Exam 1: 462 & Patho Flashcards
1
Q
What is the most appropriate thing to do when interviewing an older adult
A
All assistive devices, such as glasses and hearing aids, should be in place when interviewing an older patient.
2
Q
Which assessment findings would alert the nurse to possible elder mistreatment
A
- Agitation
- Depression
- Weight Loss
- Hypernatremia
3
Q
What is the patient bill of rights for patient admin
A
- right for someone to review med history
- informed about meds
- receive drugs safely, not unecessarily
- refuse
- consent prior to investigation
4
Q
A 67-year-old woman who has a long-standing diagnosis of incontinence is in the habit of arriving 20 minutes early for church in order to ensure that she gets a seat near the end of a row and close to the exit so that she has ready access to the restroom. Which tasks of the chronically ill is the woman demonstrating
A
- Controlling symptoms
- Preventing & Managing Crisis
5
Q
A 70-year-old man has just been diagnosed with chronic obstructive pulmonary disease (COPD). At what point should the nurse begin to include the patient’s wife in the teaching around the management of the disease?
A
As soon as possible
6
Q
Which criterion must a 65-year-old person meet in order to qualify for Medicare funding?
A
Being entitled to Social Security benefits
7
Q
What is an LIP
A
Licensed Independent Practitioner
8
Q
Who is responsibile for med admin
A
- healthcare provider,
- pharmacy, (change make recommendations)
- nurse,(call provider)
- patient/family
9
Q
What are illnesses associated with aging
A
- Obesity
- diabetes
- hypertension
- cancer
10
Q
male patient has a history of hypertension and type 1 diabetes mellitus. Because of these chronic illnesses, the patient exercises and eats the healthy diet that his wife prepares for him. Which factors will most likely have a positive impact on his biologic aging
A
- exercise
- social support
- good nutrition
- coping resources
11
Q
This is a social, recreational, and health-related services in a safe, community-based environment that would keep this patient safe
A
Adult Day Care
12
Q
This is used when the patient has rapid deterioration, the caregiver is unable to continue to provide care, and there is an alteration in or loss of the family support system
A
Long Term Care
13
Q
This is used when there is supportive caregiver involvement for patients with health needs
A
Home Health Care
14
Q
Aging primarily affects the _________of drugs.
A
Metabolism
15
Q
What are 4 components of med admin
A
- An Order
- Transcription into Electronic Health Record
- Dispensing of the meds (pharmacy)
- Administration of the meds
16
Q
What must you do prior to administering a med for clarification?
A
- all orders with the prescriber before administering medications.
17
Q
1 tablespoon =
A
15 ML
18
Q
What can LIP do
A
- assess patient,
- prescribe meds
- verbal orders
19
Q
How can LIP prescribe med
A
computer, written, telephone (repeat back)
20
Q
When should you respond to verbal order
A
urgen situation, repeat back
21
Q
What does pharmacy do
A
- receive/review order
- asess/evaluate
- pt history
- prep distribute
- educate
22
Q
A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient’s ear when administering the medication?
A
upward and outward (greater than 3 yrs)
23
Q
Whos is responsible for med administration
A
nurse
24
Q
What is the nurse’s role x5
A
- med administer,
- provide education,
- assess patient,
- monitor
- document
25
A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, “I don’t remember my child having that medication before.” What is the nurse’s next action?
Withhold the medications and verify the medication orders
26
What are resources for researching medications
* med texts
* pharmacist
* package inserts
* computer (micromedex)
* DocuCare
27
What is something IOM reported due to med errors
be careful of **abbreviations**
28
when patients have home care needs or difficulty understanding their medications, what is the nursing responsibility?
* Collaborate with community resources
* Ensure that the home care agency is aware of medication and health teaching needs
29
What are the 7 Essential Elemens for Med Order
1. patient name
2. date ordered
3. name of the drug
4. dosage (amt, #)
5. route
6. frequency
7. Signature of LIP
30
What type of med orders can we receive x7
* *standard written*
* *PRN* (as needed)
* *STAT* order
* Now
* *One Time*
* *On Call* (awaiting a procedure as prep)
* *Standing orders and Protocols*
31
What does PO mean?
by mouth
32
How does a nurse determine appropriateness of medication
* assessment findings,
* subj, obj data,
* document reason/results of medication
33
How long should you respond to an order that says "now"
within the hour
34
What is a standing order used for
* to treat occurrences
* if patient meets certain criteria
* _pre-written_ protocols
35
The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse’s next best course of action?
Ask the prescriber to change the order
36
The nurse takes a medication to a patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurse’s next action?
Ask the patient’s reason for refusal
37
A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse:
Stops the administration of the medication and follows agency policy.
38
What Orders for medications can change
* health parameters
* surgery
* transfer between different services
* transfer to another hospital or facility
* ORDERS MUST BE REWRITTEN
39
Redness, warmth, and tenderness at the IV site are signs of
phlebitis.
