Final Flashcards
(186 cards)
1
Q
Liver cirrhosis can lead to?
A
An increase in ammonia levels
2
Q
High ammonia levels can cause what complication?
A
Encephalopathy (hepatic)
3
Q
What drug should you expect to administer for encephalopathy and what does it do?
A
Lactulose. Promotes frequent bowel movements to eliminate ammonia
4
Q
What can happen if a liver cirrhotic pt has constipation
A
Confusion can be caused.
Ammonia gas sits within the colon which can get reabsorbed by the bowel.
5
Q
High Potassium level what should the nurse expect to administer?
A
- Insulin IV
- Dextrose 50% IV
- Blood draw
Insulin drives the K+ back into the cell
Glucose prevents hypoglycemia
check K levels
6
Q
How do we initially treat small bowel obstruction?
What if upper GI discomfort
A
Rest the bowel with NPO status.
NGT is inserted to remove UGI contents and gas
7
Q
What is the nurse most concerned with for Vomiting?
A
Airway management
increasing risk of aspiration if lethargic
8
Q
What effect does a right hemisphere stroke have?
A
visual spatial deficit
affects left side (neglects left side)
hemiopsia vision
9
Q
Neuro changes in older adults might be?
A
An evolving stroke
10
Q
What is highest priority assessment with evolving stroke?
A
Dysphagia
11
Q
What do you monitor for with a TBI? and what is it?
A
Cushing’s triad
BP - widened pulse pressure
HR decrease (may not be brady)
RR - change in pattern (may be fast or slow)
12
Q
Nuerogenic Shock Symptoms
A
bradycardia
hypotension
Hypothermia
13
Q
Trauma Symptoms
A
tachycardia
hypotension
clammy skin
14
Q
During Shock what is the first nursing action?
A
Administer 100% O2 via nonrebreather mask
15
Q
Head trauma Symptoms
A
declining neuro status
shown by positive Babinski and low Glasgow
16
Q
Nurse must monitor for what in a head trauma?
A
Monitor for signs of increased intracranial pressure Papilledema Cushing's triad Decreases in Glasgow (slurred speech) Decorticate posture
17
Q
What is a classic sign of autonomic dysreflexia? and what is a nursing action?
A
Throbbing headache
Nurse should check for bowel or bladder retention
18
Q
WHat life threatening conditioning mainly affects patients with spinal injuries of T6 or higher?
A
Autonomic dysreflexia
19
Q
What does spinal cord injury:C5 and above affects?
A
Breathing
20
Q
Spinal cord injuries are classified by?
A
- Mechanism of injury
- Level of injury
- Degree of injury
21
Q
What causes stroke patients who have A-fib to be at higher risk of hemorrhagic stroke?
A
Warfarin (Coumadin)
22
Q
Chronic Pancreatitis is exacerbated by
A
ETOH ingestion
23
Q
Acute renal failure may be identified from which labs?
A
lab tests with results hyperkalemia and metabolic acidosis
24
Q
GI bleeds Nurse Considerations
A
Monitor stools for bright red blood per rectum (BRBPR)
monitor for rigid, board-like abdomen (which means large bleeds into abd cavity)
25
What qualifications are necessary to give pt Altipase (TPA)?
Pt presents within 3-4.5 hrs of symptoms
it must be an ischemic stroke (not hemorrhagic)
must have CT scan (to rule out bleeds in brain)
26
What can cirrhosis pts sequester? What does that causes?
Albumin which leads to massive ascites.
fluid would be yellow/ gold in color (albumin rich.
27
Renal failure may reveal which high electrolyte?
| What drug considerations must you monitor?
high K+
Let HCP know if pt is on Spirnalactone (K+ sparring meds)
Hold the meds
28
DIarrhea may cause?
| Nurse considerations?
electrolyte depletion
Replace electrolytes as ordered
if C-diff let the body continue to purge in order to lessen amount of C-Diff
No immodium to pt
29
Vtach Nurse considerations
assess the patient's level of consciousness
| Defibrillate if unconscious w/ pulseless
30
Fluid volume overload?
