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Flashcards in Exam 3 462 Deck (152):
1

Describe Dawn Phenomenon

  • occurs for everyone
  • Hyperglycemia all night long
  • An abnormal early-morning increase in blood sugar (glucose) — usually between 2 and 8 a.m.

1

Describe a Non-tunneled CVAD

  • inserted directly into a central vein and is associated with a higher risk of infection
  • either the chest or the neck
  • can be inserted quickly at the bedside
  • Dwell Time less than a month

2

Risk factors for type 2 diabetes include all of the following except: "a. Advanced age
b. Obesity
c. Smoking
d. Physical inactivity"

C. Smoking

2

Non-pharmacological interventions for pain

  • Reposition
  • massge
  • Heat/Cold compress
  • Distraction
  • Elevation
  • Humor

3

Signs and symptoms of DKA

  • dehydration
  • tachycardia
  • dry loose skin
  • eyeballs soft/sunken
  • anorexia
  • kushmal respirations
  • orthostatic hypotension.

3

What does alcohol do for diabetic

  • high risk for hypoglycemia
  • impaire liver glucose production- glycogen breakdown
    • EAT carbs prior to alcohol consumption

3

What is the oxygen concentration for a nasal cannula?

  • 24-44%
  • 1-6 LPM

Victims w/ difficulty breathing, unable to tolerate mask

3

Normal Value for Chloride

95 - 107 mEq/L

4

What symptoms might an older woman with diabetes mellitus complain?

perineal itching

Rationale: Older women might complain of perineal itching due to vaginal candidiasis.

5

nursing diagnosis for a patient with advanced respiratory diseases.

  • Hyperthermia Related to Infectious Illness,
  • ineffective airway clearance,
  • pneumonia
  • pulmonary embolism
  • Activity Intolerance
  • Inadequate Nutrition
  • Social Isolation
  • Impaired Gas Exchange.
  • Anxiety.
  • Risk for Infection
  • Ineffective Coping
  • Fatigue.
  • Ineffective Breathing Pattern
  • Insomnia

6

Name 4 examples of an acute illness?

  1. Pneumonia
  2. Delirium
  3. Shingles
  4. Apendicitis

8

"A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. Following assessment of the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of

rapid, deep respirations

8

Glucose Value 2 hours after eating

Up to 140

9

Brown rice is what type of food

low glycemic index, a steady increasy in blood sugar

9

Create labs for someone with metabolic acidosis

low pH low HCO3

10

Name the primary veins for peripheral IV insertion

 

cephalic, median, cubital, basilic

11

Left Sided Heart Failure

  • Most Common
  • Pulmonary Congestion
  • Crackles
  • Poor Oxygenation
  • S3, Increase Afterload
  • Irregular Palpitations
  • Pulmonary Edema
  • Diastolic and systolic dysfunction
  • Blood backing up into right atria

12

What does insulin do to potassium level

push potassium back into the cells,

13

What is a good diabetic meal plan

  • guidelines for how we are all supposed to eat
  • focused on the amount of carbohydrates.

14

Intradermal Needle Size and Gauge

  • 3/8 -1/2"
  • 26-28G

14

Clinical Manifestations for a patient with Venous Insufficienty

  • Pooling of blood in the legs
  • Damage to valves in the veins
  • Eczema
  • Edema
  • Leathery brown skin

15

5 Reasons a nurse would avoid an area of the hand or arm for IV insertion

  1. Impede ADL's
  2. Tender, Red, Rash, Infected
  3. Paralysis, Dialysis, Shunt or Mastectomy
  4. Site distal to previous venipuncture
  5. Distal to sclerosed, hardened, or phlebitic veins

16

An acute metabolic condition, usually is caused by absent or markedly decreased amounts of insulin

Diabetic ketoacidosis

17

Diabetes Mellitus Type 1- Signs & Symptoms

3P's

  • Polydipsia (thirst)
  • Polyuria (urine)
  • Polyphagia (hunger)

18

Characteristics of Circulatory Overload

  • Excessive amounts of isotonic/hypertonic solution
  • Too Rapid
  • Overload is associated w/ increased risk of death

19

What ahould the nurse do if he/she believes a patient is a hypoglycemic?