40
What are the 6 rights of medication administration
1. Right *Patient*
2. Right *Med*
3. Right *Time* (30min window)
4. Right *Dosage*
5. Right *Route (*oral, respiratory, parenteral, topical, PO)
6. Right *Documentation*
41
A nurse accidently gives a patient a medication at the wrong time. The nurse’s first priority is to
Assess the patient for adverse effects
42
Assessment priorities x8
* health hx
* med history, review MAR
* allergies
* diet history
* lab values
* coordination problems
* current condition
* pregnancy/lactation status
* compliance- will patient take meds?
43
suggest or indicate that (a particular technique or drug) should not be used in the case in question
contraindicated
44
What would affect a patients adherence
* memory problems
* alcohol
* ability to pay
* transportation to pharmacy
45
What is the phys assessment prior to meds? x7
* vital signs
* ability to swallow- gag reflex
* GI motility
* Muscle mass
* Venous Access
* Body sys assessment
* right to refuse
46
What is the 3 part statement for a nursing diagnosis
1. Diagnosis
2. Related To
3. As Evidence By
47
What are examples of nursing diagnoses related to med admin
anxiety, deficity of knowledge, impaired mobility, impaired swallowing, fall risk
48
What is stock-supply of medication?
* bulk quanitity
* central location
* not client-specific
49
What is a unit dose
* individually packaged meds
* client specific drawers
* 24 hr supply
50
What is self administration
* Individual containers
* kept at patients bedside
* (eye drops)
51
What is automated dispensers
* password accessible locked cart
* computerized tracking
* can combine stock and unit
52
What is "COW"
* Computer on Wheels
* automated dispenser
* Not appropriate term
53
What are nurse's 3 checks?
1. Remove meds from drawer//*Label against order*
2. After your pour//*verify label again MAR*
3. At Bedside//*Check ID band against MAR*
54
What are basic rules for administering medication x9
* prep for ONE patient at a time
* compare order with me davailable
* calc drug dose
* Verify order
* Check if it seems excessive
* take meds directly to the patient
* Check 2 patient identifiers
* complete required assessent prior to giving
* DO NOT LEAVE at bedside, stay until that complete
55
How should you prepare liquid medications?
at eye level
56
What is the 3 Bears Rule
"just the right amount"
57
When applying topical meds what PPE do you need
* *gloves*
* (otherwise you will be taking it)
58
Where do you put medications applied sublingual?
under the tongue
59
What do you do for enteral medications
* crush and dissolve in water
* flush with water/saline between medications
* make sure wont clog tube
60
What is a PEG tube?
* percutaneous
* endoscopic
* gastric
61
What are precautions for phthalmic medications
* make sure it says for ophthalmic use only
* no cross contamination
62
Precautions for Ear-Otic Medications
* Proper temperature
* child vs adult
63
What are nebulizer precautions (MDI)
* coordinated movements required
* local effect
* a fine spray of liquid
64
What are precautions for rectal admin
* Past internal sphincter and against the rectal mucosa (side)
* local or systemic effects
* suppositories/enemas
* WEAR GLOVES
65
What are precautions for vaginal administration
* foams, jellies, creams
* body temperatures
* standard precautions (gloves)
* privacy if client self administer
66
What are precautions for parenteral medications
* med by injection
* invasive
* proper administration (location!!)
67
What is a needle's gauge
thickness of the needle
68
Is 25 gauge bigger or smaller than a 16 gauge needle
smaller
69
Needle Precautions
* do not recap a dirty needle
* place directly into a sharps container
70
If you do have to recap a needle what is the technique?
* scoop, with no touching!
71
What did the Occupational Health and Safety ACt require
to use safety engineered needles
72
Layers for parenteral Medications Sites x4
* Intradermal
* subcutaneous
* intramuscular
* intravenous
73
What are intradermal injections for?
* Skin Testing
* 26 gauge
* light pigmentation, free of lesions, hairless
* Mantoux TB Skin test
74
How do you do a mantoux TB Skin Test
* 0.1 ml of Protein Purified Derivative
* read 48-72 hrs later
* diamter of the "induration"
75
How do you administer a Subcu Shot
* 45-90 degree angle
* stomach, back, shoulder, thighs
* into the fat
76
Characteristics of SubQ
* Abbreviations SC, SubQ, SQ
* 0.5-1ml fluid
* 25-27 gauge
* Absorbs slower that IM route
* do not require aspiration
77
Insulin Syringes
* subq
* syringe depend on manufacturer
* orange, must be specific
* units
78
IM injections
* intramuscular, assess muscle
* 90 degree
* dont go too low with deltoid
* absorbs faster more blood supply
* 1/2 - 3" in length
* need to aspirate before injecting
* 21-25 gauge
* Less than 3 mL
79
What is Z-Track IM
* medications that could damage tissues
* 1-1.5 "
* hold skin and keep needle in place 10 sec
* withdraw needle and release skin
* (example: iron)
80
Mixing Meds precautions
* have to be "compatible"
* don't contaminate, change needles
* final dose is accurate
* insulins can be mixed
81
What is sliding scale insulin
If blood glucose level is within a specific range, this is how much you will give
82
When giving a shot, how do you minimize **anxiety**?
