EXAM 3 Flashcards

Question

MEDICAL Hx FOR ACIDOSIS/ALKALOSIS

Answer 1

RECENT SURGERY (PHYSIOLOGICAL STRESS) GI OUTPUT ACUTE ILLNESS/TRAUMA- RESPIRATORY DISORDERS, BURNS, TRAUMA CHRONIC ILLNESS- CANCER, HF, OLIGURIC RD

Answer 2

INDICATOR OF FLUID STATUS MAKE SURE TO USE SAME CONDITIONS

Answer 3

NO, SUBTRACT IT

Answer 4

SAME EFFECTIVE OSMOLALITY AS BODY FLUIDS

Answer 5

EFFECTIVE OSMOLALITY LESS THAN BODY FLUIDS THUS DECREASING OSMOLALITY BY DILUTING BODY FLUIDS AND MOVING H2O INTO CELLS

Answer 6

HAVE AN EFFECTIVE OSMOLALITY GREATER THAN BODY FLUIDS AND DRIVES H2O OUT OF CELLS

Answer 7

TOO RAPID OR EXCESSIVE INFUSION OF ANY IV FLUID HAS THE POTENTIAL TO CAUSE SERIOUS PROBLEMS COULD CAUSE FLUID OVERLOAD OR MYOCARDIAL INFARCTION

Answer 8

BRUISING INFECTION EXTRAVASATION INFILTRATION PHLEBITIS

Answer 9

IV ADMIN OF WHOLE BLOOD OR BLOOD COMPONENT *TAKES 2 NURSES TO VERIFY *STAY FIRST 15 MINUTES

Answer 10

CHECK,CHECK, CHECK MONITOR 2 PEOPLE MIN

Answer 11

IMMEDIATE = FEVER, CHILLS, NAUSEA, DYSPNEA, TACHYCARDIA, HYPOTENSION

Answer 12

IF IT LOOKS BAD... TAKE IT OUT INFECTION, BRUISING, EXTRAVASION, INFILTRATION, PHLEBITIS... TAKE IT OUT

Answer 13

https://www.youtube.com/watch?v=URCS4t9aM5o (solving some problems)

Answer 14

https://www.youtube.com/watch?v=3neNB0w1P9M (partially compensated vs fully)

Answer 15

https://www.youtube.com/watch?v=URCS4t9aM5o (interpreting problems)

Answer 16

USUALLY ONLY GOOD FOR 3 DAYS SO YOU NEED TO KNOW WHEN TO TAKE IT OUT-- SAME FOR TUBING

Answer 17

Level of consciousness/confusion, generalized weakness, decreased BP, skin turgor. Youshould assess for dehydration

Answer 18

Dehydration: due to not feeling thirsty.

Answer 19

Sodium (Na*): 136 to 145 mEq/ L

Answer 20

Potassium (K*): 3.5 to 5 mEq/L

Answer 21

Calcium total (Ca*·): 9.0 to 10.5 mg/dL

Answer 22

Magnesium(Mg-): 1.3 to 2.1 mEq/ L

Answer 23

Phosphorus (PO ):3.0 to 4.5 mg/dL

Answer 24

Chloride (CI):98 to 106 mEq/ L

Answer 25

PH PACO2 PAO2 HCO3

Answer 26

pH : 7.35 to 7.45

Answer 27

PaC02 : 35 to 45 mm Hg

Answer 28

Pa02 : 8O to 100 mm Hg

Answer 29

HC03 (bicarbonate):21 to 28 mEq/L

Answer 30

https://www.youtube.com/watch?v=Ry5Rh3wO8Sw

Answer 31

LOW PH HIGH pCO2 RETENTION OF CO2 BY LUNGS

Answer 32

INCREASE IN BASE OR DECREASE IN ACID INCREASE PH INCREASE HCO3

Answer 33

HEADACHE LETHARGY ANOREXIA DEEP, RAPID RESPIRATIONS (KUSSMAUL) N&V DIARRHEA ABDOMINAL DISCOMFORT COMA DANGEROUS DYSRHYTHMIAS

Answer 34

CARDIAC DYSRHYTHMIAS AS A RESULT OF DECREASED K+ PHYSICAL WEAKNESS MUSCLE CRAMPING HYPERACTIVE REFLEXES CONFUSION CONVULSIONS TETANY

Answer 35

The body must maintain a delicate balance of acids and bases .*  Metabolic and respiratory processes must work together to keep hydrogen ion (H+) levels normal and stable.

Answer 36

CONCENTRATION OF H+

Answer 37

1) Does the pH indicate acidosis or alkalosis? 2) Is the cause of the pH imbalance respiratory or metabolic? 3) Is there compensation for the acid-base imbalance?

Answer 38

within normal range

Answer 39

a case of complete compensation .*  You will need to do one extra step to diagnose the origin of the imbalance. *  You will be noting two pH values on the grid

Answer 40

Record the one in the normal range as “pH(1)” *  Recalculate pH using the exact midpoint of the normal range, or 7.40, for your reference point. – Thus, a pH of less than 7.40 would indicate acidosis, and one greater than 7.40 would be alkalosis *  Note this adjusted pH in the appropriate box as “pH(a)”

Answer 41

correcting the underlying cause with immediate care focused on correcting the pH level.

Answer 42

(http://www.ismp.org/Tools/confuseddrugnames.pdf)

Answer 43

Any substance that alters physiologic function, with the potential of affecting health

Answer 44

a substance used in the diagnosis, treatment, cure, relief, or prevention of health alteration. Regulated by the FDA.

Answer 45

e.g. assessment of liver function or diagnosis of myasthenia gravis

Answer 46

e.g. heparin to prevent thrombosis or antibiotics to prevent infection

Answer 47

e.g. replacement of fluids or vitamins, supportive purposes (to enable other treatments, such as anesthesia), palliation of pain and cure (as in the case of antibiotics).