  • Determine if they can swallow, could aspirate
    • check gag reflex
  • Check Blood glucose, if less than 70
  • If can swallo, give them carbohydrate, skim milk. Protein prevents rebound effect

19

What direction is the bevel facing for an intradermal medication

up

19

Diagnostic Testing for Heart failure

  • BNP
  • ANP
  • Creatnine Kinase
  • Troponin
  • Fibronogen
  • Chest Xray
  • EKG
  • Coronary Angiogram
  • Echogram

20

What is the highest priority for a patient with DVT or VTE

Skin Integrity b/c of amputation risk

21

Aspiration Pneumonia Definition

  • Aspirated something into their lungs

  • Decreased LOC

22

Lab Value when fully compensated

pH will be normal

23

The nurse is teaching a community class to peole with Type 2 diabetes mellitus. What is the explanation for that?

Cells become resistant to circulating insulin

Normally insulin binds to special receptor sites on the cells and initiates a series of reactions involved in metabolism. In Type 2 diabetes these reactions are diminished primarily as a result of obesity and aging."

24

Care for DKa

  • Fluid/electrolyte imbalance
  • normal saline 0.45%
  • blood glucose level
  • acidosis
  • IV insulin

25

If a diabetic has ketoacidosis what will potassium be?

  • hyperkalemia
  • hypovolemia
  • Renal failure

26

What angle do you hold the needle for an average sized subQ injection?

45 degrees

28

Explain polyphagia for diabetes

We get hungry because our cells are starving for energy.

29

What should diabetic patient due prior to exercise

eat a snack. No need for carbohydrate intake when blood glucose lis over 100 before activity.

29

Fats for diabetic

  • Less than 200 mg/day
  • less than 7%

29

"When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask?

lost any weight? Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy.

29

This type of illness is sudden.  It can last 3-6 months. It can also be reversed

Acute Illness

30

A blood sugar is well controlled when hemoglobin A1c is what percentage?

7%

31

HYPER- glycemia mneumonic

hot/dry sugar high

31

Nursing Diagnoses for patient with VTE

  • Ineffective Peripheral Tissue Perfusion
  • Acute Pain
  • Risk for impaired physical mobility
  • Risk for Embolization
  • Impaired Skin Integrity

32

When administering an intradermal injection, what angle should the nurse position the needle for insertion?

5-15 degrees

33

Trauma Assessment Priorities

  • Airway
  • Breathing
  • Circulation
  • Disability
  • Examine
  • Fahrenheit
  • Get vitals
  • Head to toe assess
  • Intervention

33

What is the oxygen concentration for a Resuscitation mask w/ oxygen inlet (simple mask)?

  • 35-55%
  • 6-15 LPM

Victims who are NOT breathing, or difficulty breathing

34

Clinical Manifestations for Hypervolemia?

  • Pulse is bounding JVD
  • High BP
  • Tachypneic
  • dyspnea
  • crackles
  • headache, confusion, muscle spasms
  • Anorexia, weight gain, ascites
  • peripheral edema

35

"A frail elderly patient with a diagnosis of type 2 diabetes mellitus has been ill with pneumonia. The cliet's intake has been very poor, and she is admitted to the hospital for observation and management as needed. What is the most likely problem with this patient?

Hyperglycemic hyperosmolar non-ketotic coma.

35

How far should the drip chamber be filled?

1/3 -1/2 full

36

"What insulin type can be given by IV?

Regular Insulin

37

Etiology for Thromboembolism

  1. PICC line
  2. Bed Rest
  3. Previous Hx
  4. Heart Failure
  5. COPD
  6. Smoking
  7. Obesity

38

the leaking of IV fluid into the tissue surrounding the vein. This occurs when IV fluids continue to be delivered even though the tip of the catheter is no longer in the vessel or is blocked.

Infiltration

38

Acutal Problem means

we have evidence (AEB)

38

A well written nursing diagnosis contains 3 components

Diagnosis,

Related To

As Evidence By

39

What is the name of the device which controls the IV flow rate for gravity infusion?

Roller Clamp "EID"

39

Administration of an intermittent IV medication such as an antibiotic, given in a small IV bag of fluid is called..

Secondary IV solution (Piggy Back)

40

If someone has diabetes but not ketoacidosis they are

hypokalemia

40

PE interventions?