Drug management
Nurse considerations
loop diuretic furosemide
Monitor Serum K+ and NA+ levels
Monitor daily weight gain in HF
31
Monitor for decompensating Heart Failure?
Right Sided HF symptoms
Left Sided HF symptoms
R: JVD, pedal edema
L: pulmonary edema, auscultate for crackles
32
Heart Failure Maintenance care?
moderate tolerable activity.
Stable Na and K intake
Monitor Heart rate
Monitor Body weight
33
Beta-blocker use Pt education
Expect some orthostatic hypotension
| change positions slowly (from lying to sitting)
34
Prior to blood transfusion premedicate patient with
Diphenydramine and acetaminophen
35
Blood Transfusion
| Nursing Considerations
stay with the client for the first 15 to 30 minutes of infusion via a large bore venous access ( 20 gauge or larger)
36
Transfusion hemolytic reaction symptoms
Nurse Considerations
headache
low back pain becomes apparent w/in 15-30 min.
Immediately stop blood transfusion and infusion NS w/ new tubing
37
Transfusion access ports
PICC and triple lumen catheters have one 20 gauge and one 18 gauge both appropriate for transfusion.
PICC central line can be inserted in the upper extremity.
38
PICC care includes
flushing both lumens daily w/ 10 mls sterile NS to maintain potency
Sterile occlusive dressing needs to be changed weekly
Never advance a catheter that has been pulled out a couple inches
39
Diabetes Type I Insulin Pump Care
Change the needle at least every 3 days
40
Sick day care for DM I
monitor for ketones
monitor serum glucose
continue insulin regimen when sick
41
DM II Metformin education
No hypoglycemia
weight loss of approximately 8 lbs
best taken with evening meal
42
Hypothyroid maintenance
Monitor for symptoms associated w/ decreased metabolism, constipation, always cold
43
Osteoarthritis: OA
affects articulating cartilage
herbeden nodules affect DIPS (distal interphalanges)
Pt joint stiff & has pain on movement but will improve with activity
44
Multiple sclerosis Presenting symptoms
Numbness, weakness
| visual impairment/ sudden loss of vision de to optic neuritis
45
Normal Hgb and Hct
Hgb: 13.5 - 17.5
Hct: 41 - 53
46
Severe anemia requires
blood transfusions
47
Packed red blood cells Considerations
only contain red cells, so if 3-5 units are transfused know that they lack clotting factors
Pt needs fresh frozen plasma or clotting factors
48
Pre-renal failure
Signs and Symptoms
low or no urine output due to hypotension/shock
| must send urine to lab for specific gravity - which should be high
49
GI Bleed can result in Anemia
| Symptoms
Fatigue and/or SOB
| low Hgb can decrease oxygen carrying capacity
50
Why must you monitor Hemoglobin count with anemia?
Asses for oxygen carrying capacity of the blood
51
Must monitor pt on Heparin infusion for
| Nursing Considerations
must be prolonged range (60-80)
| electric razor use is suggested for shaving
52
In pre-op assessment monitor for
medication use and let provider know if use Anticoagulant or NSAID use
Procedures may need to be delayed (w/ anti-coags or NSAIDS use)
53
Dentist must be aware of which drugs use and what is done?
Anticoagulant or NSAID use in order to administer topical clotting agents in dental procedures
dental procedures are scheduled w/o discontinuing med
54
Thrombocytopenia (what is it and risk)
low platelet count
| Predisposes the client to bleeding tendencies
55
Normal Platelet Count
150,000 to 400,00
56
RA :(affects)
synovial joints bilaterally
57
Initial Rx for RA and nursing considerations
ASA, Steroids
high risk for GI Bleeds so check w/ Guaiac stools
58
Stronger Rx for RA and nursing considerations
Methotrexate
s/e is decreased WBC (<4000/uL)
59
Neurologic dysfunction can be expressed as
seizures
60
Antiseizure med Nursing considerations
Monitor for drowsiness, ataxia, diplopia
61
Seizure Nurse consideration Teaching
do not restrain limbs
do not stick anything into pt mouth
Educate pt: keep diary of them, can't drive care, can't take tub baths
62
Single most important action to prevent transfusion reactions?
