & rule based
145
Nurse receives a prescription for anti obit of for pt who has cellulitis. Nurse checks clients medical record, discovers allergy to antibiotic, & calls provider to request prescription for different antibiotics. Which of the following critical thinking attitudes did the demonstrate?
A. Fairness
B. Responsibility
C. Risk taking
D. Creativity
B.
Rationale: part of standards of practice; TRAMP
146
A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should nurse take? (Select all that apply)
A. Find mentor
B. Use journal to write outcomes of clinical judgment
C. Review articles about EBP
D. Limit consultations w/ other professionals involved in care
E. Make quick decisions when unsure about pt needs
A, B, C.
Rationale:
Learn from experienced peers
Journaling helps w/ reflections/improve critical thinking
New info= new knowledge
147
A nurse is caring for a client who has a new prescription for anti-HTN med. Prior to admin, nurse uses an electronic database to gather info about med & effects it may have. Which components of critical thinking is the nurse using when reviewing med info?
A. Knowledge
B. Experience
C. Intuition
D. Competence
A.
Rationale: taking initiative to gain more knowledge (1st of critical thinking process)
148
A nurse uses a head-to-toe approach to conduct a physical assessment to a client who will undergo surgery following week. Which of the following critical thinking attitudes did nurse demonstrate?
A. Confidence
B. Perseverance
C. Integrity
D. Discipline
D.
Rationale: use systemic thinking ; thorough & calculated info gathering
149
What is the PASS sequence for a fire?
P= pull
A= aim
S= squeeze
S= sweep
150
A nurse is caring for a client who fell at a nursing home. The pt is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply)
A. Place belt restraint on the pt when they’re sitting on beside commode
B. Keep the bed in it’s lowest position w/side rails up
C. Make sure pt call light is in reach
D. Provide pt w/ no skid footwear
E. Complete fall risk assessment
C, D, E.
Rationale:
Fast contact of fall happens
No slipping
Basis for care plan
151
A nurse manager is reviewing w/ nurse on the unit in the care of pt who has had a seizure. Which of the following statements by a nurse requires further instruction?
A. “I will place client on their side”
B. “I will go to the the nurses station for assistance”
C. “I will note the time that the seizure begins”
D. “I will prepare to insert an airway”
B.
Rationale: never leave PT
152
Nurse observes smoke coming from under the door of the staff’s lounge. Which of the following actions is the nurse’s priority?
A. Extinguish fire
B. Activate alarm
C. Move nearby clients
D. Close all open doors on unit
C.
Rationale: greatest pt risk
153
A nurse is caring for a client who has fall HX. Which of the following actions is nurses’ priority?
A. Complete fall risk assessment
B. Educate client/family about fall risks
C. Eliminate safety hazards from clients environment
D. Make sure pt uses assistive aids in their possession
A.
Rationale: 1st action in nursing process
154
Nurse discovers small trash can fire in pt bano. Pt is moved to safety & alarm is pulled. Which following action should the nurse take?
A. Open windows to pts room to allow smoke to escape
B. Obtain class C fire extinguisher to extinguish fire
C. Remove all electrical equipment from room
D. Place wet towels alone door base of clients room
D.
Rationale: contained smoke/fire to room
155
Nurse is providing discharge instructions to a pt who has prescription of O2 use at home. Which of the following info should nurse include? (Select all that apply)
A. Family who smoke must be at least 10 ft away from O2 I use
B. Nail polish shouldn’t be near pt getting O2
C. No smoking sign should be on tank
D. Cotton bedding / clothes should be replaced w/ wool
E. Fire extinguisher needs to be close
A, C, E.
Rationale:
Remind not to use nail polish in home, or other flammables
No smoking signs everywhere
Fire extinguisher is important in case of fire
156
Nurse educator is presenting a module on basic first aid for new HHA nurses. Pt who has heat stroke will have which of the following?
A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea
A.
Rationale: manifestation of heat stroke
157
A nurse educator is conducting a parenting class for new guardians/parents of infants. Which of the following statements made by a participant indicates understanding?