  • Rotate patient
  • High fowlers
  • oxygen (non-rebreather)
  • Continuous vital signs
  • I/O's
  • Anticoagulants/Thrombolytics

41

A patient is admitted with diabetes mellitus, has a glucose level of 380 mg/dl, and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which of the following respiratory patterns would the nurse expect to find?

Kussmaaul Respirations

 

the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored.

43

Complication of Type II Diabetes

Hyperosmola hyperglycemic syndrome

44

Normal Value PCO2

34-45

44

Normal Value for Potassium

3.5 - 5 mEq/L

45

Describe a port CVAD?

  • for patients who require long-term, intermittent vascular access
  • completely under the skin, there is no need to cover the device while bathing or showering
  • less frequent flushing

47

Insulin Definition

allows sugar to go from the blood into the cells for energy.

 

48

Define Ventilator Acquired Pneumonia

  • 48 hours after intubation, before the onset of the event

49

6 Rights of Medication Administration

  1. Patient
  2. Time
  3. Medication
  4. Dose
  5. Route
  6. Documentation

50

Acute pain is directly related to...

tissue damage

52

Intermediate Acting Insulin Onset/Peak

onset 1 to 2 hours, peak 6 to 14 hours

54

The guidelines for Carbohydrate
Counting as medical nutrition therapy for diabetes mellitus includes

  • Flexibility in types and amounts of foods consumed
  • Including adequate servings of fruits, vegetables and the dairy group
  • Applicable to with either Type 1 or Type 2 diabetes mellitusb. Unlimited intake of total fat, saturated fat and cholesterol"

55

Hyperglycemia

dry skin, dehydrated

56

Short Acting Onset/Peak

onset 30-60 min, peak 1 to 5 hours

57

what is lipodystrophy

scar tissue, if you do not rotate injection sites

58

IV calcs for regulating an IV pump are usually measured in...

hours

60

Techniques for increasing venous distention in preparation for needle insertion

 

  • apply tourniquet 6-12" above chosen site
  • apply warmth to extremity for several min.

61

What angle do you hold the needle for an obese patient for a SubQ injection

90 degrees

63

"The risk factors for type 1 diabetes include all of the following except:
"a. Diet
b. Genetic
c. Autoimmune
d. Environmental"

A. Diet

65

"The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with Type 1 diabetes at 1600. Which action should the nurse implement?

 

  • ensure the client eats the bedtime snack
  • Humulin N peaks in 6-8 hours, making the client at risk for hypoglycemia around midnight
  • This snack will prevent nighttime hypoglycemia.

66

What is the oxygen concentration for a non rebreather mask?

  • Up to 90%
  • 10-15 LPM

Breathing victims only

67

Normal Value for HCO3

22-26

68

What is the problem with exercise and insulin site location?

it can metabolize too quickly

70

HYPO glycemia

cold clammy need candy

71

A normal fasting (no food for eight hours) blood sugar level is

between 70 and 99 mg/dL

73

Explain Polyuria for diabetes

The body tries to remove excess glucose by producing extra urine. The body then requires more water.

74

What degree angle for an IM injection?

90 degrees

75

The nurse determines the patient's IV has infiltrated. What would be the appropriate action by the nurse?

  • Stop the infusion
  • Monitor patient
  • apply heat or cold for hypotonic or isotonic
  • apply cold for hypertonic

76

How long can hypoglycemia occur after exercise

up to 48 hours

77

SubQ needle size and guage?

  • 5/8"
  • 25G

78

Reasons for hypovolemia

  • ng drainage,
  • burns (3rd spacing),
  • dehydration,
  • shift of plasma into interstitial spaces,
  • peritonitis,
  • ascites (abdomen)

79

This is the inadvertent administration of a vesicant fluid or solution into the surrounding tissue

Extravasation

80

What is Acute Arterial Ischemic Disorder?

  • Sudden interruption in arterial blood supply to an organ or tissue
  • May orginiate from aneurism, or left sided heart failure

82

Diabetes is balancing what

insulin, diet, exercise

83

nursing assessment data which would require immediate medical intervention for a patient with arterial insufficiency.

A resting ankle-brachial index less than 1 is abnormal

84

Rapid Acting

onset 10-15mintues

peak 30 to 90 minutes.

85

Describe the purpose of pursed lip breathing in the COPD Patient

To reduce overall work of brathing

87

What is a treatment for dawn phenomneon?

increase insulin at bedtimes

88

Whenever insulin is peaking what should we be wathcing for?

hypoglycemia

89

IM / Z-Track needle size and gauge?