Pt identification by two RNs
63
Glomerulonephritis can result from
1. viruses that cause measles or hepatitis
2. accumulation of antibody-antigen complexes & complement
ex. Strep
64
Common cause of Hemolytic jaundice
is blood transfusion reaction
65
Common cause of post-hepatic jaundice
gallstone obstructing the common bile duct
66
Most common cause Hepatic jaundice?
cirrhosis or hepatitis
67
Support care during tonic clonic seizure
Rescue position, loosen restrictive clothing, prepare to clear airway
68
seizure inpatient precautions
maintain patent IV access
padded siderails
suction setup
69
Airborne precautions are used for?
Shingles, Herpes Zoster, Chicken Pox
70
What to do with two patients with acid fast bacilli? Room situation wise?
They can room together
71
Systemic Lupus erythematosis, Nurse Considerations
internal organs may be affected as well (Kidneys)
| so monitor I&O
72
SLE Rx and use
Prednisone to stop the autoimmune hyperactivity
73
Postop stress may result in
Body retaining fluid so urinary output is decreased.
| Day 2 stress response decreases and urinary output increases
74
S&S of a Transfusion reaction
What is the nursing action?
Increased HR, Increased RR, back pain
Stop the transfusion and change to new tubing w/normal saline infusion
75
Hemodialysis (HD)
First session complication
First sessions may be complicated by disequilibrium syndrome
Rapid solute loss from the extracellular fluid causes mild cerebral edema
Pt may complain of nausea and headache
76
Anaphylaxis (What is it and Nurse Considerations)
known allergy to bee sting
1st action is to manage airway
1st medication action is to administer Epi-pen (stops histamine release)
77
Nurses first action during post op recovery?
Continuous monitoring oxygen saturation.
| Auscultate lungs to ensure breath sounds are clear.
78
ITP - idiopathic thrombocytopenic purpura
Nurse considerations
bleeding disorder in which the immune system destroys platelets.
Avoid IM or SubQ injections
79
HD education
teach the pt to monitor I&O
Take daily weight
Pt diet: limit Na and K+
80
Gall Bladder inflammation
Pt education
cholecystitis suffers do not always have GB removed
Education: low fat diet, choose poached or baked proteins, no fried foods, no fat desserts
81
Septic shock presentation
hypotension
82
Nursing action with septic shock
Administer IV fluids
| Administer ordered vasoconstrictor to raise the BP (norepinephrine)
83
Nursing considerations for Septic shock
Monitor for target organ perfusion w/ urinary output for >30ml/hr
84
Pressure Ulcers Stage III and Stage IV?
Stage III - involves subQ tissue
| Stage IV - deeper subQ tissue and also involves underlying fascia
85
Heparin induced thrombocytopenia (HITTS)
| What is it and how is it confirmed
an immune mediated clinico pathological syndrome initiated by heparin therapy.
Confirm with decreasing activated partial thromboplastin time
86
HD pts at risk for? What S&S?
at risk for fluid volume overload (FVO)
Assessment findings for FVO: tachypnea, JVD, bounding peripheral pulses, crackles @ bases of lungs
87
Dysphagia risk and nursing considerations?
swallowing disorders carry risk of aspiration
Nurse action: avoid thin liquids (Pt must have thickened diet?
88
Femur Bone Fracture - nurse consideration
Assess for Neurovascular issues
| Check for decreased sensation below the fracture
89
Osteoporosis - Results in and pt education
bones are weakened by loss of substance and loss of density
educate pt to walk every day to give the bones work
90
THA (total hip arthroplasty) Nurse Considerations
keep abductor pillow in place
Monitor for DVT
Educate pt when discharge don't cross legs
don't bend trunk to reach below waistline
Pt should use elevated toilet seat
91
Nurse consideration for emergency care sprains or fractures?
1. check pulse
2. stabilize lightly
3. apply ice to site
92
Assessment and actions are guided by what first?