A. “I will set my water heater at 130 degrees”
B. “Once my baby can sit up, they will be safe in the bathtub”
C. “I will place my baby on their stomach to sleep”
D. “Once my infant starts to push up, I will remove the mobile from over the crib”
D.
Rationale: guardian/parent should remove crib toys from over crib to infant can’t pull themselves up with them
158
A HHA nurse is discussing the dangers of carbon monoxide poisoning w/a client. Which of the following info should the nurse include?
A. Carbon monoxide has distinct odor
B. Water heaters should be inspected every 5 years
C. Lungs are damaged from carbon monoxide inhalation
D. Carbon monoxide binds w/ hemoglobin
D.
Rationale: binds & reduces O2
159
A HHA nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include? (Select all that apply)
A. Most food poisoning is caused by a virus
B. Immunocompromised pts are at increased risk for food poisoning complications
C. At risk clients should only drink pasteurized dairy products
D. Healthy individuals usually recover from the illness in few weeks
E. Handling raw/fresh food separately can prevent food poisoning
B, C, E.
Rationale:
Very old/young, Immune compromised, pregnant= risk of complications w/ food poisoning
Should follow low-microbial diet
Avoids cross contamination
160
Nurse is caring for a pt who is receiving enteral tube feedings due to dysphagia. Which of the following actions is the nurse’s priority at a time?
A. Supine
B. Semi-Fowler
C. Semi-prone
D. Trendelenburg
B.
Rationale: prevents aspiration
161
A nurse is caring for a client who is sitting in a chair & asks to return to bed. Which of the following actions is the nurse’s priority at this time?
A. Obtain walker for pt to use to transfer into bed
B. Call for additional staff to assist w/ the transfer
C. Use a transfer belt & assist
D. Determine the pts ability to help w/ transfer
D.
Rationale: 1st action to take
162
A nurse is instructing pt w/ COPD about using the orthopneic position to relieve SOB. Which of the following statements should the nurse make?
A. “Lie on your back w/ your head/shoulders supported by a pillow”
B. “Have your head turned to the side while you lie on your stomach”
C. “Have a table beside your bed so you can sit on the bedside & rest your arms on table”
D. “Lie on your side with your top arm resting on bed and your weight on your hip”
C.
Rationale: position allows chest wall expansion for better breathing
163
Nurse manager is reviewing guidelines for preventing injury w/ staff nurses. Which of the following instructions should the nurse manger include? (Select all that apply)
A. Request assistance when repositioning
B. Avoid twisting your spine or bending at the waist
C. Use smooth movements when lifting and moving pts
D. Keep knees slightly lower than your hips when sitting for long time
E. Take a break from repetitive movements every 2-3 hrs to flex and stretch the joint muscles
A, B, D.
Rationale:
Reduces injury risk
Increases base support
Keeps center of gravity
164
A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should nurse identify as an indication that an attendee understands the teaching? (Select all that apply)
A. “My line of gravity should fall outside my base of support”
B. The lower my center of gravity, the more stability I have”
C. “To broaden my base of support, I should spread my feet apart”
D. “When I lift sun object, I should hold it as close to my body as possible”
E. “When pulling an object, I should move my front foot Forward”
B, C, D.
Rationale:
Closer to the ground= low sense of gravity
Wide base= more support
Avoids off putting center of gravity
165
Nurse provides introduction to client as the 1st step of a comprehensive physical examination. Which of the following strategies should the nurse use with the client? (Select all that apply)
A. Address client w/ appropriate title & their last name
B. Use a mix of open and close ended questions
C. Reduce environmental noise
D. Have pt complete a printed Hx form
E. Perform general survey before exam
B, C, E.
Rationale:
Open ended= help tell story
Closed= clarify & verify
Quite/comfy helps focus
General surgery= noninvasive
166
Nurse in providers office is documenting finding following an examination performed for a new pt. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply)
A. Posture
B. Skin lesions
C. Speech
D. Allergies
E. Immunization status
A, B, C.
Rationale:
Posture= general appearance/structure; part of general survey
Skin= part of General survey
Speech= part of behavior
167
A nurse is collecting data for a pt’s comprehensive physical examination. After inspecting the client’s abdomen, which of the following skilled of the physical examination process should nurse perform next?