Answer 48

manufacturer who develops, help to recognize class (will see on NCLEX

Answer 49

its desired effect on body system

Answer 50

solid, liquid, topical, parenteral, sterile for body cavity instillation

Answer 51

expected /predicted response on body system

Answer 52

are unintended and nontherapeutic effects, which can range from tolerable to harmful and sometimes to irreversible damage or death. Ex- GI bleeding from ASA (aspirin)

Answer 53

opposite or different response than expected such as hyperactivity w Benadryl

Answer 54

2 drugs cause greater body response when given together (positive or negative)

Answer 55

SESNSITIZED IMMUNE RESPONSE, UNPREDICTED, SIMPLE (ITCHING, HIVES, RASH, RHINITIS), OR ANAPHYLACTIC (EMERGENCY ABC PROBLEM, TX FOR BRONCHOSPASMS, WHEEZING, AND EDEMA)

Answer 56

itching of the skin with or without rash.

Answer 57

edema due to increased the permeability of the blood capillaries.

Answer 58

Inflammation of mucous membranes lining nose; causes swelling and clear, watery discharge.

Answer 59

how meds enter & exit the body, are absorbed & distributed, reach their site of action, alter body processes, & are metabolized

Answer 60

Passage of medication molecules into the blood from the site of administration

Answer 61

After absorption, distribution occurs within the body to tissues, organs, and specific sites of action.

Answer 62

Physical and chemical properties of the medication Physiology of the person taking it: Circulation Membrane permeability Protein binding

Answer 63

Medications are metabolized into a less-potent or an inactive form. Kidneys, blood, intestines, and lungs play a role.

Answer 64

Biotransformation occurs under the influence of enzymes that detoxify, break down, and remove active chemicals.

Answer 65

Medications exit the body through the: Kidney- urine Liver- bile Bowel- stool Lungs- gases Exocrine glands- lipid-soluble meds Chemical makeup of medication determines the organ of excretion.

Answer 66

adverse or prolonged effect

Answer 67

mec- wants a constant blood level

Answer 68

concentration is too low to cause therapeutic effect

Answer 69

constant blood level between mec & toxicity

Answer 70

Peak is considered the maximal therapeutic level, max serum dose, time varies.

Answer 71

A trough is the lowest therapeutic level.

Answer 72

body response time

Answer 73

is the time it takes for excretion to lower the blood concentration of a drug to decrease by 50%. Determines how often med is given.

Answer 74

occurs when a medication blood serum concentration reaches therapeutic effect and remains there

Answer 75

30 minutes before or after scheduled time; non-time critical- within 1 hour of time due

Answer 76

Right patient Right medication Right dose Right time Right route Right documentation Other rights (assessment, evaluation, refusal, education)

Answer 77

Administered until the dosage is changed or another medication is prescribed

Answer 78

Given one time only for a specific reason

Answer 79

When a medication is needed right away, but not STAT

Answer 80

Given when the patient requires it

Answer 81

Given immediately in an emergency

Answer 82

Medication to be taken outside of the hospital

Answer 83

to develop, update, coordinate, and communicate accurate client medication information during transitions of care.

Answer 84

5 or more meds on a nonhospitalized client May be meds with same actions or chemical class or to treat same illness Risk of drug-drug or drug-food interactions Taking herbal or nutritional supplements OTC meds Multiple pharmacies, providers

Answer 85

Medications applied to the skin and mucous membranes generally have local effects. Applied to skin Rectal Vaginal Otic Optic Nasal

Answer 86

Easiest and most desirable route Food may decrease therapeutic effect. Empty stomach- 1 hr before or 2 hrs after meals.

Answer 87

With tube feeding, if medication is to be given on an empty stomach, allow at least 30 minutes before or after feeding. Risk of drug-drug interactions is higher.

Answer 88

Verify that the tube location is compatible with medication absorption. Dissolve or pierce simple gelatin capsules. Do NOT crush sustained release or enteric coated & double-check capsule before opening b/c interferes with design of med and/or increases potency. Follow American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines.

Answer 89

Administer to patient sitting Dissolves under tongue Don’t swallow drug, eat, drink, or smoke until after absorbed

Answer 90

Exhale 1st and then Inhale slowly, hold for 5-10 sec. to disperse med to get full effect. 30 sec. between puffs. Teach to rinse & spit after using inhaled steroids to decrease risk of developing thrush. Teach to monitor usage to know when to reorder.

Answer 91

Transdermal patches: Remove old patch before applying new. Document the location, time & date of application of the new patch. Document removal of the old patch as well. Ask about patches during the medication history. Apply a label to the patch if it is difficult to see.

Answer 92

Nasal drops are effective in treating sinus infections. saline safer than decongestant spray which vasoconstricts and can increase BP rebound effect- worsens nasal congestion.

Answer 93

Artificial tears, vasoconstrictors. Avoid touching the cornea- very sensitive, pain fibers. Avoid the eyelids with droppers or tubes to decrease the risk of infection. Pull down conjunctival sac and press lacrimal duct. Never allow a patient to use another patient’s eye medication.

Answer 94

Structures are very sensitive to temperature. Room temp to prevent vertigo, dizziness, nausea. Young child <3yrs- pull outer ear down & back, Older children & adults- pull ear up and back

Answer 95

Use sterile solutions in case ear drum is ruptured. Drainage may indicate eardrum rupture. Never occlude the ear canal. Do not force medication into an occluded ear canal.

Answer 96

Perineal care, assess for drainage. Gloves, aseptic technique. Supp- foil wrappers, refrigerate to prevent melting, avoid handling.

Answer 97

Rectal suppositories are thinner and more bullet-shaped than vaginal suppositories. The rounded end prevents anal trauma during insertion. Keep in fridge and avoid handling- may melt.