* educate patient
* be calm
* calm family
83
If med error occurs what ACTIONS do you take
* assess the patient immediately
* report to charge nurse
* be honest
* report error and findings to primary care provider
* incident reports
84
Why is older adults in US growing
* increase avg life span
* baby boomer (1946-65)
85
What common challenges for the older adult
* losses
* decrease ability to respond to stress
* phys changes
* high risk for illness and functional loss
* ASSESS
86
Normal Phys changes with aging
* body composition
* body cells less able to replace themselves
* reduces lean body mass
* loss of subq fat
* body shrinkage due to loss of cartilage
* body fat atrophy (sagging)
* hard to maintain body temp
* increas risk of dehydration, decrease intracellular fluid
87
Cardiovascular changes for aging
* decreased contractility
* impaired blood flow
* alter preload/afterload
* vessels tortuous
* heart valves rigidity
* increase atherosclerotic
88
Respiratroy changes in older adult
* rigid thoracic cage
* decrease vital capcity
* decrease cough efficiency
* decrease in ciliary action- (flow of mucous)
89
Endocrine changes in adult
* thyroid- decreased metabolism
* pancreas-insufficient release of insulin
* pituitary-decrease release in hormones
90
Renal Changes in Adult
* decrease *bladder capacity*
* decreased *concentrating / diluting abilities*
* decrease *creatinine clearance (*buildup)
91
GI changes in adult
* tooth loss
* decrease saliva
* altered digestion
* weakened esophageal sphincter
* decrease in blood flow
* decrease size in organs
* decrease peristalsis
92
Nervous sys changes in adult
* decrease in neurons & speed of conduction (driving)
* decrease brain weight
* decrease peripheral nerve function
93
Sensory changes in adult
* presbyopia
* glaring
* difficult distinguishing btwn blue & green
* presbycusis
* ear wax build up
* decrease taste
94
Reproductive changes in adult
* vaginal mucosa thinning and atrophy
* decrease breast tissue
* decreased libido
95
skin changes
* heat regulation
* elasticity
* epidermal renewal
* screation of oil/perspiration
* decrease infammatory response
96
How much of the body's water is intracellular
* 2/3
* ICF Intracellular Fluid Compartment
* within the cells
97
How much of the body's water is extracellular
* 1/3
* interstitial fluid 25%
* intravascular (blood plasma) 8%
* transcellular (lymph, synovial, pleural)
98
What are the 2 components of extracellular compartment:
1. interstitial
2. intravascular
99
What percent of total body water is part of body weight?
60%
100
How does water move throughout the body
freely across membranes
101
What is aldosterone
it is a hormone that is secreted when sodium levels are depressed.
102
What is hyperchloremia
* electrolyte disturbance in which there is an abnormally elevated level of the chloride ion in the blood.
* is a result of an underlying disorder
103
What is **hypo**(na)tremia
an outcome of serious burns, vomiting, or diarrhea
104
What is hyperkalemia
* It often occurs in acidosis.
* MACHINE (meds, acidosis, cellular destruction, hemolysis, intake, nephrons, excretion, impaired)
105
A patient has deep and rapid respirations. Laboratory tests reveal decreased pH and bicarbonate. This patient is experiencing:
metabolic acidosis
106
increased filtration of fluid from capillaries and lymph into surrounding tissues (edema) is caused by: x4
1. increased hydrostatic pressure
2. decreased plasma oncotic pressure
3. increased capillary membrane **permeability**
4. lymphatic **obstruction**
107
causes of hypernatremia
1. admin too much hypertonic saline solution
2. too much aldosterone.
3. Cushing syndrome
108
common clinical manifestations of hypokalemia
1. carbohydrate metabolism is affected due to decreased insulin secretion.
2. Renal function is impaired.
3. neuromuscular excitability is decreased
109
intravascular water is
blood
110
Children vs Adult Water Retention
* 70% kids
* 45% older adults
* prone to dehydration
111
Water composition of the body
* primary body fluid
* varies with age, sex adipose tissue
* contains solutes (electr or non electric)
112
What are solutes
* solid substances that dissolve in the body
* Na+ or glucose int the blood plasma 90%
* 60% in interstitial fluid
113
Functions of body fluid
* maintain blood volume
* regulate body temp
* sweating (insensible loss)
* transports material to and from cells
* food digestion
* medium for excreting waste
114
What are non electrolytes
* most organic molecules
* do not dissociate in water
* carry NO net electrical charge
* (example: protein, glucose)
115
What are electrolytes
* dissociate in water to ions
* inorganic salts, acids, bases, *some* bases
* more osmotic pwr (attract water)
116
Functions of electroylyes
* regulate nerve/muscle function
* hemodynamically stable
* stay hydrated
* manage pH
* blood pressure
* damaged tissue repair
117
Common ECF electrolytes
* NA+
* Chloride Cl-
* Biocarbonate HCO3-
118
Common Electrolytes ICF
* Potassium (K+)
* Phosphate (PO42-)
119
This is a physical barrier that encloses a fluid space within the body. It i *Selectively* permeable
Cellular membrane
120
relating to the flow of blood within the organs and tissues of the body
hemodynamic
121
How do we maintain homeostasis
* movement of fluids & electrolytes
* fluid intake and fluid output
* hormonal regulation
* adh, Adosterone, Renin, Angiotensin, Natriuretic Peptides
122
Pressure exerted by a fluid within a closed system
* hydrostatic pressure
* *causes a leak (like a soaker hose)*
123
What changes the hydrostatic pressure
force of the weight of water molecules pressing against the confining walls.