A. Olfaction
B. Auscultation
C. Palpation
D. Percussion
B.
Rationale: palpation/percussion alters sound
168
Nurse is preparing to perform a comprehensive physical examination of an older adult pt. Which of the following interventions should the nurse use in consideration of pt’s age? (Select all that apply)
A. Expect the session to be shorter than for a younger pt
B. Plan to allow plenty of time for position change
C. Make sure the pt has any essential sensory aids in place
D. Tell the client to take their time answering questions
E. Invite client to use the bano before beginning the exam
B, C, D, E.
Rationale:
Have mobility issues, needs more time to move
Needs to hear to participate
Needs more thinking time
Courtesy
169
Nurse in a providers office is performing physical examination of adult pt. Which part of the hands should the nurse use during palpation for optimal assessment of skin temp?
A. Palmar surface
B. Fingertips
C. Dorsal surface
D. Base of fingers
C.
Rationale: most sensitive to temp
170
A nurse is caring for a pt in the emergency department who has an oral body temp of 38.3 C (101 F), PR is 114/min, and RR of 22/min. Client is restless w/ warm skin. Which of the following interventions should the nurse take? (Select all that apply)
A. Obtain culture and specimens before initiating antimicrobials
B. Restrict pts oral fluid intake
C. Encourage pt to rest and limit activity
D. Allow pt to shiver to dispel excess heat
E. Assist pt w/ oral hygiene frequently
A, C, E.
Rationale:
Identify infection before meds
Rest conserves energy
Prevents dry mucous membranes
171
Nurse is instructing an AP about caring for a pt who has low platelet count. Which of the following instructions is the priority for measuring VS for this pt?
A. “Do not measure pt’s temp rectally”
B. “Count radial pulse for 30 secs and x by 2”
C. Do not let pt know you are counting RR
D. “Let pt rest 5 mins before you measure BP”
A.
Rationale: most important risk for low platelets for bleeding reasons
172
Nurse is instructing group of AP in measuring RR. Which of the following guidelines should nurse include? (Select all that apply?
A. Place pt in semi-Fowlers position
B. Have pt rest arm across abdomen
C. Observe one full respiratory cycle before counting rate
D. Count the rate for 30 secs irregular
E. Count and report any sighs the pt demonstrates
A, B, C.
Rationale:
Sitting up creates full ventilation
Easy to count respirations
Obtains more accurate count
173
A nurse is measuring BP for a pt who fractured their femur. BP is reading 140/94 mm Hg, and the pt denies any Hx of HTN. Which of the following actions should the nurse take?
A. Request a prescription for an anti hypertension med
B. Ask pt if they’re having any pain
C. Request s prescription for an anti anxiety med
D. Return in 30 min to recheck pts BP
B.
Rationale: 1st action needing to be taken in nursing process
174
A nurse is performing an admission assessment on a pt. Nurse determines pt radial PR is 68/min and the simultaneous apical pulse rate is 84/ a minute. What is the clients pulse deficit?
16/min
Rationale: pulse deficit= apical - radial= PD
175
What should you teach to female pts about self examines?
Best to palpate in shower
Pregnant/postmenopausal= same time every day
Best time for everyone else is 4-7 days after period or directly at end
176
What should the nurse document after doing a patients breast examination and finding a nodule on the left breast?
Location
Size (cm)
Shape
Consistency (soft, firm, or hand)
Discreetness (well-defined border mass)
Tenderness
Erythema
Dimpling/ retraction over mass
Lymphadenopathy
Mobility
177
What position should the nurse place the patient for assessing the posterior thorax?
Sitting or standing
178
How do you position the client when assessing the anterior thorax?
Sitting, lying, or standing
179
What are the vertical chest land marks?
Midsternal line: through center of sternum
Midclavicular line: through midpoint of clavicle
Anterior auxiliary line: through anterior axillary fold
Midaxillary line: apex of the axillae
Posterior axillary line: through posterior axillary line
Right/Left scapular line: through interior angle of scapula
Vertebral line: along center of spine
180
What are the percussion & auscultation sites?