Answer 98

bevel shaft barrel tip plunger gauge number hub know where to measure know where to avoid touching

Answer 99

1/4-3/4 inches long 27-25 gauge

Answer 100

25-18 gauge 1-1.5 inches long

Answer 101

3/8-5/8 inches long 27-25 gauge

Answer 102

Snap off ampule neck Aspirate medication into syringe using filter needle to prevent small glass fragments from entering syringe

Answer 103

If dry, use solvent or diluent as needed. Some meds unstable in solution so left as powder until reconstituted/dissolved w sterile water or normal saline for use. Inject air into vial to create positive pressure to make med removal easier.

Answer 104

It is administered by subcutaneous injection and occasionally IV because the GI tract breaks down and destroys an oral form of insulin. Rapid, short, intermediate, and long-acting (basal- lasts 24 hrs)

Answer 105

Timing of insulin attempts to mimic normal pattern of release of insulin from pancreas- before meals (ac) and at bedtime (hs). Rotate vial to resuspend soln rather than shake- creates air bubbles Rotate injection sites to avoid lipodystrophy- loss of fat cells, can be a lump or small dent in skin from repeated injections, interferes with insulin absorption.

Answer 106

https://www.youtube.com/watch?v=EW55TFDFrZ0

Answer 107

Verify insulin doses with another nurse while preparing the injection.

Answer 108

Do not mix insulin with any other medications or diluents unless approved by the health care provider Never mix basal insulins- insulin glargine (Lantus) or insulin detemir (Levemir) with other types of insulin.

Answer 109

blood glucose (mg/dL) = insulin (units) 61-150 = 0 151-200 = 3 201-250 = 5 251-300 = 8 301-350 = 10 351-400 = 12 greater than 400 = 15 and contact dr

Answer 110

The volume of medication to administer The characteristics and viscosity of the medication The location of anatomical structures underlying the injection site

Answer 111

under loose connective tissue, with minimal vascular supply and some pain receptor presence. The injection site chosen needs to be free of skin lesions, bony prominences, and large underlying muscles or nerves.

Answer 112

the outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs.

Answer 113

the abdomen.

Answer 114

Pinch an inch, give at 45 degree angle; Pinch 2 inches, give at 90 degrees.

Answer 115

prevents DVTs! Subcutaneous route. ALWAYS 90 degrees in Abdomen; hold 10 seconds after injecting.

Answer 116

use the right or left side of the abdomen at least 2 inches from the umbilicus Administer LMWH lovenox (enoxaparin) in its prefilled syringe slowly with the attached needle at 90 degree angle do not expel the air bubble in the syringe before giving the medication leave in place 10 seconds after administering. Do not rub skin. Hold pressure at site.

Answer 117

ventrogluteal vastus lateralis deltoid

Answer 118

Palpate the lower edge of the acromion process, which forms the base of a triangle in line with the midpoint of the lateral aspect of the upper arm. The injection site is in the center of the triangle, about 3 to 5 cm (1 to 2 inches) below the acromion process. Locate the site by placing four fingers across the deltoid muscle, with the top finger along the acromion process. The injection site is then three finger widths below the acromion process.

Answer 119

Position in a supine or lateral position with knee and hip flexed to relax muscle. Place palm of hand over greater trochanter of patient’s hip with the wrist perpendicular to femur. Use right hand for left hip, and use left hand for right hip. Point the thumb toward the patient’s groin and the index finger toward the anterior superior iliac spine; extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle; the injection site is the center of the triangle.

Answer 120

Anterior lateral aspect of thigh, and extends in an adult from a handbreadth above knee to a handbreadth below greater trochanter of femur. Use middle third of muscle for injection. The width of muscle usually extends from the midline of thigh to midline of outer side of thigh. Lying flat with knee slightly flexed or in sitting position relaxes muscle.

Answer 121

Muscle is less sensitive to irritating and viscous medications.

Answer 122

Adults: 2 to 5 mL can be absorbed, 3 or less mL per injection is preferred.

Answer 123

Assess site, find landmarks away from nerves. Aspirate 5-10 seconds to assess for blood vessel before injection of the medication. Use 90 degree angle for insertion

Answer 124

involves the gluteus medius; it is situated deep and away from major nerves and blood vessels. ****preferred and safest site for all adults, children & older infants. Recommended for vol > 2mL & for viscous, irritating meds.

Answer 125

often used for infants less than 7 months and for very thin patients or patients who do not walk secondary to paralysis, etc.

Answer 126

Use this site for small medication volumes (Less than 2mL).

Answer 127

https://www.bing.com/videos/search?q=video+on+z+track&view=detail&mid=CF857160FA29E8B35631CF857160FA29E8B35631&FORM=VIRE

Answer 128

Pull on the overlying skin during intramuscular injection to move tissue laterally to prevent later tracking (return of the medication to the skin surface). One hand holds skin 1 to 1.5 inches laterally or downward; other hand injects at rate of 10 seconds per mL. Then, keep needle inserted for 10 seconds to allow med to evenly disperse, rather than channel back. Release skin after withdrawing needle. Creates zig-zag path.

Answer 129

Used for skin testing (TB, allergies) Slow absorption from dermis to avoid anaphylaxis Skin testing requires the nurse to be able to clearly see the injection site for changes

Answer 130

Use a tuberculin or small hypodermic syringe for skin testing. 27 or 25 gauge Angle of insertion is 5 to 15 degrees with bevel up.

Answer 131

A small bleb will form as you inject; if it does not form, it is likely the medication is in subcutaneous tissue, and the results will be invalid. Sites are hairless, light pigmentation, free of lesions. Ex- inner forearm, upper back.

Answer 132

no more than 1.5 ml

Answer 133

ventrogluteal- 3 ml deltoid- 2 ml vastus lateralis- 1-3 ml

Answer 134

ventral aspect of the forearm- 0.1 ml

Answer 135

Safest and easiest method of IV administration Large volumes (500 or 1000 mL) are used. Common- NS, D5W, lactated Ringer’s. Vitamins or Potassium Chloride can be added. If infused too rapidly, patient is at risk for overdose and/or fluid overload.

