Passpoint 2 Flashcards by Jade Ring

Why is 20mL of urine output a concern for a nurse with a client who just suffered from MI

Oliguria is a sign of cardiogenic shock, due to reduced blood flow to the kidneys.

Low BP
Rapid weak pulse
Confusion due to reduced blood flow to brain

Cardiogenic shock is serious with 90% death rate

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Which is most important for a client with pertussis

A. Gloves & Gown
B. Negative Pressure Room
C. Masks for everyone
D. Use goggles for direct contact with child

Pertussis (whooping cough) is spread via droplets

Masks requiered for first 5 days after start of medical treatment

TB, Measles, Varicella need negative pressure

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Respiratory Alkalosis S/S

Respiratory Acidosis

Alkalosis = lightheaded / paresthesia

Acidosis = Nausea, Vomit, Diarrhea

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Left-sided heart failure S / S

Right-sided heart failure

Left = pulmonary edema, bibasilar crackles (Bubbling orcracklingsound originating from the base of the lungs. Occur inflation or deflation)

Right = jugglar vein distention, right quadrant pain (hepatomegaly), and dependent edema (Gravity Caused feet & hands) - Usually Chronic

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Cystitis is …

an infection of the bladder that almost always follows (is secondary to) bacterial infection in the urine. It is the most common type of urinary tract infection (UTI), particularly in women.

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After surgery

Establish air patency
Check: Bleeding, VS, and promote urine output

VS: HR 130, BP 98 / 56, Respiration 24

These are signs of

Shock

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rare condition caused by a combination of four heart defects that are present at birth.

defects cause oxygen-poor blood to flow out of the heart and into the rest of the body.

Risk factors include a viral illness such as rubella during pregnancy, maternal alcoholism, or a family history of the condition.

Tetralogy of Fallot

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Polyneuritis

disorder affecting several or many peripheral nerves, especially when thought to be of inflammatory origin.

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Guillian-Barre syndrome
(Immune system attacks the nerves)
which assessment is most important

Lungs
ICP
pain
Metabolic State

Lungs

Polyneuritis causes weakness and paralysis, which may ascend to the trunk amd lungs

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Which will help a client with thick secretions

A. Elevation of bed 30 degrees
B. Turning q2hrs
C. Increase of fluids
D. Cool room temperature

Increase fluids

Helps to thin the thickened mucous

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Match

Wheezing in Single lung field

Decreased / absent lung sounds in base of lungs & decreased Ox Sat

Wheezing Bilateral lung fields, coughing, shortness of breath

Acute bronchitis

Atelectasis

Aspiration pneumonia

Wheezing in Single lung field

Atelectasis

Decreased / absent lung sounds in base of lungs & decreased Ox Sat

Acute bronchitis

Wheezing Bilateral lung fields, coughing, shortness of breath

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IV corticosteroids are prescribed for asthma, bronchitis, ______

Anaphylaxis

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Client has an obstruction due to foreign body aspiration

What is required to remove it

Bronchoscopy

Bronchoscope, a thin, flexible tube with a light and camera on the end, to look for signs of blockages or disease in the throat, airways, and lungs

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_____ aka ataxic or Biot’s breathing, is a dangerous, irregular, unpredictable deep breaths followed by periods of apnea.

Alert HCP

Cluster breathing

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Which is most important for nurse to include in discharge for asthma patient with a Rescue Inhaler

Monitor HR
Report Nausea/ Vomiting
Watch for hyperactivity
Record change in taste

Monitor Hr

Tachycardia is the most serious SE of rescue inhalers

All other SE are valid

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A lesion in the upper medulla or lower pons is usually the cause of (this type) of dangerous breathing

cluster

pattern characterized by rapid, shallow, rhythmic breathing cycles in clusters, followed by periods of apnea

Biot’s respiration

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Sucking stab wound in chest gets covered with gauze and tape on 3 side.

Why is this done?

Prevent pneumothorax (Collapsed Lung)

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Cardiac tamponade (Fluid in pericardial sac) is a medical emergency

It prevents ____ from filling with blood

Manifestaciones

Pulsus Paradoxus ( condition where a patient’s blood pressure drops by more than 10 millimeters of mercury (mmHg) during inspiration.)
hypotension, chest pain, jugular distention, diminished heart sounds

Left ventricle

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Tension pneumothorax occurs when an injury to the chest allows air to enter but not leave the pleural space.

