Med Surg Pt. 2 Flashcards
(128 cards)
1
Q
To prevent deep vein thrombosis from developing with a patient with a cerebrovascular accident (CVA), what preventative measures should be included?
A
The used of sequential compression stockings, frequent position changes, and mobilization.
2
Q
What intervention should you implement to a stroke patient regarding a decreased endurance and impaired balance due to paralysis on one side of the body?
A
Frequent rest periods from sitting in the wheelchair should be provided by returning the client to bed after therapies and meals.
3
Q
What is shoulder subluxation?
A
Should subluxation can occur if the affect arm of a stroke patient is not supported. The weight of the arm is such that is can actually cause a painful dislocation from its socket.
4
Q
Interventions for should subluxation?
A
When sitting the client in bed, the wheelchair, or during ambulation should be accomplished with an arm sling or strategically placed pillows.
5
Q
Which side do you tell the client to hold the quad-cane with?
A
Have the patient keep the cane on the stronger side of the body.
6
Q
What are the steps to proper cane use?
A
- Keep the cane on the stronger side.
- Place the cane forward 15-25cm (6-10in), keeping weight on both legs.
- The weaker leg is moved forward to the cane so body weight is divided between the cane and stronger leg.
- The stronger leg is then advanced past the cane so the weaker leg and the body weight are supported by the cane and the weaker leg.
- Repeat.
7
Q
What is bariatric surgery?
A
Bariatric surgeries are done as a treatment for morbid obesity when other weight control methods have failed.
8
Q
Client education regarding bariatric surgery should include what?
A
Client education, regarding bariatric surgery should include:
- The client should be limited to liquids or pureed foods for the first 6 weeks.
- The client’s meal size should not exceed 1 cup.
- The client should walk daily for at least 30 minutes.
9
Q
Nursing action regarding postoperative meals for a patient who just had bariatric surgery.
A
- Provide 6 small meals a day when the client can resume intake. Observe for signs of dumping syndrome. The client’s first feeding may only consist of 30 mL of liquid.
10
Q
What are signs of dumping syndrome?
A
Cramps, diarrhea, tachycardia, dizziness, and fatigue.
11
Q
How long should a dietary restriction of liquids or pureed foods be implemented in a client who just had bariatric surgery?
A
The client should be limited to liquids or pureed foods for the first 6 weeks.
12
Q
What is a pressure ulcer?
A
A pressure ulcer (formerly known as a decubitus ulcer) is a specific type of tissue injury caused by unrelieved pressure the results in ischemia and damage to the underlying tissues.
13
Q
Interventions for health promotion and disease prevention of pressure ulcers include maintaining clean, dry skin and wrinkle-free linens.
A
- Appropriate use pressure-reducing surfaces and relieving devices.
- Inspect the skin frequently and document the client’s risk using a tool such as Braden Scale.
- Clean and dry the skin immediately following urine or stool incontinence.
- Apply moisture barrier creams to the skin of clients who are incontinent.
- Use tepid water (not hot), use minimal scrubbing, and pat the skin dry.
- Encourage clients to consume diets high in protein and vegetables.
- Encourage clients to take vitamin and supplements.
14
Q
Pressure ulcers nursing interventions:
A
Reposition the client in bed at least every 2 hours and ever 1 hour in a chair. Document position changes. and Providing adequate hydration.
- Place pillows strategically.
- Maintain HOB at or below 30 degrees, unless contraindicated.
- Keep client from sliding down bed (this increases shearing forces that pull tissue apart).
- Lift, rather than pull, client up in bed.
- Raise client’s heels off of the bed.
- Ambulate the client ASAP.
- Implement active/passive exercises.
- Do not massage bony prominences.
15
Q
In a patient with anemia how do you know if medication therapy has been effective?
A
Medication therapy is effective if the client’s Hgb (F12-16/M14-18) and Hct (F37-47%/M42-52%) levels return to a value within normal reference range and if the client reports less fatigue.
16
Q
A client you are caring for has a Hgb level between 6 to 10 g/dL, you know this is an indication of what?
A
The client with a Hgb level of 6-10 g/dL has anemia.