Answer 136

Intermittent venous access (saline lock)

Answer 137

Flush often, before and after use if not continuous fluids. Cover saline lock with an antimicrobial cap

Answer 138

is when IVF is infusing into tissues outside of the vein.

Answer 139

is inflammation in the walls of a vein. Thrombophlebitis is blood clot formation at the site of the inflammation.

Answer 140

is usually a bacterial infection at the site and has similar S&S of phlebitis and tx but is more severe. Tx is similar but includes antibiotics, antipyretics, analgesics if needed.

Answer 141

The basic answer is that for wire and needles, you are counting how many of those things in that size will add up to one inch when lined up next to each other on a ruler. So more needles in an inch means the needles are thinner.

Answer 142

4-6.5 cm 1.5-2.5 inches

Answer 143

20 cm 8 in

Answer 144

99% of plasma components back into the vasculature. One percent of plasma filtered is seen as urine.

Answer 145

stimulates RBC production & maturation in bone marrow

Answer 146

Synthesis of VITAMIN D as stimulated by parathyroid hormone. PTH also helps regulate CALCIUM & PHOSPHATE levels within kidneys

Answer 147

anemia, hypertension, & electrolyte imbalances.

Answer 148

Bladder contracts during urination and urinary sphincters relax during urination. Bladder contraction closes off ureter openings and opens urethral sphincters.

Answer 149

holds 600-1000 ml urine

Answer 150

Urge to void for Adults (250-450 mL in bladder) Children (50-200 mL) (q 2-4h)

Answer 151

Vary by individual Usually after waking up, around meals, before bed, 5–6 times/day

Answer 152

Children- control at 18-24 mos.- nerves innervated, pregnancy, normal aging process)

Answer 153

NPO, anesthetics decrease bladder contractility, sensation= retention

Answer 154

diuretics, anticholinergics- increase retention, sedatives- reduce cognition, meds can change the color of urine

Answer 155

such as cystoscopy which causes trauma to urethra and hematuria

Answer 156

weakened pelvic or abdominal muscles, muscle atrophy or trauma. Women usually sit, squat while men stand

Answer 157

urethral narrowing, altered innervation of bladder, weakened pelvic or perineal muscles (females- pregnancy related)

Answer 158

enlarged prostate (obstruction) can cause urinary retention, incontinence

Answer 159

Catheter-associated UTIs- CAUTIs- one of most common HAI Urinary Incontinence Urinary Diversions (see slide)

Answer 160

unable to fully empty bladder (often from BPH) Post-void residual (PVR)- bladder scan to measure urine left in bladder after voiding

Answer 161

Infections- (often E.coli from colon) Females- at risk Upper (kidneys) or Lower (bladder, urethra) Pyelonephritis, bacteriuria, bacteremia (urosepsis) Symptoms are dysuria, hematuria, cystitis (bladder)- urgency, frequency, incontinence, foul urine odor, fever, chills, flank pain Delirium in older adults

Answer 162

coughing, sneezing, laughing, or physical activity causes urine leakage

Answer 163

a strong need or urge to urinate c leakage

Answer 164

urine leakage due to nerve damage

Answer 165

incomplete bladder emptying- bladder overfills- when full, leads to leakage

Answer 166

physical inability to reach the toilet in time

Answer 167

4-6 times/day

Answer 168

voiding at night

Answer 169

sudden strong desire to void

Answer 170

painful or difficult voiding

Answer 171

delay in initiating voiding

Answer 172

nerve pathway not intact, doesn’t sense fullness, or control sphincters

Answer 173

leaking small amounts

Answer 174

blood in the urine

Answer 175

Production of abnormally large amounts of urine

Answer 176

Extreme thirst; associated with polyuria

Answer 177

Absence of urine production

Answer 178

Decreased urine output May signal impending renal failure Less than 30 mL/h for more than 2 h is a cause for concern.

Answer 179

Urine typically sterile Average Output is 1-2L/day NURSE observes for MINIMUM of 30 ml/ h If urine output is < 30 mL/ h for more than 2 hours, assess for blood loss & call Health Care Provider.

Answer 180

pink, warm, dry, smooth, intact, look for breakdown suggesting incontinence or poor hygiene, overall good turgor (no tenting)

Answer 181

place hand on posterior flank & other hand on abdomen & gently squeeze

Answer 182

if full, felt above symphysis pubis (Bladder scan- ultrasound)

Answer 183

pink, small slit like opening – observe discharge, redness, lesions

Answer 184

Specific gravity- 1.005-1.030—Concentration of urine (Lower SG- diluted, Higher SG- dehydrated No Glucose, Ketones, RBCs, minimal WBCs

Answer 185

need full bladder, scan also after voiding to check for residual urine before catheterization

Answer 186

(KUB) kidney, ureter, bladder- no special prep

Answer 187

(use contrast dye- assess for all allergies including to shellfish/iodine or previous rxn to contrast dye, Usually NPO & requires bowel prep to clean out & be able to see urinary tract),X-rays as dye travels through urinary tract, abnormalities, calculi, tumors, cysts. Encourage fluids after. Delayed reaction possible. Facial flushing is normal with dye

Answer 188

cross-sectional images to assess for tumors or obstruction. If using contrast dye- assess for allergies to shellfish/iodine, NPO X 4h.

Answer 189

endoscopy of bladder with lighted tube- biopsy, contrast dye in bladder. May be NPO. Blood in urine (pink-tinged) after test for 1-2 days.

Answer 190

Surgically inserted abdominal catheter into peritoneal cavity OSMOSIS, DIFFUSION & ULTRAFILTRATION, around 4 exchanges per day or overnight cycling. Sterile Procedure--Risk for infection.