124
What are the results of hydrostatic pressure
* movement from an area of Greater pressure to lower pressure
* makes cell wall more permeable
125
Exerted by proteins, notably albumin, in a blood vessel's plasma (blood/liquid) that usually tends to pull water into the circulatory system.
* Oncotic pressure
* *(egg white, dense less permeable)*
* keep fluid in
126
Low Serum Albumin causes...
pitting edema
127
ROME mneumonic
* *Respiratory Opposite* (pH up PCO2= Alkalosis)
* *Metabolic Equal* (pH up HCO3 up= Alkalosis)
128
What is RUB MUM
* **R**espiratory **U**ses **B**icarb
* **M**etabolic **U**ses **B**reathing
129
Signs of hyerkalemia MURDER
* **M**uscle weakness
* **U**rine, oliguria, anuria
* **R**espiratory distress
* **D**ecreased cardiac contractility
* **E**KG changes
* **R**eflexes, hyper, or hypo
130
Capillary Bed
* Where all the action happens. CO2 converts to O2
131
fluid getting backed up in the tissue
edema
132
hydrostatic pressure=
osmotic/oncotic pressure (not inflamed)
133
the concentration of a solution expressed as the total number of solute particles per liter.
* *osmolarity*
* high, means high concentrates of solutes
134
3 Classification of Osmolarity
* *isotonic* (same as blood)
* *hypotonic* (water, more inside)
* *hypertonic* (gatorade, more outside)
135
Normal serum osmolarity
280-295 mOsm/L
136
How does the body passively tranport
* no energy used
* diffusion, osmosis, filtration
137
How does the body actively transport
* requires energy ATP to move substances
138
What directions to solutes diffuse?
high to low
139
What direction does osmosis move?
towards higher concentration
140
Moves **both water and small solutes** from high pressure to low pressure
Filtration
141
This moves a solute *against* the gradient
Active Transport
142
Where is energy produced in your cells?
mitochondria
143
What happens to the brain when osmolality increases
* hypothalamus is stimulated and the person gets thirsty
* stimulates hormone
144
What foods stimulate osmolality and hypothalamus
salt
145
Fluid Output methods
* kidney
* gi tract
* skin
* lungs
146
What are 7 mechanisms for fluid balance
1. hypothalamic,
2. pituitary
3. Adrenal cortex (on top of kidneys)
4. Kidneys
5. Heart
6. GI Tract
7. Insensible water loss
147
These hormones regulate body fluid x4
* **R**enin Angiotensin
* **A**ldosterone
* **N**atriuretic Peptides
* **A**nti**_d_**iuretic **_h_**ormone *(keep water)*
148
chief mineralocorticoid secreted by the adrenal glands. Causes sodium to be **reabsorbed** by the kidneys
* *Aldosterone*
* adrenal gland
* decreased BP
* high potassium
* low sodium
149
body exchanges sodium for potassium because
it wants to get rid of potassium
150
is released in response to low renal blood flow and low BP by the kidneys
* *RAAS (renin angiotensin sys)*
* in response to low BP and low volume
* *natriuretic peptides oppose this sys*
151
RAAS stimulates
* Angiotensinogen* (renin)\> *Angiotensin I* (enzyme) \> *Angiotenin II* \> potent **vasoconstrictor, stimulates aldosterone secretion**
ex: ace inhibitor (decreases BP), low sodium
152
hormones secreted by your heart in response to BP and blood volume that stretch heart tissues
NP- Natriuretic Peptides
153
lowers your blood pressure
* NPs
* vasodilation
154
losing water thru kidneys
diuresis
155
excreted by hypothalamus and stored in posterior pituitary gland
* *ADH (antidiuretic hormone)//Vasopressin*
* vasoconstrictor (increases BP)
* maintains water balance
* promotes water reabsorption
156
When does ADH respond
* to serum osmolaltiy,
* fever,
* pain,
* stress,
* opiods
* (LOW BLOOD VOLUME)
157
It is better to be lacking fluid than
osmolarity
158
When do you need to keep water
when osmolarity is high
159
With a decrease in ADH release, urine will be more
dilute
160
with a decrease in ADH release, specific gravity of urine will be
low
161
Types of fluid volume imbalances
* deficit
* excess
* shift
* **ECF it is accompanied by changes in the serum sodium levels**
162
Causes a fluid volume deficit
* shift of fluid from plasma into insterstitial fluid
* (other obvious ones)
163
Causes for fluid volume excess
* renal fail (decrease urine formation)
* cardiac dysfunction
* head injuries
* meningitis
* tumors
* too much ADH release
164
Fluid Volume Shift causes
* EDEMA
* severe sepsis (3rd spacing)
* excessive accumulation of fluid w/in the interstitial spaces
* cant get BP UP
* increased hydrostatic pressure
* increased capillary membrane permeability
* lymphatic channel obstruction "lymphedema"
165
What is 3rd spacing
* constantly leaking out
* not easily exchanged with ECF
166
Cations have a positive or negative charge?