17
Q
What is the normal reference range for Hgb?
A
Normal Hgb Levels:
Females is 12-16 g/dL
Males is 14-18 g/dL
18
Q
What is the normal reference range for Hct?
A
Normal Hct Levels:
Females 37-47%
Males 42-52%
19
Q
What should you teach the client who is taking Folic acid supplements for anemia?
A
Tell them that taking Folic acid will turn the client’s urine dark yellow.
20
Q
Client education regarding iron supplements - ferrous sulfate (Feosol), ferrous fumarate (Feostat), ferrous gluconate (Fergon)
A
- Instruct the client to have Hgb checked in 4 to 6 weeks to determine efficacy.
- Vitamin C may increase oral iron absorption.
- Instruct the client to take iron supplements between meals to increase absorption.
21
Q
Do you take iron supplements with or without meals?
A
Instruct the client to take iron supplements between meals to increase absorption.
22
Q
How is parenteral iron administered?
A
Parenteral iron is administered using the Z-track method.
23
Q
When should a client be advised to have their Hgb levels checked if they are taking ferrous sulfate, or any other iron supplement?
A
Instruct them to have Hgb checked in 4 to 6 weeks to determine the efficacy.
24
Q
What vitamin aids in oral iron absorption?
A
Vitamin C may increase oral iron absorption.
25
What is anginal pain described as?
Anginal pain is often described as a tight squeezing, heaving pressure, or constricting feeling in the chest. The pain can radiate to the jaw, neck, or arm.
26
Which type of angina is relieved by rest or nitroglycerin (Nitrostat)?
Stable angina (exertional angina) occurs with exercise or emotional stress and is relieved by rest or nitroglycerin (Nitrostat).
27
How do you differentiate MI from angina?
Pain that is unrelieved by rest of nitroglycerin and lasting for more than 15 minutes differentiates an MI from angina.
28
True or False: Vasodilators such as nitroglycerin (Nitrostat) can cause orthostatic hypotension.
True: Vasodilators such as nitroglycerin (Nitrostat) can cause orthostatic hypotension so encourage the client to sit and lie down slowly.
29
Nursing consideration: Why is nitroglycerin (Nitrostat) given to patients?
It is given to treat angina and help control blood pressure.
30
Nitroglycerin: client education regarding response to chest pain:
- Stop activity and rest.
- Place nitroglycerin tablet under the tongue to dissolve (quick absorption).
- If pain is unrelieved in 5 minutes, the client should call 911 or be driven to an emergency department.
- The client can take up to two more doses of nitroglycerin at 5-min intervals.
31
Nitroglycerin: what is a common side effect?
Common side effect of nitroglycerin is headache.
32
Because the nitroglycerin can cause orthostatic hypotension, what do you want to do? (Patient education)
Teach the patient to sit and lie down slowly when changing position.
33
If the client's angina is unrelieved by one nitrostat tablet, what should you do?
Call 911 or be driven to the emergency department.
34
What are indications for a nontunneled percutaneous central catheter (triple lumen)?
Indications include:
- Administration of blood
- Long-term administration of chemotherapeutic agents
- Long-term administration of antibiotics
- Total parenteral nutrition.
35
How is TPN administered?
TPN administration is usually through a central line, such as a nontunneled triple lumen catheter or a single- or double-lumen peripherally inserted central line (PICC).
36
How long is a nontunneled percutaneous central catheter and how many lumen can it have?
15 to 20 cm in length with 1 to 3 lumens.
37
What is the standard length of use of a nontunneled percutaneous central catheter?
You can use it up to 3 months.
38
What is isotretinoin (Accutane) prescribed for?
Isotretinoin (Accutane) is used in patients who have acne and is prescribed only by a dermatologist.
39
How does Accutane work?
Accutane works against acne by effectively affecting factors involved in the development of acne.
40
A teen-aged patient who is pregnant wants to use isotretinoin (Accutane) to control her acne, what do you say to the patient?
isotretinoin 13-cis-retinoic acid is teratogenic. therefore, it is
contraindicated in women of childbearing age who are not taking oral contraceptives.
