TEST 2 Flashcards
(143 cards)
1
Q
Impaired gas exchange related to ___ AEB dyspnea, restless, pulse of 89%.
A
ventilation-perfusion mismatch from clot blocking pulmonary circulation
2
Q
Ineffective peripheral tissue perfusion related to ____ AEB history of smoking , BP 198/100, diminished pulses
A
vasoconstriction of peripheral blood vessels
3
Q
Bedrest during acute phase, avoid massaging extremity, administer increase fluid intake with cardiac tolerance, warm compresses to extremity, give 10,00 units heparin subcutaneously
A
interventions for nursing diagnosis of ineffective peripheral tissue perfusion
4
Q
noninvasive study to identify blood clot
A
Doppler ultrasound
5
Q
major surgery, cancer, pregnancy, oral contraceptives, immobilization
A
risk factors for developing thromboembolism
6
Q
Contrast studies are used to visualize flow in blood vessels in many parts of the body - pulmonary angiography, cardiac angiography, etc. because contrast medium (dye) must be excreted through the kidneys, certain chemicals can destroy kidney function, before performing contrast studies such as angiography, check to see the creatinine level is normal and ask about this before performing angiography or contrast studies
A
allergies to iodine, sea food. contrast dye
7
Q
calf pain, swelling, tenderness, prolonged immobility
A
clinical manifestations of DVT in leg
8
Q
d-dimer, PT/INR, PTT
A
lab tests that identify clotting problems
9
Q
patient has history of alcoholism, liver is damaged, expect to find jaundice, clay-colored stools, itchy skin, amber colored urine, bruises, increased clotting times
A
AST 60, ALT 45
10
Q
kidneys are functioning normally
A
creatnine 1.2
11
Q
Liver is functioning normally
A
AST 15, ALT 10
12
Q
decreased glomerular filtration rate, hypertension, decreased urinary output, elevated BP
A
Creatnine 3.0
13
Q
artificially elevated when patient has dehydration, hemoconcentration
A
hemoglobin, hematocrit, BUN, other lab values
14
Q
patient is on Coumadin and is at risk for bleeding
A
PT 36, INR 3.5
15
Q
patient is on heparin and needs to have heparin dosage increased
A
PTT is 30
16
Q
teach causes of FVE
A
information is key to self management problems
17
Q
instruct patient to avoid NSAIDS (ibuprofen) and other steroids
A
these medicines can cause fluid retention
18
Q
administer IV fluids, if ordered, through an IV infusion pump
A
ensures accurate deliver of IV fluids
19
Q
collaborate with pharmacist to maximally concentrate IVs and medication
A
decrease use of unnecessary fluids
20
Q
on patients that are on a ventilator to support respirations, elevated HOB 30 degrees, provide oral care, administer H2 (histamine 2 blockers) and antacids to decrease gastric acid secretions that could be aspirated into lungs
A
CDC guidelines to prevent nosocomial (hospital acquired) pneumonia
21
Q
medicines that reduce the risk of infection and prevent removal of granulating skin
A
topical silvadene, Neosporin, sulfamylon
22
Q
monitor for temperature >38.5 C, monitor wound for erythema or presence of odor
A
burn patients are at great risk for infection
23
Q
keep body and limbs in correct anatomical position
A
prevent contractures (shortening) of muscles
24
Q
monitor for disorientation, fever, ileus (hypoactive or absent bowel sounds)
A
infection may have spread to blood and patient may be going into septic shock
25
reduces swelling in legs and feet
elevate extremities
26
this medicine would be given prophylactically to treat complaint of heart burn; prevents formation of gastric acid that burns lining of stomach and esophagus
Protonix
27
patient has CAD- coronary artery disease; this medicine is given in pediatric dosage to keep clots from forming in the coronary arteries; it is a platelet inhibitor
aspirin 81 mg daily
28
this medicine is given to lower elevated cholesterol, triglycerides, LDLs and increase HDLs that contribute to CAD
pravastation 20 mg daily
29
give this medicine by mouth twice a day
Metoprolol 25 mg BID po
30
this medicine would be given to prevent DVT when the INR is 1.4
Coumadin 5 mg hs
31
organism most often causing this is E coli, cloudy urine, manifests as confusion in the elderly, elevated temp, increased WBC
UTI- urinary tract infection
32
airway is occluded when sleeping; patient snores and wakes up multiple times during the night and is sleepy during the day; treated with a CPAP machine (constant positive airway pressure) to keep the airway open