Answer 191

artificial kidney circulates blood as electrolyte fluid bathes it & removes wastes & excess fluid OSMOSIS, DIFFUSION, & ULTRAFILTRATION. Usually 3Xwk, 4 h treatments. Risk for infection, fluid overload– may need fluid restriction, electrolyte imbalances.

Answer 192

A- Continent urinary reservoir, B- Urostomy, ileal conduit

Answer 193

One or both ureters is connected to abdominal wall opening (stoma) or tube into renal pelvis. Diversions can be via Nephrostomy tube into kidney or ureters Ureterostomy. Can be continent or incontinent- urine stored in pouch or body-catheterize pouch. Skin care/ pouching. Body image issues, sexuality.

Answer 194

is a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow.

Answer 195

is Foley catheter with fluid in balloon to hold catheter in bladder. Infection prevention through hygiene, PO fluids, emptying drainage bag when ½ full.

Answer 196

Drink 2-3L daily Limit caffeine, alcohol, acidic drinks, artificial sweeteners Limit fluids 2h before bedtime Regulate bowels Full urinary continence with 8 weeks of starting a pelvic exercise program (Kegel). Stop smoking Good voiding habits

Answer 197

wear cotton panties, cleanse front to back, no bubble baths or feminine hygiene sprays or douches, tight clothing, void after sexual intercourse, drink at least 2-3L of water daily, no excessive dairy products, and have a glass of cranberry juice each morning

Answer 198

Strengthening pelvic floor muscles- Kegel Exercises Bladder retraining- reduce frequency, less dribbling Habit training- improve voluntary control- functional incontinence Self-catheterization- aseptic technique-chronic disorders such as spinal cord injury Maintenance of skin integrity- cleansing, barrier cream Promotion of comfort- clean & dry, reduced symptoms

Answer 199

Toileting schedule- q 2-3 h, before/after meals, tried in initial incontinence r/t cognitive/ mobility impairment, consistency, individualized Pelvic exercises for sphincter control (Kegel Exercises) Prevent urinary tract infections Catheterization- Intermittent (Straight, In & Out) or Indwelling (Foley)

Answer 200

closed drainage systems- free drainage by gravity. Urine should flow unobstructed. Securement device- females to inner thigh.

Answer 201

Maintain daily fluid intake of at least 2-3L if not contraindicated. Catheter irrigation and instillations- Continuous bladder irrigation Intermittent/ Straight cath or indwelling (5 French for infant, 16 fr for adult) Removal of indwelling catheter- Smoothly & slowly, Withdraw plunger slightly & allow to drain by gravity. Make sure catheter is intact after removal.

Answer 202

Male Incontinence Device/Condom catheters. Change condom cath Q 24h. PrimoFit Monitor urine for amount, color, clarity, and odor. Patient education very important regarding catheter and decreasing CAUTI Smallest catheter size possible. Discontinue as soon as possible. Keep bag below bladder for drainage. Never let bag touch the floor. Empty bag Q 4-8 h or when ½ full

Answer 203

Follow principles of surgical and medical asepsis Identify patients at risk for latex allergy (i.e., patients with history of hay fever; asthma; and allergies to certain foods such as bananas, grapes, apricots, kiwi fruit, and hazelnuts). Identify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.

Answer 204

moves food, cardiac sphincter at end of esophagus & stomach entrance- stops stomach reflux

Answer 205

storage, mix with digestive juices (HCl, mucus, pepsin, intrinsic factor) into chyme. Mucus protects stomach from acid

Answer 206

Internal & external sphincters- involuntary & voluntary control, sensory nerves

Answer 207

Infancy- small stomach, rapid peristalsis,

Answer 208

Fiber- bulk-forming foods such as whole grains, fruits, veggies- help remove fats & waste products more efficiently & decrease risk of colon cancer, may also produce gas- esp onions, broccoli, cauliflower, beans. Gas stretches abd walls, increases colon motility- may be painful post-op. Spicy foods can increase peristalsis, cause indigestion, or loose stools. Food intolerances- GI distress, diarrhea, gas, cramps

Answer 209

DAILY GOAL- Men- 3.7 L, Women- 2.7 L Enough for soft stools, fruit juices soften stools & increase peristalsis, prune juice- high fiber, warmed fluids- stimulate peristalsis

Answer 210

promotes peristalsis, immobility slows it down. Early & frequent ambulation after surgery, illness. Weakened abdominal & pelvic floor muscle tone- can’t bear down or control sphincter well, increased risk for CONSTIPATION. Long-term illness, spinal cord injury, neurological diseases

Answer 211

Depression-slow GI activity- constipation. Anxiety/ emotional stress increase digestion & peristalsis leading to gas distention, diarrhea. Stress worsens GI diseases such as IBS, ulcers, Crohn’s disease, ulcerative colitis

Answer 212

squatting, sitting to lean forward, exert abdominal pressure, contract gluteal muscles. 30-45 degrees for bed pan use, BSC if possible, ambulating to bathroom

Answer 213

hemorrhoids, rectal surgery, anal fissures (split in tissue), abdominal surgery

Answer 214

etus pressure on rectum, decr peristalsis- constipation, straining- hemorrhoids

Answer 215

general anesthetic agents stop or slow peristalsis- block parasympathetic nerve impulses. Any surgery that directly manipulates intestines STOPS peristalsis temporarily & causes ILEUS- for 24-48 hrs. Ambulation, activity, eating helps return to normal function.

Answer 216

opioids - pain control- slow peristalsis- constipation. Antibiotics kill normal flora- diarrhea. Laxatives or Cathartics soften stool, increase peristalsis. Laxatives- 1st fiber, 2nd osmotic. *Avoid stimulant laxatives long-term bc of intestine dependency due to decreased reflex to defecate.