positive
167
Table page 102
168
Can we measure intracellular electrolytes
NO
169
Normal Serum Sodum Level
135-145 mEg/L
170
What is the major cation in the blood
Sodium (Na+)
extracellular
171
Excess sodium
* *hypernatremia*
* kidney failure
* steroids
* cushings disease
172
Low Sodium/Causes
* *Hyponatremia*
* Diuretic
* GI fluid loss
* Aldosterone
* excessive intake of hypotonic fluid (nursing error)
173
How much potassium is in ECF
2%
174
Norm level of Potassium
* 3.5-5 mEq/L
* must be ingested daily by diet
175
How much potassium per day
40 mEq/d
176
What causes low potassium
Severe nausea and diarhea
177
Function of the potassium
* transmits electrical impulses in multiple body sys
* regulates conduction of cardiac rhythm
* contracts skeletal, smooth & cardiac muscles
* Maintain Acid Base Balance
* works with Na+
178
What regulates potassium
* aldosterone.
* Increase aldosterone increase excretion of potassium
* everytime you pee lose potassium
* Na+ & K go opposite one another
179
High potassiums is greather than
5
180
Causes for hyperkalemia
renal failure
high potassium intake
ACE inhibitors, aspirin, beta blockers, chemo
hypoaldosteronism
181
Following a bilateral mastectomy, a 50-year-old patient refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. How should you reply?
“I see that you’ve combed your hair and put on makeup.”
## Footnote
*matter-of-fact approach and acknowledges a change in the patient’s behavior or appearance, it allows the patient to establish its meaning.*
182
A patient diagnosed with major depressive disorder has a nursing diagnosis of chronic low self-esteem related to negative view of self. What would be the most appropriate cognitive intervention by the nurse?
Focus on identifying strengths and accomplishments
## Footnote
*to minimize the emphasis on failures assists the patient to alter distorted and negative thinking*
183
“Should I have a cup of coffee or a cup of tea?” and “Should I take a shower now or wait until later?” How should you interpret the patient?
Inability to make decisions reflects a self-concept issue.
184
An adult woman is recovering from a mastectomy for breast cancer and is frequently tearful when left alone. What does the patient need?
support in dealing with the loss of a body part.
## Footnote
*encourage the patient to **talk about** the threats to **body image**, including the meaning of the loss, the reactions of others, and the ways in which the patient is grieving.*
185
When caring for an 87-year-old patient, the nurse needs to understand that \_\_\_\_\_\_\_\_\_\_\_affects the patient’s current self-concept
role change, loss of loved ones, and physical energy
186
A 20-year-old patient diagnosed with an eating disorder has a nursing diagnosis of **situational low self-esteem**. What nursing interventions would be best to address self-esteem?
Offer **independent** decision-making opportunities
187
The nurse asks the patient, “How do you feel about yourself?”
The nurse is assessing the patient’s:
Self Esteem
188
The nurse can increase a patient’s self-awareness by these actions...
1. Helping define her problems clearly
2. Allowing to openly explore thoughts/feelings
3. Reframing thoughts/feelings in a positive way
189
When developing an appropriate outcome for a 15-year-old girl, the nurse considers that a primary developmental task of adolescence is to:
Form a sense of identity
190
involves attitudes related to the body, including physical appearance, structure, or function
Disturbed Body Image
191
In planning nursing care for an 85-year-old male, the most important basic need that must be met is
**Self-esteem** is essential for physical and psychological health across the life span
192
The home health nurse is visiting a 90-year-old man who lives with his 89-year-old wife. He is legally blind and is 3 weeks’ post right hip replacement. He ambulates with difficulty with a walker. He comments that he is saddened now that his wife has to do more for him and he is doing less for her.
**Risk for Situational Low Self Esteem** *as his mobility improves, his low self-esteem will also resolve*
193
Pulmonary Edema Treatment
MAD DOG
* ***M**orphine*- vasodilation, decrease BP
* ***A**minophylline-* relazes airways to make breathing easier
* ***D**igitalis*- improve heart function
* ***D**iuretic(Lasix)*- pull excess fluid off
* ***O**xygen*- improve oxygenation
* ***G**asses*- assess respiratory status
194
Signs of Hypernatremia
You are FRIED
* Fever
* Restless
* Inc BP
* Edema
* Dec urinary (too much aldosterone)
195
A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate:
Metabolic Acidosis
196
A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first?