OSA - obstructive sleep apnea
33
patient gets short of breath with activity; may need help with ADLs
DOE - dyspnea on exertion
34
s/s polyuria (increased tonicity of blood pulls fluid form cells into vascular space, kidneys excrete it), polydipsia (increased thirst due to fluid loss in urination) polyphagia(increased hunger because sugar cannot get into cells); high blood sugar levels reduced with insulin or glycemic medication
diabetes mellitus
35
loss of cartilage between joints causes bones to rub together producing inflammation manifested as pain, warmth, tenderness in knees, hips
osteoarthritis
36
atria of heart are quivering; impulses may not get through to ventricles; patient has increased risk of blood clots - will be on Plavix or Coumadin to prevent blood clots; monitor for DVT (deep vein thrombosis) by checking for warmth, tenderness in calves of legs
atrial fibrillation
37
elevated blood pressure; may complain of headaches; causes end target organ damage due to impact on blood vessels to heart, kidneys; may cause CVA (stroke)
hypertension
38
long term, chronic obstruction of airways; patient may retain CO2 (carbon dioxide), air may be trapped in alveoli producing barrel chest
COPD - chronic obstructive pulmonary disease
39
frequent changes of position, allay anxiety, monitor arterial blood gases, oximetry, oxygen by mask as needed, diuretics as ordered
interventions for ineffective tissue perfusion with crackles in lungs
40
impaired gas exchange related to _____ AEB crackles, BNP 215.
fluid in lungs
41
damage to vessel wall leads to platelet activation with platelets adhering (sticking) together
thrombus formation
42
vessel breaks away from original site and moves
thromboemoblism
43
patient maintains adequate fluid volume and electrolyte balance as evidenced by vital signs within normal limits, clear lung sounds, resolution of edema
common expected outcomes of treatment of fluid volume excess
44
weight gain, edema, bounding pulse, shortness of breath, orthopnea (can breathe well lying down), pulmonary congestion on x-ray, abnormal breath sounds - crackles, rates
defining characteristics of fluid volume excess
45
give this medicine as a follow up to treatment of acute asthma with IV solumedrol; weaning dose over a period of several days
Medrol pack at discharge
46
give this medicine at bedtime
Lantus 30 units q hs
47
this anti-inflammatory medicine would be given to treat acute asthma attacks
IV solumedrol
48
this medicine is given to lower blood glucose levels
Humulog 8 units with meals; Lantus 30 units q hs
49
Pt has afib and has an INR of 5. The doctor's order will tell the nurse to
give vitamin K to prevent bleeding
50
patient of Coumadin has bleeding gums and multiple bruises the nurse should
check PT/INR levels
51
Pt on Coumadin has INR of 1.2. The doctor's order will tell the nurse to
increase Coumadin Daily until INR is 2-3
52
Pt has afib and is on Coumadin. Pt is 15 seconds - nurse should with doctor's order
increase Coumadin dosage daily until PT is 22-28 seconds
53
When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except:
an elevated hematocrit level
54
When a client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system?
neurological
55
Of all the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is:
a 42-year-old with severe diarrhea
56
A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is:
0.45 % normal saline (NS)
57
The client has been experiencing right flank and lower back pain. Which of the following laboratory values would be most desirable for the nurse to obtain based on the client's assessment?
Serum calcium
58
The health care provider orders 1000 mL of D5LR with 20 mEq KC1 to run for 8 hours. Using an infusion set with a drop factor of 15 gtt/mL, the nurse calculates the flow rate to be:
32 gtt/min
59
The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In selection of a site, the nurse should:
avoid sites on the extremity away from a dialysis graft
60
A client has intravenous therapy for the administration of antibiotics and is stating that the "IV site hurts and is swollen." Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration?
Warmth of integument surrounding the IV site
61
A cline complains of a headache, nausea, and vomiting during a blood transfusion. Which one of the following actions should the nurse take immediately?
stop the blood transfusion
62
For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms?