Answer 217

clear view of gastric mucosa- NPO, clear liquids, laxatives or enemas to cleanse stool

Answer 218

Constipation SYMPTOM- of low-fiber diet, poor liquid intake, decreased activity, medications SIGNS- infrequent BM (<3/wk), hard & dry stools that are difficult to pass. Decreased peristalsis- fecal mass exposed longer to intestinal walls- more water loss

Answer 219

Impaction- unrelieved constipation & unable to expel the hardened feces in rectum. (Debilitated, confused, unconscious- dehydrated, weak or unaware of defecation need, stool dry & difficult to pass)

Answer 220

Sign- inability to pass stool for several days in spite of urge to defecate Oozing of liquid stools, feces leaks from above impaction. Anorexia, N&V, abd distention & cramping, rectal pain

Answer 221

inability to control passage of feces and gas from anus. Risk for Skin breakdown

Answer 222

gas accumulation within intestinal lumen. Mouth- belching or Anus- flatus. Abd fullness, pain, cramping, esp if slower peristalsis. Ambulation helps.

Answer 223

faster peristalsis, increase in stool #, liquid, unformed stool.

Answer 224

infectious agent such as bacteria, viruses, parasites; emotional distress, tube feedings; GI disorders. Infectious agents must shed through diarrhea but also lose bicarbonate, Antibiotics destroy normal GI flora & allow C.difficile to overgrow. SOAP & H2O handwashing essential to remove spores. Bleach 10% solution to clean surfaces

Answer 225

small sample (FOBT- fecal occult blood test) Guaiac- 3 samples No NSAIDS within 7 days of testing Avoid Vitamin C, fruits, fruit juices for 3 days Don’t eat red meats within 3 days of testing Positive results require flexible sigmoidoscopy or colonoscopy

Answer 226

Lighted FiberopticTube to visualize esophagus, stomach, and small intestine (Upper GI tract). Can remove polyps for biopsy. Anesthetic to throat, some clear liquids ok, NPO before & until gag reflex returns

Answer 227

NPO, bowel prep- Tube in to visualize LI/ colon, remove polyps for biopsy or find source of bleeding

Answer 228

NPO, drinks barium-opaque contrast solution, clear liquids and laxative day before; shows pharynx, esophagus, stomach.

Answer 229

barium enema- NPO, barium into anal opening, shows large intestine.

Answer 230

serum blood tests for hepatitis, pancreatitis (most accurate results after fasting – NPO)

Answer 231

obstruction or abnormality, no prep

Answer 232

how food moves through colon, swallows capsule with radiopaque markers, X-ray on 5th day

Answer 233

cross-section views, Oral and/or IV sedation-contrast dye- assess for any/all allergies for IV (older idea was for shellfish allergies) NPO 4-6 h before- depends on if oral contrast is used

Answer 234

magnet and radio waves to see inside body, NPO 4-6 h before, NO METAL objects on/in pt

Answer 235

elimination comfort teaching and learning/ patient ed fluid and electrolyte balance tissue integrity mobility

Answer 236

Routine time for defecation (Urge most likely one hour PC- GASTROCOLIC REFLEX mass peristalsis, Offer bedpan, BSC, BRP after each meal) Safety & comfort Privacy & modesty Abdominal tightening exercises 4X day Ambulation, activity (Best way to stimulate peristalsis) Low-residue foods for diarrhea- white rice, potatoes, bread, bananas, cooked cereals (BRAT diet) Skin integrity – no-rinse spray, barrier cream, assess skin around wafers of ostomies

Answer 237

Laxatives- bulk forming, stool softeners, osmotic- saline-based laxative, stimulant cathartics. Suppositories- may act more quickly than oral meds. (Goal- soft, formed brown stool w/o pain or difficulty) Chronic use- weakens bowel’s response to distention from feces-promotes dependency on laxatives. Antidiarrheal agents- slow motility, reabsorb fluid Antiflatulent agents- merge gas bubbles & help to pass

Answer 238

(Decompression, compression, enteral feeding, lavage) Clean- NOT sterile technique, Placement check= pH < 5 or less for stomach, X-ray- gold standard to verify placement, NG tube measured before placement from tip of nose to ear lobe to xyphoid process, water-soluble lubricant used for insertion(less toxic than oil if aspirated), Document length of tube extending from nares to help with placement check.

Answer 239

Bowel training, Chronic constipation, fecal incontinence 2nd to cognitive impairmt- timed toileting, hot drinks such as tea or juices (prune), privacy, nonhurried, exercise as able *make sure to take them when they have the urge

Answer 240

temporary or permanent opening (stoma) surgically created in abdominal wall to allow passage of fecal matter

Answer 241

pink or beefy red- NEVER purple or black or pale------ Call HCP immediately if so! Skin care- priority & body image. Skin wafer around stoma, bag to collect stool.

Answer 242

piece of large intestine; more formed stool from colon

Answer 243

piece of small intestine (More liquid, diarrhea like stool from small intestine) so increase fluids (drink 8oz for each emptying of bag). Avoid indigestible fiber- popcorn, corn, pineapple, Chinese cabbage, raw mushrooms, fresh pineapple. These foods may be eaten in small amounts, chewed well, and when drinking fluids with the foods.

Answer 244

Position client in left Sims Insert tube 3-4 inches for adult, 2-3 in for child. Hold tube 12-18 inches above anus as fluid instills. Clean not sterile technique. If c/o cramping, lower container & briefly pause solution. Ask to retain for as long as possible.

Answer 245

Stimulates BM- Risk of water toxicity

Answer 246

Irritant promotes bowel peristalsis

Answer 247

safest due to equal osmotic pressure, Volume stimulates peristalsis

Answer 248

commercially prepared, used for clients who can’t tolerate high-volume enemas

Answer 249

lubricates rectum & colon for easier stool passage

Answer 250

such as w/antibiotics to dwell for 1-3 h

Answer 251

iv = 3-5 minutes

Answer 252

im = 3-20 minutes

Answer 253

= 3-20 minutes

Answer 254

po = 30-45 minutes

Answer 255

IN THE LIVER

Answer 256

by lab draw just prior to the next scheduled dose (approximately 30 min before next dose).