  • 1-1/2"
  • 21-23G

2" if patient is obese

89

When is immediate action required for a patient with pneumonia

respiratory rate increases above 20/min

91

Benefits of using an insulin pump

  • fewer swings
  • increased flexibility in diet
  • accuracy of insulin doses and delivery;
  •  

92

What is the timeframe of administering and IM injection?

1mL every 10 seconds

93

How do you replace potassium (hypokalemia)?

  • Never IV Push
  • Oral
  • Monitor I/O
  • Potatoes, Avocado, Banana

94

Types of Insulin

  • long acting (basal) once a day
  • rapid/short acting (bolus) before meals

95

Hypoglycemia- Signs and Symptoms

 

TIRED

  • Tachycardia
  • Irritability
  • Restless
  • Excessive hunger
  • Diaphoresis/Depression

96

Respiratory Acidosis Labs

  • pH Low
  • PCO2 High

98

Describe a PICC line

  • inserted in the upper arm but its tip goes past the shoulder and ends in the superior vena cava.
  • chest x-ray is done to confirm proper placemen
  • less risk for phlebitis/infiltration
  • stay in place for a year or more
  • IV therapies that continue for 4 wks

100

Hyperosmolar Hyperglycemic Syndrome

  • which high blood sugars cause severe dehydration, increases in osmolarity and a high risk of complications, coma and death.

101

This type of illness lasts longer than 6 months. The onset is gradual, and irreversible.

Chronic illness

102

What is the oxgen concentration for a bag valve mask (BVM)?

  • 90% or more
  • 15LMP or HIGHER

Victims who are not breathing/having A LOT of difficulty breathing

102

What is the core problem a patient would have with PE

perfusion

103

What information should be listed on IV site dressing? x4

  1. Guage
  2. Date
  3. Time
  4. Initials

105

Which electrolyte replacement should the nurse anticipate being ordered by thehealth-care provider in the client diagnosed with DKA who has just been admitted tothe ICD?

1.Glucose.
2.)Potassium.
3.Calcium.
4.Sodium

Potassium

105

This is the term for
inflammation of the walls of a vein.
 

phlebitis

106

Long Acting Insulin onset/peak

onset 70 minutes, peak none

107

Treatment for HHS

  • FLUIDS FIRST
  • serious dehydration
  • normal saline

108

blood urea nitrogen (BUN)

8 - 21

8 bun twists x 3

110

The nurse is caring for a client who has normal glucose levels at bedtime, hypoglycemia at 2am and hyperglycemia in the morning. What is this client likely experiencing?

The Somogyi Effect

111

What happens in type 2 diabetes?

  • the pancreas produces insulin, but the insulin is insufficient for the body's needs or the cells do not respond to the insulin appropriately.

112

Signs of COPD

  • productive cough for 3 or more months in each of 2 successive years
  • Dyspnea
  • Chronic Fatigue
  • Bluish Red Color Skin
  • Pulmonary Hypertension

114

What is the cornerstone of care for a person with diabetes

meal plan

115

Clinical Manifestation for PE

  1. dyspnea/tachypnea
  2. dry cough
  3. distended neck veins
  4. cyanosis
  5. hypotension
  6. Dysrhymia
  7. Impending doom
  8. chest pain
  9. Blood tinged sputum
  10. sudden death

117

Lab values when only partially compensated

all three values will be abnormal. One value will be working harder to compensate.

119

Labs for someone with Metabolic Alkalosis

High pH High HCO3

120

Name some SubQ injection sites?

  1. outser aspect of the upper arm,
  2. Abdomen below costal margin
  3. Anterior aspect of the thigh

121

Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment?

  • A) BP 126/80
  • B) A1C 9%
  • C)FBG 130mg/dL
  • D) LDL cholesterol 100mg/dL

B) A1C 9%

122

Describe the patient with advance COPD and Cor Pulmonale

  • Damaged to lung tissue

  • Acute respiratory failure

  • Depression/anxiety.

  • Anger.

  • Pulmonary Hypertension.

123

A client with diabetes melllitus has a blood glucose of 644mg/dl. The nurse intreprets that this client is most at risk of developing which type of acid base imbalance?

metabolic acidosis

The body breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis."