Hypertension
63
A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert to the presence of:
Cardiac dysrhythmias
64
A rapid infusion of citrated blood has been given to the client. The nurse observes for:
Chvostek's sign
65
The nurse anticipates that the client with a fluid volume excess will manifest a(n):
increased blood pressure
66
The nurse recognizes that the client, based on the imbalance that is present, will require fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the health care provider is:
Lactated Ringer's
67
A client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain. After stopping the transfusion, the nurse should:
obtain and send a urine specimen to the laboratory
68
A client is prescribed 0.9% sodium chloride (normal saline), which is an isotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to :
expand the volume of fluid in the vascular system
69
A client is prescribed 3 % sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:
pull fluid from the cells
70
A client is prescribed 0.45% sodium chloride, which is a hypotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:
move fluid into the cells
71
The nurse recognizes which of the following clients is at the greatest risk for dehydration?
a 79 year old client who has been diagnosed with advanced Alzheimer's disease
72
Which of the following clients is at greatest risk for insensible water loss?
a 15 year old experiencing an asthmatic attack
73
Which of the following foods will have the greatest impact of the water balance of the person consuming it?
a pickle
74
Which of the following foods will have the greatest impact on the heart's conductivity of the person consuming it?
a banana
75
Which of the following foods will have the greatest impact on the blood-clotting mechanism of the person consuming it?
a milkshake
76
Which of the following foods will have the greatest impact on the neurochemical activity of the person consuming it?
a spinach salad
77
Which of the following clinical assessment findings is most likely seen in a client experiencing partial-thickness burns over 35% of the body as a result of hyponatremia?
nausea and vomiting
78
Which of the following clinical assessment findings is most likely seen in a client experiencing hypernatremia as a result of diabetes insipidus?
dry, sticky tongue
79
Which of the following clinical assessment finding sis most likely seen in a client experiencing hypokalemia as a result of the misuse of potassium-wasting diuretics?
decreased bowel sounds
80
Which of following clinical assessment findings is most likely seen in a client experiencing hyperkalemia as a result of adrenal insufficiency?
increased anxiety
81
A client who takes furosemide presents at the emergency department with weakness and fatigue and complains of nausea and vomiting for 3 days. Upon assessment, the nurse finds that the client has decreased bowel sounds and ECG abnormalities including a flattened T wave and flattened ST segment. The nurse knows that these are signs of:
hypokalemia
82
A mother brings her 2 year old daughter to the clinic with a 2 day history of a fever of unknown origin. The mother explains to the nurse that the air conditioning in her apartment is not working and it has been very hot; her daughter has been vomiting for 2 days and has had a fever, and the child is lethargic. The child's rectal temperature is 101.1. The nurse knows the child is probably dehydrated and should do which of the following first?
prepare to start an IV
83
The nurse is caring for a 73 year old female client who is 3 days postoperative for a bowel obstruction. fluid balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and antidiuretic hormone (ADH) are increasingly secreted, causing sodium and chloride retention and potassium excretion. Because of this , it is important for the nurse to closely monitor:
urine output
84
Which of the following clients is most at risk for fluid volume deficit?
45 year old woman with second degree burns over 20% of her body
85
A 66 year old female client is admitted to the hospital with diabetic ketoacidosis. The client has a running IV line through which she receives her medications and fluid maintenance. Which of the following would not be counted on the daily intake and output (I&O)?
mashed potatoes
86
A client with transient atrial fibrillation has been taking 83 mg of aspirin daily for the past 3 years. When preparing the client for discharge from the hospital, the nurse discontinues his IV line. In order to prevent a hematomoa, the nurse needs to hold pressure on the IV site for:
5 to 10 minutes
87
The nurse is preparing to replace a bag of IV fluids for a client receiving fluid therapy. When assessing the client, the nurse notes that the IV solution is not dripping. Which of the following should the nurse do to assess the patency of the site?
carefully adjust the roller clamp to see an increase in flow rate
88
A client has been hospitalized following a myocardial infarction. The client has an IV line running with multiple drips. The nurse assesses the client's medical record to determine the last time the IV tubing was changed, because the nurse knows that the CDC recommends that IV tubing be changed:
every 72 hours
89
Blood replacement or transfusion is the IV administration of whole blood or a component such as plasma, packed red blood cells (RBC's), or platelets. The minimum gauge IV cannula necessary for administering a blood transfusion is:
20 guage
90
The nurse is discontinuing a client's IV line in preparation for the client's discharge home. Upon withdrawing the cannula from the peripheral site, the nurse notes that the tip of the cannula is missing. The first think that the nurse should do is:
apply a tourniquet high on the extremity
91
A client with partial-thickness burns over 40% of the body is likely to lose body fluid via:
a. Water vapor that is lost through the skin that is burned
b. plasma and interstitial fluids that are lost as burn exudate
c. blood leakage via damaged capillaries in the dermis
d. plasma that leaves the intravascular space and becomes trapped in blisters
e. sodium and water shift that out of the vessels because of increased permeability
92
A cline experiencing acute congestive heart failure (CHF) is likely to present with which of the following clinical signs?