Answer 257

up to 2 mL

Answer 258

up to 1 mL

Answer 259

up to 0.5 mL

Answer 260

- except don’t aspirate prior to giving immunizations (CDC, 2021)

Answer 261

By “piggyback” infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line

Answer 262

Older adults- Decreased thirst, ability to delay voiding, & bladder capacity. Increased urgency, incidence of overactive bladder & contractions, loss of bladder contractility (strength). Incontinence due to chronic illness, medications, mobility issues, cognition, nocturia.

Answer 263

manual compression of bladder to help with emptying

Answer 264

insert catheter at 90 degree angle to straighten urethra & ease insertion, insert until bifurcation to ensure balloon not inflating in prostatic urethra, secure to upper thigh or lower abdomen.

Answer 265

curvature at end to maneuver through enlarged prostate (Requires special training for insertion).

Answer 266

gauze w/ suction tube connected to suction, canister- Change Q 8-12h

Answer 267

Elderly- decreased chewing ability, Arteriosclerosis decreases GI blood flow, Innervation decreases esophageal emptying & peristalsis, Decreased perineal & sphincter muscle tone, taste bud atrophy, decreased gastric acid.

Answer 268

planned times after a meal when they have the urge

Answer 269

identifying times in the client's pattern to promote self control of defacation

Answer 270

1. check to see if suction equipment is working 2. later it might be necessary to get order for anxiety meds, irrigation, or removing and reinserting, but not at first

Answer 271

1. should be taken prn 2. if first dose doesn't relieve pain, seek emergency care and possibly 2 more tabs at 5 minute intervals 3. take 1 taab at first indication of pain 4. do not drink/eat until dissolved and observed

Answer 272

ng tube to suction

Answer 273

1. increased iron 2. decreased protein 3. decreased potassium 4. decreased salt

Answer 274

1. 2 RNs, 1 RN and 1 PN, cannot use an AP (assistive personell) 2. might premedicate with antipyretic but not an antiemetic 3. infuse over 4 hr to prevent bacteria growth 4. remain with pt for first 15-30 minutes

Answer 275

check the client's medical record for the prescription/order

Answer 276

you might get a stomach ache or indigestion the coating prevents breakdown in the stomach and decrease the possibility of gi distress

Answer 277

lower the height of the solution container to slow the flow momentarily. this allows the intestinal spasms to pass and then continue at a slower rate

Answer 278

1. excessive laxative use 2. ignoring the urge to defecate 3. inadequate fluid intake

Answer 279

uti there is presence of wbcs, rbcs, and bacteria

Answer 280

at the bedside before administration

Answer 281

slow the flow of solution briefly to prevent cramping

Answer 282

position client in supine position

Answer 283

urine output of 175 mL over 8 hrs. this is less than the norm of 30 ml/hr. it indicated fluid imbalance, decreased fluid volume, possibly inadequate renal perfusion

Answer 284

1. pull skin 1-1.4 inches down or to the side 2. insert needle quickly and smoothly 3. 90 degree angle 4. aspirate for 5-10 seconds

Answer 285

1. keep the open vial at room temp to reduce tissue injury and lipodystrophy 2. inject into subq tissue 3. not necessary to aspirate 4. mix compatable solutions to reduce qty of injections

Answer 286

1. clamp ng tube during auscultation 2. perform auscultation between meals 3. auscultate for 3.- minutes 4. auscultate prior to palpating to prevent alterations

Answer 287

1. effects begin within minutes 2. does not dissolve clots 3. stops new clots from forming

Answer 288

usually started after heparin po does not dissolve clots

Answer 289

after inspection before percussion

Answer 290

1. does not cause cardiac side effects 2. is an inhaled glucocorticoid 3. not administered with food 4. rinse after administration to reduce fungal growth 5. caffeine does not interact with this

Answer 291

calcium- decreased rbc- decreased wbc- increased magnesium- decreased amylase- increased

Answer 292

enzyme that changes complex sugars to simple sugars for body use produced by pancrease and salivary glands released into mouth, stomach, and intestines to aid in digestion with pancreatitis- elevates 12-24 hr and remains elevated 2-3 days

Answer 293

tap the top place a sterile gauze around the neck break off the top by bending it toward your body

Answer 294

initiate an incident report

Answer 295

18-24 hours and is administered once a day

Answer 296

1. ask Hx 2. inspect 3. auscultate 4. palpate 5. percuss

Answer 297

1. use 25-26 gauge needle 2. 3/8 inch or shorter needle 3. inject into abdomen above the level of the iliac crest 4. do not massage for 1-2 minutes

Answer 298

if pt is allergic to shellfish because the dye may cause reaction

Answer 299

1. verify med against Rx and med label 2. scan bar code on med and arm band 3. check orders and confirm dosage in pdr 4. document after administering

Answer 300

1. don clean gloves 2. assist to left sims position 3. hang container no more than 18 inches above 4. only insert up to 4 inches

Answer 301

discontinue the iv line

Answer 302

1. apply new patch each day 2. apply patch in the morning and leave for 12-14 hrs before removing in the evening 3. rotate sites to reduce local skin irritation 4. has delayed onset so good for prophylaxis but not for immediate relief

Answer 303

still under the tongue

Answer 304

send total qty of stool at one time to lab

Answer 305

collect in a culture tube with sterile and aseptic technique

Answer 306

warm stool samples over a period of days for evaluation

Answer 307

pull auricle up and out

Answer 308

pull auricle down and back

Answer 309

1. use non dominant hand to separate labia 2. dominant hand handles cath during insertion 3. coat tip with water soluble lubricant for comfort and tissue protection

Answer 310

1. monitor vs q2h 2. over 240 mL or 8 oz oral fluids every 4 hours 3. check iv site and monitor infusion q1h

Answer 311

1. increase fluids post procedure 2. you may have pink tinged urine post procedure 3. dark red urine should be reported because indication of bleeding