Airway!!!!!!!
| If he's breathing what is the oxygen saturation
93
Intercranial Pressure (ICP) consist of
Pressure inside the skull
Brain tisse
CSF
Blood
94
ICP Pressure normal
7-15 mmHg
95
Nursing interventions for ICP increase
Position pt supine with HOB @ 30 degrees
| Limit head movements and turning of pt
96
Head injuries can cause?
Increase in ICP and Brain Edema
97
Increase of ICP Symptoms
```
change in Level of Consciousness
increasing Lethargy (ALWAYS REPORT)
```
98
Normal Sinus Rhythm
| Athletes HR
Normal 60-100 bpm and regular
| Athletes 50 bpm
99
What ECG dysrhythmia is lethal? and Nursing Action
V-fib
| Shockable rhythm - Grab Crash Card Defib or AED
100
What happens to patient if they have a really fast rate?
Pt feels racing n their chest
| The cardiac output drops and pt feels faint
101
Cancer - S&S
profound fatigue,
| increased risk for DVT due to decrease clotting time (make clots fast)
102
Cancer diets
should be high in calories and protein
| low in fats, low in empty carbs, not too many sweets
103
Hemophiliacs Nurse considerations and Educations
Danger of bleeding without knowing they are bleeding internally
Educate pt to seek immediate medical attention if have abdominal pain
104
UTI Teaching
Hydration will help physically wash bacteria off the bladder wall and decrease colonization
105
UTI (Cystitis)
| What is it and risk to kidney (S&S of kidney)
overgrowth of bacteria in the urinary system.
Bacteria can translocate to kidney
Pt may experience flank pain and develop pyelonephritis
106
Stress incontinence
| S&S and treatment
dribble of urine with sneeze
| May be improved with 3 months of pelvic floor exercises
107
Nurse considerations for GERD patients
lying patients flat can increase risk of aspiration
| Assess lungs
108
Hallmark symptom for hepatitis
Malaise
109
Hep. A transmission
oral fecal route including high fecal count in food
110
Hep. C. transmission
Blood to Blood - IV drug use, Transfusion, Hemodialysis - needle stick injuries
111
Ulcerative colitis flairs - Nurse considerations
frequent bloody stools require pt to be NPO in order to rest the gut
112
Craniotomy risk and Nurse considerations?
Infection (Meningitis)
Monitor for fever, shivering, increased WBC
Monitor for Kernig's sign
Monitor for 2-3 days
113
How do we diagnose ALS?
test reflexes which show abnormal or excessive movement at site or excessive movement seen at other parts of body
114
What happens to muscles due to ALS?
Atrophied and weakened
115
How do we diagnose MG?
test reflexes
| They are depressed and no excessive or involuntary movements
116
Glasgow Coma Scale
3-15
| 15 is normal and highest
117
AIDS diagnosis is made by
CD4 with T cell count of <200
118
HIV transmission
largely via sex or IV drug paraphernalia sharing
| Not transmitted by saliva
119
Functional incontinence and Nursing interventions
caused by barriers to toileting when urge presents
Managed by implementing a toileting schedule with assist
120
Irritable Bowel Disease (IBD) Dietary preference
Minimize fats
| stay away from fats w/ NCLEX
121
Ulcerative colitis - Monitor for?
holds potential for GI bleeding or peritonitis
be alarmed by rebound tenderness - call HCP
122
Stones/renal calculi Nurse intervention
Pain management
stones may move/irritate tissue
Pain and hematuria may alarm the pt.
123
Guillian Barre Syndrome
| Nurse Considerations
Ascending Paralysis
Monitor for when it reaches diaphragm
Concern of effective breathing
124
Parkinson's Disease (PD) S&S
Tremors (pill rolling), bradykinesia, limb rigidity
Passive ROM illicits cogwheel rigidity
125
Delirium
What is it and Nurse Teaching
confusion r/t illness hospitalization, meds
change in routine can be supported by having family to reassure them
126
Alzheimer's disease diagnosis
Can only be made when other causes of dementia are ruled out
Seek diagnosis as early as possible
so Aricept can be most effective
127
Nurse Consideration for Dementia
Reorient to place and time
128
IM injection procedure
Inject then Aspirate then inject into muscle
if get blood when aspirate: dispose of needle and med and start whole new process with new med, new syringe, new needle, new alcohol swab, new site
129
OPIOIDS - Nursing considerations
Can cause pupil constriction
decrease respiratory drive
decrease peristalsis
increase nausea and vomiting
130
Hormone replacement Therapy (HRT) - Nurse considerations
Monitor for safe administration
report complaints of lumb numbness or intense headache and calf pain
HRT increases risk of DVT
131
Thromboembolic elastic stockings used for?