41
What is a big side effect of isotretinoin (Accutane) that must be monitored closely?
Depression, suicidal ideation, and/or violent behaviors are side effects of Accutane that must be monitored closely.
42
What is the purpose of TPN?
The purpose of TPN administration is to prevent or correct nutritional deficiencies and minimize the adverse effect of malnourishment.
43
How does TPN provide complete calories?
TPN contains complete nutrition, calories included through a high concentration of (20-50%) dextrose.
44
What is PPN
PPN is partial parenteral nutrition or peripheral parenteral nutrition is less hypertonic and is intended for short-term use in large peripheral veins. Usually dextrose concentration of 10% or less.
45
Is TPN a hypertonic solution?
Yes, TPN is a hypertonic solution.
46
If the TPN solution is unexpectedly ruined or the next bag is not available, what do you want to keep at the bedside?
Keep dextrose 10% in water at the bedside. This will minimize the risk of hypoglycemia with abrupt changes in dextrose concentrations.
47
Regarding, TPN, how often should to check capillary glucose?
Check capillary glucose every 4 to 6 hours for at least the first 24 hours.
48
What type of insulin will be needed in clients receiving TPN?
Clients receiving TPN frequently need supplemental Regular insulin until the pancreas can increase its endogenous production of insulin.
49
A newly licensed nurse states "never abruptly stop TPN" because she knows that...?
Never abruptly stop TPN. Speeding up/slowing down the rate is contraindicated. An abrupt rate change can alter glucose levels significantly.
50
A client is experiencing malabsorption/malnutrition, a complication of bariatric surgery, what should you teach the client in regards to how much servings of proteins to eat?
Tell the client to eat 2 servings of protein a day.
51
A client is experiencing malabsorption/malnutrition, a complication of bariatric surgery, what should you teach the client in regards to what kinds of foods to eat?
Tell the client to eat only nutrition-dense foods, Avoid empty calories, such as colas and fruity juice drinks.
52
A client is fluid overload, as a complication of TPN, why does this complication occur?
Fluid volume excess is possible due to the hyperosmotic solution (three to six times the osmolarity of blood), which poses a risk for fluid shifts.
53
In regards to TPN, older adults clients are more vulnerable to complication, particularly fluid and electrolyte imbalances.
Clients who have a history of congestive heart failure may need a more concentrated solution to avoid fluid overload.
54
Older adult clients need a more concentrated solution of TPN for what reasons?
Older adults clients are vulnerable to fluid shifts, so they needed a more concentrated solution to avoid fluid overload.
55
In regards to TPN, what is your priority nursing action for a client experiencing fluid overload?
Your first action is to assess the client's lungs for crackles and monitor him for evidence of respiratory distress.
56
What kind of pump do you want to use an intervention to prevent fluid overload, a potential complication of TPN?
Use a controlled infusion pump to administer TPN at the prescribed rate.
57
Nursing actions regarding fluid overload, a complication of TPN include:
- Assess the client's lungs for crackles and monitor him for evidence of respiratory distress.
- Monitor the client's daily weight and I&Os.
- Use a controlled infusion pump to administer TPN at the prescribed rate.
- Do not speed up the infusion to "catch up".
- Gradually increase the flow rate until the prescribed infusion rate is achieved.
58
Warn the client that excessive thirst of concentrated urine may be a sign of dehydration and the surgeon should be notified.
Dehydration is a potential complication of bariatric surgery. Notify the surgeon if this occurs.
59
As a complication of bariatric surgery, why does malabsorption occur?
Since bariatric surgeries reduce the size of the stomach or length of the intestinal track, fewer nutrients will be able to be ingested and absorbed.
60
As complication of Nasogastric decompression, why does strangulated obstruction/intestinal infarction occur?
Occurs when a portion of the intestine is twisted or the blood supply is compromised, which may cause ischemia.
61
As complication of Ostomies, why does Stomal ischemia/necrosis occur?
- Stomas should be pink or red and moist in appearance.
- Signs of stomal ischemia are pale pink or bluish/purple in color and dry in appearance.