Posterior thorax: sites between scapula & vertebrae on upper portion of back; below the scapula sites are along right & left scapular lines
Anterior thorax: along midclavicular lines bilaterally in lower portions of chest wall on both sides of sternum
Observe accessory muscle use
181
What are the expected lung sounds?
Bronchial: loud, high-pitched, hollow; expiration is longer than inspiration
Bronchovesicular: medium pitch, blowing sound, intense w/ = inspiration/expiration
Vesicular: soft, low-pitched, breezy sounds, inspiration 3x longer than expirations
182
What are adventitious/abnormal lung sounds?
Crackles/rales:
fine, coarse, bubbly
Not cleared w/ cough
Wheezes:
High-pitched whistling , musical sound
Rhonchi:
Coarse, loud, low-pitched rumbling
Pleural friction rub: dry, grating/rubbing sounds
Absence:
Nothing
183
What are the 2 unexpected findings when percussion is performed on a patient that are significant?
Dullness: fluid or solid tissue (indicate pneumonia/tumor)
Hyperresonance: presence of air (indicate pneumothorax/emphysema)
184
What is the blood flow to make the S1 sound (the lub)?
Closure of the mitral & tricuspid valves signaling contraction
185
What is t he passage of blow to makes the S2 sound (dub)?
Closure of the aortic & pulmonic valves signaling the start of relaxation
186
What does the S3 sound indicate?
Rapid ventricular refill
187
What does the S4 indicate?
Strong atrial contraction
188
What is a dysrhythmias?
Heart fails to beat regularly
189
What is another name for S3?
Ventricular gallop
190
What are gallops?
Extra heart sounds
191
What is ventricular gallop?
Occurs after S2
Sound: Ken-tuck’-y
192
What is atrial gallop?
Occurs before S1
Sound: ten-es-see
193
What are murmurs?
Heard when blood volume is high or flow is blocked/altered
Sounds: blowing & swishing
194
When does systolic murmurs occur?
After S1
195
When does diastolic murmurs occur?
After S2
196
What are thrills?
Palpable vibrations following murmurs or malformation
197
What is Bruits?
Blowing/swishing sound
Indication: obstructed peripheral blood flow
198
What does pulse and BP reflect?
Cardiovascular status
199
What are the locations to check for Bruits?
Carotid
Abdominal aorta
Renal arteries
Iliac arteries
Femoral arteries
200
What should the nurse asses the skin for?
Lesions
Scars
Silver striae/stretch marks
Dilated veins
Jaundice
Cyanosis
Ascites (fluid collection in the abdomen)
201
What are the shapes & contours of the abdomen?
Flat
Concave (sunken)
Distended (large protrusion)
202
What are the type of distentions an abdomen can have?
Fat: rolls along both sides; not taut
Fluid: flanks protrude when turning; protrusion changes sides with movement
Flatus: protrusion is mainly midline; no flank change
Hernias: protrusion through abdominal muscle; wall visible
203
What are the types of abdominal wall movements?
Peristalsis: wave movements
Pulsations: regular beats of movement midline above belly button
204
What are some unexpected bowel sounds?
Loud growling
Hyperactive sounds
Indication: increased GI motility
Causes: diarrhea, anxiety, bowel inflammation
Food reactions
205
A nurse in a provider’s office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect?
A. Smaller nipples
B. Less adipose tissue
C. Nipple discharge
D. More pendulous
E. Nipple inversion
A, D, E.
Rationale:
nipples get smaller/flatter when old
Become softer/ pendulous (loosely hanging down)
Inversion is common in older people
206
A nurse in a providers office is preparing to auscultate & percuss clients thorax as a part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply)
A. Rhonchi
B. Crackles
C. Resonance
D. Tactile fremitus
E. Bronchovesicular sounds
C, E.
Rationale:
Expected percussion sound
Expected breath sound
207
During an abdominal examination, nurse in a providers office determines that a client has abdominal distention. The protrusion is midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?
A. Fat
B. Fluid
C. Flatus
D. Hernias
C.
Rationale: flatus= protrusion mainly midline w/ no flank changing
208
During a cardiovascular examination, a nurse in a providers office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply)
A. Ventricular gallop
B. Closure of mitral valve
C. Closure of the pulmonic valve
D. Apical heart rate
E. Murmur
B, D.