| Nurse considerations
For peripheral venous disease to promote circulation
Stockings should be placed before getting out of bed in the morning
Legs should be elevated when not wearing stockings
Must be removed daily for skin check
132
What is given to expand intravascular volume?
Isotonic solutions of 0.9% NS or Lactated Ringers
133
Before IV removal Nurse Considerations?
Always assess IV site
134
Infusion Care for Peripheral IV site selection
Selection in the upper limb
Starting at or close to hand on side that has least complications
Don't use limb side of dialysis AV shunt or mastectomy site
Nondominant limb more convenient
135
IF IV site vein becomes compromised?
Fluids can leak into the surrounding tissue (extravasation) and may require removing catheter
May try flushing the line, temp. of fluid, or pH of infusion may cause intermittent discomfort but nothing is wrong w/ IV catheter
136
Discontinuation of IV site
Compare the site to the opposite entry
Put in the New IV before discontinuing initial catheter site
137
Ventricular tachycardia
assess pt LOC, if unconscious w/ pulseless vtach
dfib is indicated
138
Pacemaker teaching
Teach client to let providers know of pacemaker before procedures
139
Surgical Pre-op Teaching
Teach pt about what to expect in OR (drains, dressings, mobility limits, and how long each post op phase will last.
Teach splinting techniques to increase deep breathing and cough
140
Surgery Pre-Op allergy?
Identify especially if have iodine/shellfish allergy
141
Post anesthesia nursing Interventions?
Promote deep breathing and cough
Blow off CO2
Increase oxygenation
142
Post procedure Monitor which complaints
if abnormal VS readings - confirm equipment correctly working
Look at the patient and what is he exhibiting
143
Post op care with angiogram tests that involve catheter being placed in blood vessel
Clot may be dislodged to the lungs, heart or brain
monitor for pulmonary embolism or stroke (brain embolism)
144
Gastric hemorrhage suspected
```
NG tube is inserted to monitor rate of bleed
H2 blocker (ranitidine) decreases acid production
```
145
Situations of Respiratory distres nurses first action?
Always give Oxygen first
do not place in high fowlers first
146
Jackson-Pratt drains care
should be compressed after emptying.
Compressing and replacing the cap creates a vacuum that gently draws excess fluid from the site
147
Post-op nausea Nursing Care
may result in emesis.
If BP is normal position pt in High Fowlers
if hypotension - position side lying
148
Incisions
if edges are aligned we document them as approximated
if sides are pulled apart the wound has eviscerated
149
Evisceration - Nurse Care
maintain skin viability by applying sterile-soaked dressings to the wound
150
Osteomyelitis; Drug and Nursing Care
Antibiotic treatement of gentamycin requires monitoring for tolerance
Hearing can be ototoxic
Kidney ability for drug clearance must monitor Cr
151
Nutritional status monitoring
best by prealbumin level
23-43
152
Total Parenteral Nutrition (TPN)
Nursing care
Concentrated glucose infusion w/ elemental electrolytes, vitamins, minerals, and insulin (to counter increased glucose)
Must monitor blood glucose every 4 to 6 hours
Since solution is super sugar administer 50% of goal for first day to allow body to adjust
Cover catheter site w/ occlusive dressing
153
Thoracentesis procedure - Nurse care
Provide pain management before the procedure
Instruct the patient to take deep breaths after the procedure
154
Pleuravac Monitoring
Chest tube system is properly functioning if the water level is fluctuating in the chamber
fluctuation in water level reflects the client's respiratory cycle
155
Multidose inhalers Pt education
educate pt to wait a minimum of 1 min. between puffs and rinse mouth after use
156
Mechanical Ventilation via endotracheal tube (ETT)
| Nursing Care and Monitoring
Suctioning can stimulate the vagus nerve and drops the heart rate
if Hr drops while suctioning -->STOP and manually oxygenate the client w/ ambu bag
157
What to do when pt "fights the ventilator" mechanical ventilation via ETT
We try to "talk them down" with explanations for them to relax and allow the ventilator to work for them
158
Suction pressure
```
80-120 mmHg (green zone)
Insert catheter w/o suction
initiate cough
suction for 20 seconds
use intermittent suction while withdrawing catheter
```
159
Asthma
Treatment and S&S
Constricted airways will result in decreased forced expiratory volume (FEV) by 20%
forced vital capacity decrease
increased respiratory rate and decreased pulse ox.