Serum potassium
197
Heart failure commonly causes ICF or ECF & why?
ECF,
*because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na+ and water*
198
You assess four patients. Which patient is at greatest risk for the development of hypocalcemia?
28-year-old who has acute pancreatitis
*because calcium binds to undigested fat in their feces and is excreted*
199
Assessment findings consistent with intravenous (IV) fluid infiltration include
1. Edema and pain
2. Pallor & Coolness
200
Which of the following defi ning characteristics is consistent with fluid volume deficit?
Dry mucous membranes, thready pulse, tachycardia
201
Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl?
auscultate dependent portions of the lungs
202
While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action?
Stop the transfusion
## Footnote
*ndication of an acute hemolytic reaction. incompatible blood.*
203
The health care provider’s order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid?
Oliguria, can cause hyperkalemia
204
your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient’s breathing?
Provide frequent oral care to keep her mucous membranes moist. Hyperventilation should be ALLOWED to continue
205
Which patient is most at risk for respiratory depression related to opioid administration for pain relief?
* those who are older
* lung disease
* history of sleep apnea
* receiving other central nervous system depressants
206
Before administering celecoxib (Celebrex), the nurse will assess the patient's medical record for which medication that would increase the risk of adverse effects?
aspirin, increase risk of bleeding
207
Which assessment is of highest priority for the nurse to complete before administration of morphine?
Respiratory Rate
208
The nurse should question an order written for Percocet for a patient exhibiting which clinical manifestation?
Severe jaundice
## Footnote
*Percocet contains Acetaminophen and oxycodone which is metabolized in the liver*
209
The nurse is caring for a patient who is receiving morphine sulfate via PCA. Which patient assessment data demonstrate the most therapeutic effect of this medication?
* pain control less than 3
* normal respirations
* alert
210
The nurse should teach a patient to avoid which medication while taking ibuprofen?
Aspirin, Risk for GI bleed
211
The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient
* itching
* nausea
* urinary retention
212
The nurse is caring for a patient receiving morphine sulfate 10 mg IV push when necessary for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8/minute. Which medication would the nurse prepare to administer to treat these symptoms?
Naloxone (Narcan)
213
nonpharmacologic comfort measures include
* comfort massage
* provide distractions
* heat or cold therapy
214
he patient's neuropathic pain is not well controlled with the opioid analgesic prescribed. What medications may be added for a multimodal approach to treat the patient's pain
* Antiseizure drugs,
* tricyclic antidepressants,
* SNRIs,
* transdermal lidocaine,
* α2-adrenergic agonist
215
The patient is a known abuser of narcotics and just had surgery. The nurse is frustrated by drug addiction and worried about the high dose of narcotic analgesic prescribed for this patient. What is the best action for the nurse to take?
This patient has the right to appropriate assessment and management of pain.
216
This is a potassium-sparing diuretic that inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss.
Spironolactone (Aldactone) (contraindicated w/ hyperkalemia)
217
The nurse is caring for a 76-year-old woman admitted to the clinical unit with hypernatremia and dehydration after prolonged fever. Which beverage would be safest for the nurse to offer the patient?
orange juice
218
The nurse on a medical-surgical unit identifies that which patient has the highest risk for metabolic alkalosis?
NG tube
219
You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which anticipated primary acid-base imbalance if the obstruction is high in the intestine?
Metabolic Alkalosis
220
You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician?
Loop Diuretics, cause the kidneys to excrete sodium and potassium.
221
Hyperkalemia may result from
Hyperglycemia
222
Signs of Hyperglycemia 3Ps
1. polyphagia
2. polydipsia
3. polyuria
## Footnote
*Hot dry, sugar high*
223
You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention?
Listen to the patient's lung sounds and assess respiratory status. Should have infused after 4 hours.
224
When planning care for adult patients, which oral intake is adequate to meet daily fluid needs of a stable patient?
2000 to 3000 mL
225
While performing patient teaching regarding hypercalcemia, which statements are appropriate
1. Renal calculi may occur as a complication of hypercalcemi
2. Weight-bearing exercises can help keep calcium in the bones.
3. The patient should increase daily fluid intake to 3000 to 4000 mL
226
The dehydrated patient is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions
* lung sounds
* blood pressure
* Serum sodium level
227
When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse's priority action?
* Administer Oxygen
228
When should you never crush a medication?