What can be the result of this

Shifting of heart to uncompromised side

Result

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Why would a patient with Emphysema have respiratory Acidosis

A. Narrowed bronchioles and decreased oxygen

B. Increased work of breathing

C. Increased production of mucus, lack of oxygen

D. Alveoli lost elasticity, retains carbon dioxide

Alveoli lost elasticity, retains carbon dioxide

Narrowed bronchioles and increased mucus production is characteristics of chronic bronchitis which causes Hypoxemia

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Crackles are typically heard (inspiration/ expiration) can be high or low pitched and classified as fine or course.

Inspiration

Pneumonia, acute respitory syndrome, pulmonary edema

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____ embolism is a relatively rare but serious consideration 24 - 48 hrs after an injury to a Long Bone.

Fat

The fat breaks down into fatty acids which are toxic to the lungs, result maybe pulmonary hypertension

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Volkmann contracture….

a deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm. Th

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Lower abdominal surgeries:

This position helps gravity pull intra-abdominal organs away from the pelvis, allowing for better access to pelvic organs. It’s used for colorectal, gynecological, and genitourinary procedures.

Central venous catheter placement: This position is used to place a central venous catheter in the internal jugular or subclavian vein.

Hypotension: This position is often the first measure used to treat hypotension.

Vagal discomfort: This position is used to treat vagal discomfort.

Robotic procedures: This position is often used for patients undergoing robotic procedures

Name this posistion

Trendelenburg

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First priority for a child with vomiting and diarrhea is to replace fluid and electrolytes. Dehydration puts them at risk for which serious complication

Heart Arrhythmia caused by hypokalemia <3

Promethazine is a medication used to manage and treat allergic conditions, nausea and vomiting, motion sickness, and ____

Sedation

What is considered a normal urine output per hour.

30 - 50 mL

Which of the following are suggested with loop diuretics A. Reduce sodium B. Use salt substitutes to enhance food flavor C. Adivse HCP if edema occurs D. Take meds on regular schedule E. Take meds with evening meal

A, C, D

How many wet diapers daily should a 1 week old have

6 - 8

Destruction of malignant cells during chemotherapy causes large amounts of _____ and tubular obstruction from the crystals. Allopurinol reduces this build-up Intervention: Increase fluid intake

Uric acid

Which IV solution is compatible with blood infusions

0.9% NS

Client returns from cardiac step-down unit following cardiac catheterization Which information should be obtained first Lab values Neurological status Puncture site appearance Skin warmth and tugor

Puncture site appearance

During discharge of a client with an ileostomay to treat IBD, the nurse should stress the importance of A. Increase fluid prevent dehydration B. Wear appliance only at bedtime C. Consuming low protein, high fiber D. Take only enteric coated pills

A. Stool usually forms in large intestines Ileostomy drains mostly liquid poop Extra water is needed to prevent dehydration Avoid high fiber foods - may bother intestines Avoid enteric coated bc body cant absorb them

Accessing 4 year-old prepheral IV line and notice its not infusing. What would be the first action

Resposistion the child's extremity. Most likely reason of IV not infusing is postitional issues of the child or extremity

Which Score is used 1& 5 minutes after birth to access the health of a newborn Describe 5 characteristics & scoring What is a dangerous score

APGAR score Breathing effort Heart rate Muscle tone Reflexes Skin color 0 - 2 Zero = Worst <6

What is a normal urine output ratio

0.5 mL / kg / hr

SIADH which is the most likely outcome A. Cerebral edema B. Hypovolemic Shock C. Hyperkalemia D. Tetany

Cerebral edema is seen in SIADH Due to the hypotonic/ hypovolemic the hypotonic fluid will go into the hypertonic brain fluid

First time dialysis patient what should you monitor

Neurological Status First time may have confusion/ seizures

First time dialysis, monitor for

Neurological Status Common confusion/ seizures first time

Kegel exercises can be performed in any position 2x daily and 10 minutes Strengthen pelvic muscles When will changes be noticed

6 weeks

To prevent nausea how long should a client wait after eating dry foods to drink water.

30 minutes

Episiotomy, also known as perineotomy, is...

surgical incision of the perineum and the posterior vaginal wall generally done by an obstetrician. This is usually performed during second stage of labor to quickly enlarge the aperture allowing the baby to pass through

Bandage: joints, ankles, elbow, wrist, knee This technique

Figure 8

Bandage: use this technique to anchor a Bandage

Circular

Bamdage: Stump, hand, scalp

Recurrent

Bandage: increasing circumference. Ie. A cast

Spiral reverse

Reiki is based on which principal of healing.