Treatment - rescue albuterol
When the bronchodilator relaxes the constriction and improves measurements
160
COPD Nursing Considerations
low oxygen support (2L/min)
3000 ml/day to liquify secretions
give gauifenesin to mobilize secretions
Place pt in High fowlers position
161
TB diagnosis
Sputum is positive for acid fast bacilli
when ruling out TB; pt is placed respiratory isolation and may be cohorted w/ another patient positive for acid fast bacilli sputum
162
Acute renal failure (monitor what serum level)
associated w/ hyperkalemia
163
Dialysis (hemo) care post procedure must monitor
level of consciousness
164
Dialysis (peritoneal) nurse care
in drain phase, monitor for drainage
| monitor patient position for tube patency (no kinks)
165
Nephrectomy
Nursing Considerations
removal of kidney
immediate post-op monitor for hemorrhage
compensatory tachycardia due to blood loss
hypovolemic shock
166
Nephrostomy tube care
patient will have low grade fever (<100.4)
urine may be blood-tinged
urinary output is increased
Call HCP if pt reports back pain
167
Erectile dysfunction (Contraindication)
Nitrates,
| systemic venodilation can cause severe hypotension
168
Stress incontinence Education
instruct that adequate fluid intake is needed
It is dangerous to become dehydrated
Kegel exercises for at least a month may strengthen the pelvic floor
169
Irritable Bowel Diet
Promote 30 grams of fiber into daily diet
170
How do we check Bedside NGT placement?
NGT verified with pH that is <5
171
Immediate Burn Care
Manage airway,
| Administer aggressive IV fluids to support circulation
172
Stoma Skin Care
Surrounding skin can be protected from enzymes and bile salts in GI drainage
use skin barrier product before refitting pouch system
173
Hyperkalemia Signs
peaked T waves on ECG
174
Hypocalcemia S&S
muscle twitching, muscle spasms
175
Hypermagnesemia S&S
leads to depressed or absent deep tendon reflexes
176
High ammonia can result in
hepatic encephalopathy
177
Initial Nursing action with Heat Stroke
Initially must cool the patient
178
Initial Nursing action for Motor vehicle accident (MVA)
apply cervical collar to stabilize spinal column, spinal cord
179
Initial nursing action for Anxiety attack?
Must administer non-rebreather mask without oxygen and stay with patient
180
When pt complains of increasing pain in cast what should be nursing action?
Immediately Call Provider!!!
could be misalignment or development of compartment syndrome
poor circulation distal to fracture
181
Most concerning assessment in regard to cast care?
Pt complaint of tingling and numbness because it reflects changes to circulation and nerve function
182
Traction nursing care
log roll
maintain skin integrity
Weights must hang freely
Never place weights on floor
183
Rheumatoid arthritis (RA) non pharmacologic pain management
Can include alternating heat and cold to decrease joint inflammation
184
Hip replacement
| Anticipated finding and drug administration
site undergoes healing may be warm and red
Administer anticoagulant therapy due to high risk for DVT
185
Anticoagulant dose is appropriate when INR range is?
2.5-3.0
| PTT 2 times normal value
186
Sign of inappropriate blood clotting?
May be petechiae on the trunk