- If stoma appears black or purple, this indicates a serious impairment of blood flow and requires immediate intervention.
62
As a complication of Ostomies, why does intestinal obstruction occur?
An obstruction can occur for a variety of reasons.
63
As a complication of Enteral feedings, why does diarrhea occur?
Diarrhea occurs secondary to concentration of feeding or its constituents.
64
As a complication of Enteral feedings, why does aspiration occur?
Pneumonia can occur secondary to aspiration of feeding.
65
As a complication of TPN, why does metabolic complication occurs?
Metabolic complications include hyperglycemia, hypoglycemia, and vitamin deficiencies.
66
As a complication of TPN, why does air embolism occur?
A pressure change during tubing changes can lead to an air embolism.
67
As a complication of TPN, why does infection occur?
Concentrated glucose is a medium for bacteria.
68
As a complication of Paracentesis, why does hypovolemia occur?
Albumin levels can drop dangerously low because peritoneal fluid removed contains a large amount of protein. The removal of this protein-rich fluid can cause shifting of intravascular volume, resulting in hypovolemia.
69
As a complication of Paracentesis, why does bladder perforation occur?
Bladder perforation is a rare, but possible complication.
70
As a complication of Paracentesis, why does Peritonitis occur?
Peritonitis can occur as a result of injury to the intestines during needle insertion.
71
A client with heart failure should consume what kind of diet?
A client with heart failure should consume a diet low in sodium, along with fluid restrictions and consult with the provider regarding diet specifications.
72
Teach the client experiencing heart failure to avoid smoking.
Health promotion and disease prevention of heart failure.
73
A client with pulmonary edema should consume what kind of diet?
A client with pulmonary edema should consume a diet low in sodium, along with fluid restrictions and consult with the provider regarding diet specifications.
74
When a patient is taking digoxin (Lanoxin) what do you want to teach them?
Take apical pulse for 1 minutes before taking the medication.
75
Administering furosemide (Lasix) for a patient with pulmonary edema, promotes what?
It promotes fluid excretion.
76
What is the expected pharmacologic action for furosemide (Lasix)?
furosemide (Lasix) blocks reabsorption of sodium and chloride and to prevent reabsorption of water. Extensive diuresis results.
77
What is therapeutic effect of furosemide (Lasix)?
High ceiling loop diuretics, such as furosemide (Lasix) are used when there is an emergent need for rapid mobilization of fluid such as:
- Pulmonary edema caused by heart failure
- Conditions not responsive to other diuretics such as edema caused by liver, cardiac, or kidney disease; hypertension
78
True or false: you should take digoxin (Lanoxin) at different times each day.
False. Take the digoxin dose at the same time as antacids.
79
Digoxin should not be taken at the same time as antacids. How long should the two medications be separated by?
Separate the two medications by at least 2 hours.
80
What are signs of digoxin toxicity?
Hint: 4 (F.M.C.L.)
- Fatigue
- Muscle Weakness
- Confusion
- Loss of appetite
Note: Instruct client to report these symptoms.
81
What is a contraindication of propranolol (Inderal)?
Propranolol is contraindicated in a patient with heart failure or pulmonary edema.
82
Subjective and objective data for Left-sided heart failure.
- Dyspnea, orthopnea (shortness of breath while lying down), nocturnal dyspnea.
- Fatigue.
- Displaced apical pulse (hypertrophy).
- S3 heart sounds (gallop).
- Pulmonary congestion (dyspnea, cough, bibasilar crackles).
- Frothy sputum (can be blood-tinged).
- Altered mental status.
- Symptoms of organ failure, such as oliguria (decrease in urine output)
83
Subjective and objective data for Right-sided heart failure.
- Jugular vein distention.
- Ascending dependent edema (legs, ankles, sacrum).
- Abdominal distention, ascites.
- Fatigue, weakness.
- Polyuria at rest (nocturnal).
- Liver enlargement (hepatomegaly) and tenderness.
- Weight gain.
84
Signs of digoxin toxicity?
- Fatigue.
- Muscle weakness.
- Confusion.
- Loss of appetite.
85
What is the expected reference range of Sodium?