Energy from hands being placed lightly or at a distance can be used to heal

Can muslims have caffeine

Yes

Chloroxazone is a centrally acting skeletal muscle relaxant used to treat (acute / chronic) symptoms

Acute

What is the first intervention in the home environment fir minor and major burns

Place affected area in cool water to stop the burn

Discomfort at IV site. Blanching around site Swelling, coolness to touch WBC within normal range What is occurring A. Infiltration B. Phlebitis C. Infection D. Infection & Infiltration

A. Infiltration (IV fluid goes into tissues rather than vein) Discontinue and restart at different site Phlebitis is evident by redness at cannula tip and long length of vein

Significant hypotension doesnt occur until ___ % of volume loss occurs

Right sided heart failure Assess for Intermittent Claudication Dyspnea Dependent edema Crackles

Dependent edema: aka pitting edema, buildup in the veins, which leads to swelling in the feet, ankles, and legs. Rigjt sided heart failure: venous congestion result: peripheral edema, splenomegaly, hepatomegaly, neck vein distention. Left heart failure: Dyspnea & Crackles associated with pulmonary edema Intermittent Claudication = arterial occulsion

_______ is pain in the arms or legs that occurs while walking or using the arms. It can also feel like a cramp or fatigue in a muscle group of the lower extremity. Claudication is caused by too little blood flow to the legs or arms. It can be a symptom of _______ In most cases, lifestyle changes, exercise, and medications can slow or reverse the symptoms. Two drugs, cilostazol and pentoxifylline, are approved for treatment of intermittent claudication

Claudication peripheral artery disease (PAD).

Match Serous Purulent Clear, watery plasma Thick yellow tinged

Serous Clear, watery plasma Purulent Thick Yellow Tinged

Partial thickness burns Which IV is given first Albumin D⁵W Lactated Ringers solution 0.9 NS woth 20 mEq of potassium per 1,000 mL

Lactated Ringer's Replaces sodium & corrects metabolic acidosis, Both occur after burn Albumin is ised as adjunct therapy D⁵W isn't given during first 24 hrs , due to pseudo-diabetes effect Client after burn is Hyperkalemic, potassium would be contradicted

(Negative/ Positive) pressure wound therapy Applies subatmospheric pressure Increase local blood flow Reduce drainage Stimulate Granulation Tissue

Negative

Tropin levels (increase/ decrease) with ischemia and necrosis of cardiac muscle

Increase

Fasciotomy is a procedure to relieve ____ syndrome

Compartment

S/S this skin disease include: Painless, dry, flaky, rough patches of skin with bumps, maybe itchy Usually on Hands, Feet, Face, Chest, Neck Caused by: Stress, exacerbated by hot showers and lack of moisturizer

Atopic dermatitis aka eczema

Skin disease Proliferative inflammatory disease, well-demarcated erythematous, papules and plaques covered in Silvery Scales. (Usually appear on knees, elbows, extremities, scalp)

Psoriasis

High levels of ____ in blood can suggest a autoimmune disease such as Rheumatoid Arthritis, Scleroderma, Systemic lupus erythematous

Rheumatoid Factor (RF) is a protein produced by the immune system that can attack healthy tissue in the body

Sever itching in both hands worse at night. Gray-brown burrows with epidemal curved ridges and follicular papules. Is indicative of....

Scabies

Normal albumin levels What does albumin do? Causes hypo/hyper S/S hypo/hyper

3.5 - 5 Basically, same as K Albumin keeps blood in veins Causes Hypo: Liver / Kidney disease, malnutrition Hyper: Dehydration/ diarrea S/S Hypoalbuminemia Swelling, dry/itchy skin, thin hair, Hyper: No specific s/s

During IV infusion of a chemotherapeutic vesicant drug, the nurse observes that there is a lack of blood return from the IV catheter. What would the nurse do first

Stop Administration of Drug IV catheter with no blood return is most likely occluded or not patent. Infiltration or extravasation of vesicant drug into tissues can cause severe damage

vesicant drug....

Causes blisters or necrosis

_____ causes blanching, cyanosis, coldness, numbness, and throbbing pain in the hands when client is exposed to COLD or STRESS

Raynaud’s Phenomenon

______, also known as ringworm of the body, is a fungal skin infection . It's a common, contagious, but not serious infection that can often be treated with an over-the-counter topical fungicidal medication.

Tinea corporis

82 yrs resident LTC reports Burning, Stabbing Pain left flank wraps around to abdomen Next day, small red vesicular lesions around left flank. Which disease may it be

Herpies zooster Shingles

Post-herpetic neuralgia is..

a lasting pain in the areas of your skin where you had shingles