1. Sublingual
2. Enteric-coated
3. Extended Release
229
A.C. means
administer *before* meal
230
P.C. means
Administer med after a meal
231
Acidosis Characteristics
* hyperkalemia
* hypernatremia
* renal failure
* ECF to ICF
* Oligaria
* Hyperventilation
* Hypoaldosterone
* RAAS
* LOW BP
* vaso-dilation
232
Alkalosis Characteristics
* Hypokalemia
* hypertonic
* hypoventilation
* hypoaldosterone
* hypoventilation
* polyuria
* nausea
* diarrhea
* burns
233
Psychosocial changes for older adult
* Sexual (intimacy)
* Economic,
* Intra-family changes
* Ageism
234
Nursing Assessment
* ADLs/IADL (cooking, driving)
* cognitive evaluation
* phys assessment
* **functional**
* Social
* Environmental
235
Wellness in aging
* Unique approach
* Lifestyle changes
* Treatment of Chronic Illness
* Outreach (AARP)
236
Health Definition according to World Health organization
"complete physical, mental, and social well-being" (not just absence of disease)
237
Sociologic Definition of Health
ability to conduct ADL's
238
Illness-Wellness Continuum
* we manage a person at any point on the continuum
239
How would you encourage higher level of wellness on a person who is well?
Maintenance, preventive, mammograms, prostate checks, encourage independence
240
What is health promotion?
* wellness
* self care
* health screening
* nutrition ed
* genetic testing
241
Ilness Definition
* the result of a disease or injurty that affects functioning
* How do they view their illness? Any symptoms?
242
Acute illness
* 3-6 months
* reversile
* pneumonia, delirium, shingles, apendicitis
243
Chronic Illness
* longer than 6 months
* gradual onset
* irreversible
* diabetes, alzheimers, parkinsons, MS
244
What is illness behavior?
* the way a person acts when their sick
* sociocultural
* past experiences
* acceptance
245
What happens to a person in chronic illness vital signs
* stays the same
* body adapts
246
4 Typical "modifiable" behaviors of chronic illness
1. physical inactivity
2. poor nutrition
3. use of tobacco
4. excessive alcohol
247
Characteristics of chronic illness
* long term and persistant
* predictable
* wellness/illness shift
* overwhelming for the family
* adjust and adapt
* requires a caregiver
248
Chronic Management
* Flu vaccines
* mamograms
* prevention of acute conditions
* independence
249
ADA disability defintion
* record of impairment
* physical/mental problem that limits disability
* regarded as having a disability
250
What are types of disabilities
* body system
* developmental
* acquired (after your born)
* MS, SCI, COPD, age related
251
Challenges for caregivers of those with disability
* prejudice
* lack of respite
* conflict of decisions
* time/energy
* not meeting their own needs
* financial
* lack of education
252
A treatment/treatments designed to facilitate the process of recovery
rehabilitation
253
Types of Rehab
* Physical Therapy
* Occupational therapy (ADL's)
* Speech
* Dietitician
254
Nursing Interventions for Disability
* Listening, patients
* Increase Socialization
* Encourage independence
* Ask for feedback
* promote dignity
* Do not remove personal belongings
* Touch
255
Normal Osmolality Levels
285-295
256
CBC Means
* *Complete Blood Count*
* RBC, Hemoglobin, WBC, Hematocrit, Platelets
257
BMP
* Basic Metabolic Panel
* glucose, electrolyts, creatinine
258
BUN
Blood Urea Nitrogen
259
Creatinine
by product of muscle metabolism
260
Liver Enzymes
AST, ALT
261
Normal Range for WBC
5,0000 -10,000
262
Normal range platelet count
150,000- 300,000
263
Cholestorol Normal
less than 200
264
Good Cholestoerol
\>30
265
Bad Cholesterol
Less than 130
266
What is specific gravity
Concentration of urine
267
Urine Tests
* Creatinine Clearance (kidney function)
* Presence of Protein
268
Sputum Testing
* Culture organisms and Sensitivty (antibiotics)
269
Stool Samples
270
Specific Gravity Norm
1.002-1.030
271
Protein, Bilirubin, Glucose, Ketones, Occult, Bacteria Test
should be negative
272
Ketones is common in
diabetic patients
273
Occult Blood Test are commonly used
* in stools
* looking for hidden blood
274
What is a urine dipstick
* color coding
275
What is telemetry EKG Monitory
* can be mobile
* Tech constantly monitoring
276
Patient short of breath, fever, cyanosis around moth, coughing up thick green sputum. What labs should you get
* X-ray
* **Sputum**
* **CBC- WBC (5-10,000)**
* MBP
277
Patient has chest pain moving down left arm, SOB, weak, nausea, what labs would you get?
* EKG
* CBC
* BMP
* Cardiac Enzymes
278
Think Potassium, think
Heart
279
Patient 36 wks pregnant, burning w/ urination, back aches, fever, which labs?
* Urinalysis
* CBC
280
Patient has small bruises all over. Skin is dry, tenting, turgor, dry oral mucosa. Patient is frail, malnourished. Which labs?