Na+ = 136 to 145 mEq/L
86
What is the expected reference range of Potassium?
K+ = 3.5 to 5.0 mEq/L
87
What is the expected reference range for Chloride?
Cl = 98 to 106 mEq/L
88
What is the expected reference range for Calcium?
Ca = 9.0 to 10.5 mg/dL
89
What is the expected reference range for Magnesium?
Mg = 1.3 to 2.1 mEq/dL
90
What is the expected reference range for Phosphorus?
P = 3.5 to 5.0 mg/dL
91
What is hyponatremia?
Hyponatremia is a net gain of water or loss of sodium-rich fluids that results in a sodium level less than 136 mEq/L.
92
Nursing care for a patient with Hyponatremia.
- Report abnormal lab findings to the provider.
- Fluid overload: Restrict water intake as prescribe by the provider.
- For clients with heart failure and hyponatremia, provide loop diuretics and ACE inhibitors.
- Restoration of normal ECF volume: Administer isotonic IV therapy (0.9% sodium chloride, Ringer's lactate).
- Monitor intake and output, and daily weights.
- Monitor vital signs and level of consciousness, report abnormal findings to the providers.
- Encourage the client to change positions slowly.
93
Nursing care for acute hyponatremia.
- Administer hypertonic oral and IV fluids as prescribed.
- Administer 3% sodium chloride slowly and monitor sodium levels frequently.
- Encourage foods and fluids high in sodium (cheeses, milk, condiments).
94
Care after discharge: patient with hyponatremia.
- Encourage the client to weigh daily and to notify the provider of a 1 to 2 lb gain in 24 hours, or 3 lb gain in a week.
- Instruct the client to consume a high-sodium diet, including reading food labels to check sodium content, and keeping a daily record of sodium intake.
95
A client is experiencing acute hyponatremia as a complication of hyponatremia, what are the nursing actions for this client?
- Maintain an open airway and monitor client's vital signs.
- Implement seizure precautions and take appropriate action if seizure occurs.
- Monitor the client's level of consciousness.
96
A patient with angina/MI is being discharged, what is the priority teaching?
- Instruct the patient to monitor and report signs of infection, such as fever, incisional drainage, and redness.
- Teach the client to avoid straining, strenuous exercise, or emotional stress, when possible.
97
What are signs of infection?
Hint: (3) F.I.R.
- Fever.
- Incisional drainage.
- Redness.
98
Health promotion and disease prevention of a client with seborrheic dermatitis includes:
- Keep the skin dry; avoid overheating and perspiring.
| - Do not scratch the pruritic lesions.
99
What is seborrheic dermatitis?
A skin disorder caused by inflammation of areas of the skin that contain a high number of sebaceous glands.
100
How is seborrheic dermatitis characterized?
Seborrheic dermatitis is characterized by papulopustules (oily form) or flaky plaques (dry form) that form on the surface of the skin. Dandruff is an example.
101
What are the two medications for seborrheic dermatitis?
(1) Topical corticosteriods.
| (2) Antiseborrheic shampoos.
102
What is a positive Kernig's sign?
A positive Kernig's sign is characterized by resistance and pain with extension of the client's leg from a flexed position. This is a physical assessment finding for a patient with Meningitis.
103
Client education regarding position after a liver biopsy:
Instruct the client to lie on the affected side after the biopsy in order for hemostasis to occur.
104
What denotes a positive Mantoux test?
An induration of 10mm indicates a positive Mantoux test. An induration of 5mm indicates positive reaction in immunocompromised patients.
105
After a CABG, encourage the client to splint the incision while deep breathing and coughing.
This is an appropriate post-procedure nursing intervention.
106
Ambulation and movement after a CABG include:
- Dangle and turn client from side to side as tolerated within 2 hour following extubation.
- Assist the client to a chair with 24 hours.
- Ambulate client 25 to 100 ft by first postoperative day.
107
Client education on ways to prevent and monitor for infection, after a CABG.
- Instruct the client to monitor and report signs of infection: fever, incisional drainage, and redness.
108
Client education regarding activities after a CABG.
Week 1 - Remain home and resume normal activities slowly.