Rationale:
5th intercostal is over mitral valve when it closes
Apical HR is over 5th intercostal
209
A nurse in a providers office preparing to auscultate & percuss a clients abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply)
A. Tympany
B. High-pitched clicks
C. Borborygmi
D. Friction rubs
E. Bruits
A, B.
Rationale:
Tympany= drumlike sound; normal
BM sounds= high pitched clicks & gurgles
210
What is bronchoconstriction?
Smooth muscle contraction causing the bronchus to tighten
211
What is the bronchodilation?
Airway expansion in the bronchus
212
What is the pleural cavity?
Space between the visceral and parietal layers of lungs
213
What is the pleura?
Protective layer of membrane covering the lungs
214
What is the inhalation/exhalation process aided by?
Diaphragm & intercostal muscles
215
What is the diaphragm?
The muscle that separates chest from abdominal wall
216
What is surfactant?
Lubricant made in lungs
217
What is the condition atelectasis?
Collapsing of lungs during expansion
Collapse of airways & small sections of the lungs as a result of shallow breathing
218
What is atelectasis commonly due to?
General anesthesia / opioids
219
What is ventilation?
Flow of air inside/outside the alveoli
220
Perfusion is…
Blood flow
221
What is lung compliance?
Lungs expand is response to pressure increase in the alveoli
222
What is inspiratory reserve volume?
Normal amount of air you breath in
223
What is tidal volume?
Volume of inspired/expired w/ each breath
224
What is residual volume?
Volume air in alveoli after expiration
225
What is the vital capacity?
Volume of air still in the lungs after max inspiration
226
What is vital capacity ?
Max air volume of air expelled after max inspirations
227
What is total lung capacity?
Volume of air remaining in lungs after max inspirations
228
What is the purpose of pulmonary circulation?
To move move blood from Heart capillaries to lungs for gas exchange & back
229
What happens in the heart during Diastole?
Mitral & tricuspid valves allow blood to flow to atria into ventricles
230
What happen in the heart during Systole?
Mitral 7 tricuspid valves closes & aortic / pulmonic valves open
231
What happens during S1?
Mitral / tricuspid valves open to allow blood flow into the ventricles/aorta/pulmonary artery
232
What is Cardiac Output (CO)?
Volume of blood ejected by heart ventricles in 1 minute
233
How is cardiac output (CO) calculated?
CO = HR x SV
234
What is stroke volume (SV)?
Volume of blood ejected from ventricles during contraction
Heart beat
235
What factors affect stroke volume?
Preload
Afterload
Contractility
236
What is an ostomy?
Surgically opening to the abdominal wall to allow for elimination of pee/poop
237
What is an ileostomy?
Surgical creation for external opening into ileum to bypass large intestines
238
What is an end colostomy?
Removal of damaged Bowels w/ working end then brought through to skins surface
(Permanent)
239
What is anastomosis?
Surgical connection between 2 structures
240
What a loop colostomy?
Bowel is brought to surface temporarily supported by plastic bridge/rod
241
What are double-barrel colostomy?
2 separate stoma creations; both ends of bowel brought to surface
242
What are the 4 locations for placing an colostomy in the abdomen?
Ascending Colon (right abdomen)- O/P: liquid/semi-liquid, very irritating to skin
Transverse colon (mid-abdomen)- location used for temporary ostomy, w/ stoma constructed as a loop
O/P: pasty
243
What is the Descending upper colon (left upper)?
O/P: semi-formed from more water absorption; poop stuff still in ascending/transverse colon
244
What is the sigmoid colon (left lower)?
Permanent colostomy; O/P: formed
245
What is an ileostomy?
Surgical opening into ileum to bypass large intestines; LOC: LRQ
246
What is a ureterostomy?
Both ureters are rerouted from kidneys to outside abdomen
247
When do you change the ostomy bag?
When it is 1/3-1/2 full
248
Following a urostomy, the nurse should monitor the patients output is at 30 ml per hour or more to prevent…
Hydronephrosis
249
What is hydronephrosis
Kidney enlargement from urine collecting in renal pelvis/ kidney tissue