Answer 312

1. do not add amount of bladder irrigation to output 2. use sterile technique when preparing irrigation solution- many pt are older with other chronic diseases making more susceptible 3. ensure drainage tubing is patent and without obstruction or kinks is correct 4. if pt reports continual need to void, you will not need to contact dr because they already have an indwelling catheter that is giving this sensation 5. you may have a few small clots or pink tinged drainage but should contact dr if urine is bright red, ketchup like, large clots

Answer 313

1. dr may prescribe anticholinergic to suppress contractions and increase bladder capacity 2. limit fluids in the evening to prevent overload while sleeping 3. restrict caffein because it is an irritant 4. you won't need catheterization or vaginal repair as these are used in other types of incontinence

Answer 314

reflex incontinence

Answer 315

stress incontinence

Answer 316

1. decreased Na 2. decreased K+ 3. urine specific gravity 1.005-1.030 4. decreased hct to normal range

Answer 317

1. sunken anterior fontanel 2. hyperpnea 3. 13 % weight loss 4. capillary refill greater than 4 seconds

Answer 318

bladder infection

Answer 319

urinary hesitancy of difficulty initiating stream of urine

Answer 320

oliguria or a diminished urinary output

Answer 321

lack of intrinsic factor which is needed to absorb vit b12 from the gi tract. b12 is also needed to form rbc.

Answer 322

blood in urine

Answer 323

1. urinary retention 2. low back pain 3. inconfinence

Answer 324

less than 400 mL in 24 hr or less than 30 mL/hr

Answer 325

1. 5 lb weight gain in 24 hours (acceptable is 2 lb or less per day) 2. distended neck veins 3. o2 level less than 92 4. adventitious lung sounds indicating pe 5. edema

Answer 326

1. feeling pressure 2. tenderness over symphysis pubis 3. distended bladder 4. voiding 30 mL frequently

Answer 327

1. anxiety 2. disturbed body image 3. impaired skin integrity 4. infection

Answer 328

1. use non sterile object like a tongue blade unless culture where you would need sterile swab 2. sterile container is not necessary but should collect in dry container free of urine 3. place in clean biohazard bag that is labeled and prevents contamination and spillage during transport 4. send immediately to lab

Answer 329

1. cystitis

Answer 330

degenerative kidney disorder than can cause kidney ischemia and fibrosis

Answer 331

n&v fatigue

Answer 332

abdominal pain nausea leads to perionitis

Answer 333

improve strength and manage urinary incontinence kegels

Answer 334

when auscultating lung sounds

Answer 335

1. dribbling urine 2. overflow incontinence 3. indication of bladder distention

Answer 336

prescribed schedule bladder distention dribbling present

Answer 337

prevent bladder trauma or infection

Answer 338

regular schedule to drain flacid bladder with no longer than 8 hr between catheterizations

Answer 339

cause of hematuria so rbc in a ua is not a contraindication

Answer 340

a renal ultrasound

Answer 341

clear liquids

Answer 342

intake fluides to promote elimination of the dye

Answer 343

1. temporary urinary retention 2. if client does not urinate for 6-8 hrs after removal, reinsertion may be necessary 3. urinary frequency might be temporary but a couple of days indicates possible uti 4. there should be no blood in the urine nor should it be highly concentrated

Answer 344

hematocrit hct the therapeutic effect of this med is enhanced rbc production which is reflected in an increased rbc, hgb, and hct

Answer 345

antianemic indicated in those with anemia due to reduced production of endogenous erythropoietin which may occur with end stage renal disease or myelosuppression from chemotherapy

Answer 346

voiding a small amount of urine (less than 100 ml) frequently (2-3 qh) and dribbling of urine

Answer 347

kidney disease

Answer 348

diabetes mellitus

Answer 349

1. increased serum concentration of creatine 2. increased serum concentration of K+. 3. hyperkalemia- could rise quickly and become life threatening 4. increased serum concentration of Mg

Answer 350

dried apricots high fiber foods encourage cooked cabbage, bananas and other low fiber foods

Answer 351

limit phosphorous to 700 mg/day limit protein to 0.55-0.6 g/kg/day reduce foods high in K+ reduce foods high in Na

Answer 352

bounding pulse crackle of lungs pitting edema urine specific gravity greater than 1.030

Answer 353

1. cath q4hr 2. infrequent cath can result in stasis and uti 3. maintain increased fluid intake 4. suppository to stimulate bowel mvmt ever 1-2 days as appropriate

Answer 354

poor skin turgor tachycardia hypotension dark urine flat neck veins

Answer 355

1. ileostomy adaptation can occur over time 2. frequent draining 3. stoma should be pink to chery red but never pale, bluish, or dark 4. the skin around the stoma should be normal and not red

Answer 356

small intestine begins to perform some of the absorption function previously completed by the colon. causes a stool volume decrease. stool becomes thicker and paste like and turns yellow/gree/brown. reduces frequency of drainage

Answer 357

rbc unaffected protein unaffected Ca increased decreased K+

Answer 358

increased K+ (hyperkalemia) decreased ph metabolic acidosis hypocalcemia high Ca high PO elevated bun

Answer 359

diminished/absent bowel sounds N&V abdominal tenderness anorexia restlessness confusion tachycardia oliguria

Answer 360

inflammation of the peritoneum complication of peritoneal dialysis

Answer 361

relieves urinary retention never for nurse/staff convenience good for measuring residual urine after urination no for routine urine specimen good in case of open perineal wound

Answer 362

hand hygiene package to work surface open away open sides open closest to you use inner surface as sterile field

Answer 363

2/3 full to prevent leakage, skin irritation and infection

EXAM 3 Flashcards

FLUID, ELECTROLYTE, ACID/BASE, ABG, MEDICATION ADMINISTRATION, ELIMINATION, SPECIMEN COLLECTION WEEKS 7-9 (408 cards)