Week 2 - possible return to work part time, increase in social activities.
Week 3 - Lighting of up to 15 lbs, avoidance of heavier lifting for 6 to 8 weeks.
109
When can clients resume sexual activity following a CABG?
Clients can resume sexual activity based on the advice of the primary care provider. Walking 1 block or climbing 2 flights of stairs symptom-free generally indicates that it is safe for the client to resume normal sexual activity.
110
Discharge teaching for a client with an abdominal hysterectomy.
- Instruct the client about a well-balanced diet that is high in protein and vitamin C for wound healing, and high in iron if the client is anemic.
- Instruct the client to restrict activity (heaving lifting, strenuous activity, driving, stairs, sexual activity) for 4 to 6 weeks.
111
What is glaucoma?
Glaucoma is a disturbance of the functional or structural integrity of the optic nerve. Decreased fluid drainage or increased fluid secretion increases intraocular pressure (IOP) and can cause atrophic changes of the optic nerve and visual defects.
112
What is the leading cause of blindness?
Glaucoma is the leading cause of blindness. Early diagnosis and treatment is essential in preventing vision loss from glaucoma.
113
What is the expected reference range for IOP?
10 to 21 mm/Hg.
114
Subjective and objective findings for Angle-closure glaucoma include:
- Rapid onset of elevated IOP.
- Decreased of blurred vision.
- Seeing halos around lights.
- Pupils are nonreactive to light.
- Sever pain and nausea.
- Photophobia.
115
Subjective and objective findings for Open-angle glaucoma include:
- Loss of peripheral vision.
- Decreased accommodation.
- Elevated IOP (> 21 mm Hg)
116
What is a positive Cullen's sign?
A positive Cullen's sign is characterized by a Bluish periumbilical discoloration due to the seepage of blood-stained exudates into the tissue.
117
Following an ERCP, what do you want to withhold from the patient?
Withhold fluids until the client's gag reflex returns.
118
Postprocedure intervention of an ERCP: Monitor for
Monitor and notify the provider of bleeding, abdominal or chest pain, and any evidence of infection.
119
Signs of hemorrhage after a ERCP include:
- Bleeding.
- Cool clammy skin.
- Hypotension.
- Tachycardia
- Dizziness
- Tachypnea.
Note: If these occur, the PCP should be notified immediately.
120
After the ERCP, instruct the client to report:
- Fever.
- Pain.
- Bleeding.
121
When are chest tubes clamped?
Due to the increase risk of causing a tension pnuemothorax, chest tubes are only clamped when ordered by the provider in specific circumstances, such as air leak, during drainage system change, accidental disconnection of tubing, or damage to collection device.
122
What happens when you strip or milk the tubing from a chest tube?
Stripping creates a high negative pressure and can damage the client's lung tissue.
123
What do you do during accidental disconnection, system breakages, or removal of chest tube systems.
If tube separates - exhale as much as possible and cough. The nurse should clean tips and reconnect.
If drainage system breaks - the nurse should immerse the end of the tube in sterile water to restore water seal.
If the chest tube is accidentally removed, an occlusive dressing taped on only three sides should be immediately placed.
124
Clinical manifestations of hepatitis B include:
Influenza like symptoms: Headache. Fatigue. Arthralgia and myalgia. Pruritus.
- Low grade fever.
- Right upper quadrant abdominal pain.
- Nausea and Vomiting.
- Jaundice.
- Dark Urine.
125
Laboratory findings in Hepatitis.
- Elevated ALT, AST, and ALP.
| - Elevated bilirubin (0.1 to 1.0 mg/dL)
126
ABG Interpretation:
pH: 7.35 - 7.45 (acidosis or alkalosis)
PaCO2: 45 - 35 (respiratory in origin)
HCO3: 22 - 26 (metabolic in origin)
127
Client education: Pacemakers
Avoid avoid microshock, advise the client not to use an electric razor or blow dryer.
128
Assess the client for hiccups, which may indicate that the generator is pacing the diaphragm.
Report signs of dizziness, fainting, fatigue, weakness, chest pain, hiccuping, or palpitations.