* BMP
* CBC
* electrolytes
* Serum Albumin (malnourished)
* Blood Clotting
281
Tricks to remember What are the best years of your life
35-45
282
Who is potassiums little brother
Magnesium (1.5-3.5)
283
BiCarb
22-26
284
Hemoglobin
Women 12-16, Men 14-18
285
Hematocrit Level
35-45
286
Calcium Level
10
287
BUN level
10
288
Fluid located in between the cells
Extracellular
289
What do lab values tell you
concentration of the particles in the plasma
290
Nursing Interventions for Fluid MGMT
* Measure Ins/Outs
* Record hourly (ICU), every 4 hrs, every shift (follow protocol)
* Totals recorded every 24 hrs
* Why? Kidney Function, to prevent dehydration or fluid overload
* **Daily Weight**- **most accurate measurement of fluid MGMT**
291
IOM recommendation for fluid intake
* 2700 ml for women, 3500 for women
292
How much fluid comes from food metabolism
20%
293
Fluid intake regulated by thirst associated with
change in plasma osmolality, hypothalamus
294
How do we measure oral fluid
mL (30mLs per ounce)
295
How many mLs in tablespoon
15
296
How many mLs in teaspoon
5 mLs
297
How do you measure ice chips
1/2 the measured container volume
298
The average person should have how much **urine output** per hour?
* 30mL per hour \*\*\*
299
Average outmut of feces per day
100-200 mL
300
Do you add in the stool with the calculation?
NO
301
Reasons for hypovolemia
ng drainage, burns (3rd spacing), dehydration, shift of plasma into interstitial spaces, peritonitis, ascites (abdomen)
302
Lab Findings Hypovolemia
* Hemoglobin/Hematocrit will be ELEVATED
* Everything will be elevated
303
Nursing Role for hypovolemia
report findings, assess & monitor, call physician
304
What clinical manifestation of hypovelmia
* Pulse: weak/thready, tachycardic
* BP Low
* orthostatic
* hyperthermic
* neuro: confused, lethargic
* Gi: thirsty, weight loss, anorexia(appetite loss)
* Renal: oliguria, concentrated
* flat veins, decrease cap refill, seizure, sunken eyes, coma
305
What is "related to"?
Etiology
Example: Diarrhea, Burn, Confusion, Loss of body fluid
306
What is "As Evidence By"
Objective Data
307
Does Risk for include "aeb"
no
308
What is considered ECF x2
blood vessel, interstitial fluid
309
Hypervolemia clinical findings
* Respiratory changes
* dyspnea, orthopnea, crackles
* tachypneic (fluid in the lungs)
* neuro:muscle spasms, headache, confusion
* peripheral edema
310
2.2 kg of fluid equals how much mLs
1000
311
What pathos associated with edema
vascular insufficient, pregancy, heart failure, cirhossis, renal failure
312
Edema in the lungs
pulmonary edema
313
Extremties edema
peripheral edema
314
Abdomen edema
Ascites (3rd spacing)
315
This type of pitting is a vascular cause
pitting
316
nonpitting edema is caused by
lymphatics
317
What is Anasarca?
generalized edema (systemic)
318
Is "heart failure" a nursing diagnosis or medical diagnosis?
Medical Diagnosis- say "decreased heart function"
319
What is RESTRICT
* Reducie IV flow rate
* Evaluate breath sounds
* Semi Flower's Positi
* Treat w/ oxygen and diuretics
* Reduce fluid and sodium
* I&O and daily weight
* Circulation, color
* T
320
Primary regulator of sodium balance
kidneys
321
Adrenal insufficiency
cant retain sodium, related to Aldosterone
322
True hyponatremia (not hypervolemia)
* tachycardia, hypotension
323
Wherever sodium goes..
water follows. Cant hold on to water without sodium
324
Major Problems with Sodium imbalances
Neurological (seizures, coma)
325
Hypernatremia True (hypovolemia)
* hyperthermia, tachycardia, orthostatic hypotension
* NEURO
326
Clinical Manisfestation of Hypokalemia
* weak pulse, **bradycardia****,** hyperthermia
* EKG changes- inverted T waves
* Heart monitor
327
How do you replace potassium?
* Never do IV push
* oral
* potatoes, bananas, avocado
328
HyperKalemia
* IV, or salt substitutes
* Renal Failure
* tissue damage
* hypotension.
* PEAKED T waves
* Diarhhea
* Insulin
* Dialysis
329
Hypocalcemia Characteristics
* blood transfusion
* alkalosis
* decrease intake of calcium rich foods
* Renal Disease
* NEUROMUSCULAR
* decrease heart rate, myocardial contractility
330
A 5-year-old male presents to the ER with delirium and sunken eyes. After diagnosing him with severe dehydration, the primary care provider orders fluid replacement. The nurse administers a hypertonic intravenous solution. Which of the following would be expected?
Intracellular Dehydration
331
Which of the following conditions would cause the nurse to monitor for hyperkalemia?
Acute Acidosis
332
Signs of HypoKalemia 6L's
1. Lethary
2. Lethal Cardia Arrhythmia
3. Leg Cramps
4. Limp Muscles
5. Low Shallow respiration
6. Less Stools (constipation)
333
Which of the following buffer pairs is considered the major plasma buffering system?
Bicarb