124

Minimizing Risk for DVT/VTE

  • Exercise
  • Walk
  • DO NOT cross legs
  • Ted Hose

125

a chemical agent that causes burns and destruction of tissue both internally and externally

Vesicant

126

What is the technique for administering IV Bolus (push)

  • Flush w/ normal saline first
  • administer medication
  • Flush again
  • Monitor Pt's tolerance
  • Document any adverse effects

128

What are 2 groups of drugs for diabetes

  • Insulin- subQ, not given orally b/c destroyed by gastric enzymes
  • antidiabetic agents

129

Glycemic Index

  • how fast blood sugar rises, based on the carbohydrate containing food

130

Type 2 diabetes meal plan

calorie reduction, achieving glucose control, blood pressure, high fiber

131

Signs (AEB) Hypokalemia

6L's

  1. Lethargy
  2. Lethat cardiac arrhthymia
  3. Leg cramps
  4. Limp Muscles
  5. Low, shallow respirations
  6. Less stool (constipation)

132

When discontinuting an IV for a paitent who is receiving anticoagulant medication such as heparin, the nurse should hold pressure on the IV site for how many minutes?

5-10 minutes

133

Protein for diabetic

15-20%

135

Calculate the IV flow rate for 1200 mls of NS to be infused in 6 hours. The infusion set is calibrated for drop factor 15 gtts/mL=_____gtts/min?

 

1200/6= 200

200x15/60(for minutes)=

50 gtts/min

136

What are 4 examples of Chronic Illness

  1. Diabetes
  2. COPD
  3. Parkinsons
  4. MS

137

What is the term used to clear the tubing of air before administering fluids to a patient?

Priming

138

Hospital Acquired Pneumonia

  • Occurring 48 hours or longer after admission
  • Not incubating at time of hospitalization

139

Discharge instructions for a patient with peripheral vascular disease

  • look at feet every night
  • avoid exposure to cold or hot
  • wear loose clothing
  • stop smoking
  • avoid caffeine
  • Monitor blood glucose

140

When on an anticoagulation for VTE, how should vitamin K be used?

even and consistent

141

What hand should you use for initial IV site selection?

non-dominant hand

142

Name a side effect of the insuline pump?

weight gain

143

Describe a Tunneled CVAD

  • inserted into a central vein and the remainder is tunneled subcutaneously to a distant exit site
  • tunneling helps secure catheter in place & reduce infection
  • inserted in the chest
  • placed in a surgical or radiology suite
  • may remain in place for several months to years

145

A nurse is caring for a client with type 1 diabetes mellitus. Which client complaint would alert the nurse to the presence of a possible hypoglycemic reaction ?

classically as nervousness, irritability, and tremors.

146

A nurse is preparing a plan of care for a client with diabetes mellitus who has hyerglycemia. The priority nursing diagnosis would be:

Deficient fluid volume.  An increased blood glucose level will cause the kidneys to excrete the glucose in the urine

147

What is the cause of JVD

  • Right Sided Heart Failure
  • increase the central venous pressure and the amount of jugular vein distention.

148

The 6Ps of Acute Arterial Ischemic Disorder

  1. Pain
  2. Pallor
  3. Pulselessness
  4. Parasthesia
  5. Poikilothermia (inability to maintain temp)
  6. paralysis

149

Clinical Manifestation of a patient with Chronic Arterial Disease

  • Arteries narrowed
  • Atherosclerosis
  • Inc Risk for Heart Attack/Stroke
  • Pallow
  • Parasthesia
  • Inadequate around boney prominents
  • Gangrene/Amputation
  • Weak Pulses

150

Name 3 location sites for IM injection

  1. Vastis Lateralis
  2. Deltoid
  3. Ventrogluteal

151

The client, an 18-year-old female, 5'4'' tall, weighing 113 kg, comes to the clinic for a wound on her lower leg that has not healed for the last two (2) weeks. Which diseaseprocess would the nurse suspect that the client has developed?

Type 2 diabetes is a disorder that usually occurs around the age of 40, but it is now being detected in children and young adultsas a result of obesity and sedentary life-styles. Wounds that do not heal are a hall-mark sign of Type 2 diabetes.

152

If the patient is NOT alert enough to swallow and is hypoglycemic?

  • 50% dextrose IV
  • or Glucagon IM, SubQ
    • takes awhile to kick in