Physiological Adaptation Flashcards
What is the most effective way to prevent infection?
handwashing
The simple step of handwashing appropriately is the most effective way to prevent infections.
The LPN suspects the client has hypocalcemia & inflates an upper arm blood pressure cuff above the systolic blood pressure for a few minutes. What is the LPN testing for?
Trousseau’s sign
Clients with hypocalcemia will demonstrate Trousseau’s sign after the blood pressure cuff is inflated for about 3 minutes. If the client develops a carpal spasm in the arm, the client is positive for Trousseau’s sign.
When removing a chest tube, the LPN should ask the client to perform the ___ maneuver.
Valsalva
When a chest tube is removed, the client should be asked to take a deep breath, exhale forcible, & bear down when the tube is pulled. This is called the Valsalva maneuver.
Clients with ileostomies are at increased risk of ___.
electrolyte imbalance
When a client has an ileostomy, food does not pass through the large intestine. This impacts how electrolytes are absorbed or excreted. Clients with ileostomies should be monitored closely for electrolyte imbalance.
Angling the head of bed to ___ helps to prevent ventilator-associated pneumonia.
30-45 degrees
Keeping an intubated or ventilator dependent client’s head of bed elevated to a minimum of 30-45 degrees will assist in secretion management and avoid pooling of secretions that can cause pneumonia.
What is the ideal range for intracranial pressure?
5-15 mmHg
In most clients, the ideal range for intracranial pressure is 5-15 mmHg.
What is the normal value for a client’s temperature?
98.6 degrees Fahrenheit (or 37 degrees Celsius)
While there are minor variations, especially in pediatric clients, the “normal” value is 98.6 degrees Fahrenheit, which is converted to 37 degrees Celsius.
Which stage of seizure does not occur in all seizure types?
aura
Auras may occur in focal seizures & tonic-clonic seizures. They do not occur in absence, atonic, or myoclonic seizures. The four stages of a seizure follow this order: prodromal, aura (if applicable), ictus, & post-ictus.
The umbilical cord has how many arteries & how many veins?
two arteries & one vein
The umbilical cord has two arteries & one vein. The acronym AVA is commonly used to remember this.
When removing sutures or staples, in what order should the sutures or staples be removed?
Every other suture or staple first
The LPN should remove every other suture or staple & apply a dressing after each to monitor for wound dehiscence.
When irrigating an infected wound, what is the ideal flow for the irrigation fluid?
from the least contaminated to most contaminated
When irrigating a wound, the LPN should have the fluid flow from the least contaminated area to the most contaminated area when possible. This helps prevent additional contamination and/or infection.
___ occurs when an organ protrudes from a separated surgical wound.
eviseration
Dehiscence & evisceration are both disruptions of an open wound following surgery. Evisceration occurs when the wound edges separate (dehiscence) and internal organs protrude from the wound.
What should the LPN instruct the client to do following each dose of an inhaler that contains a steroid?
rinse his or her mouth
Rinsing the mouth or gargling warm water following each dose will ensure that there is no residual medication left in the mouth & prevent oral candidiasis.
What IV line complication is more serious: infiltration or extravasation?
extravasation
Extravasation occurs when there is an IV line infiltration & caustic medication infiltrates the surrounding tissue. This can cause significant tissue damage.
The ideal window to administer antithrombotic medications in the event of a suspected thrombolytic stroke is ___.
3-4 hours
For maximum impact, antithrombotic medications should be administered as soon as possible in the event of a thrombotic stroke. This will ideally occur within 3-4 hours of the initial event.