a. Bilateral crackles
b. +2 ankle edema bilaterally
c. History of a 5 pound weight gain in 3 days
d. systemic blood pressure 15 mm Hg above usual baseline
93
Which of the following clients is at risk for fluid, electrolyte, and acid-base imbalances?
a. 50 year old with hypertension
b. 40 year old with a fractured femur
c. 15 month with diarrhea for 2 days
d. 76 year old with advanced Alzheimer's disease
e. 25 year old with partial thickness burns over 40% of the body
94
The free movement of solutes (electrolytes) across a membrane is called
diffusion
95
In _____, water moves down its pressure gradient through a semipermeable membrane from diluted fluid to a more concentrated fluid until equilibrium occurs.
osmosis
96
______ occurs when water crosses the capillary membrane into the interstitial space.
filtration
97
_____ ______ in the vascular system is the blood pressure created in the vessels by the contraction of the heart.
hydrostatic pressure
98
_____ is the concentration of molecules per volume of solution.
osmolarity
99
______ provides a measure of body fluid concentration and is reflected in the body's hydration status.
osmolality
100
Which finding s indicate that a patient may have hypervolemia?
a. increased, bounding pulse
b. JVD - jugular venous distention
c. presence of crackles
d. elevated blood pressure
e. skin pale and cool to touch
101
The difference in concentration to particles that is greater on one side of a permeable membrane than on the other side is known as what?
concentration gradient
102
A patient's blood asmolality is 302 mOsm/L. What manifestation does the nurse expect to see in the patient?
Thirst
103
A patient is at risk for hypervolemia. For self management at home, what does the nurse teach the patient to do?
a. call the physician if swelling occurs
b. limit the amount of free water intake
c. weigh self each day on the same scale
d. avoid high-sodium foods
104
An older adult patient at risk for fluid and electrolyte problems is vigilantly monitored by the nurse for the first indication of a fluid balance problem. What is the indication?
mental status changes
105
Which intake-output record represents the norm for the average adult?
1500 mL of fluid per day, ingesting an additional 800 mL of fluid from food.
106
What are the consequences for a patient who does not meet the obligatory urine output?
a. lethal electrolyte imbalances
b. toxic buildup of nitrogen
c. acidosis
107
A patient who loses a lot of fluid and sodium is likely experiencing an increase in ____ secretion.
aldosterone
108
Patients with which conditions are at great risk for deficient fluid volume?
a. fever of 103
b. extensive burns
c. thyroid crisis
d. continuous fistula drainage
e. diabetes insipidus
109
The nurse is working in a long-term care facility where there are numerous patients who are immobile and at risk for dehydration. Which task is best to delegate to the unlicensed assistive personnel (UAP)?
offer patients a choice of fluids every 1 to 2 hours
110
The nurse is assisting a community group to plan a family sports day. In order to prevent dehydration, what beverage does the nurse suggest be supplied?
bottled water
111
The nurse is assessing the weight of a patient with chronic renal failure. The patient shows a 2 kg weight gain since the last clinic appointment. This is equivalent to ____ liters of fluid.
2
112
Which factors affect the amount and distribution of body fluids?
a. age
b. gender
c. body fat
113
The nurse is caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. in evaluating the respiratory system for this patient, what does the nurse expect to assess?
increased respiratory rate, because the body perceives hypovolemia as hypoxia
114
The nurse is assessing skin turgor in a 65 year old patient. What is the correct technique to use with this patient?
pinch the skin over the sternum and observe for tenting an resumption of skin to its normal position after release
115
The emergency department (ED) nurse is caring for a patient who was brought in for significant alcohol intoxication and minor trauma to the wrist. What will serial hematocrits for this patient likely show?
hemoconcentration
116
The nurse is caring for a child at risk for dehydration secondary to diarrhea, vomiting, and fever. The child is alert, quiet, and clinging to the parent. What is the best nursing intervention to rehydrate this patient?
have the parent give small sips of preferred diluted fluids every 5 to 10 minutes.
117
Which statements about the function of the lymphatic system are true?
a. lymph flow is slower than blood flow.
b. lymphatic vessels carry lymph fluid toward the heart.
c. lymph fluid is filtered by lymph nodes
118
The nurse is caring for several older adult patients who are at risk for dehydration. Which task can be delegated to the UAP?
stay with patients while they drink and note the exact amount ingested
119
The nurse assessing a patient notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs, and increasing peripheral edema. These findings reflect a condition of fluids ____.
excess
120
A patient is at risk for fluid volume excess and dependent edema. Which task does the nurse delegate to the UAP?
assist he patient to change position every 2 hours
121
The nurse is reviewing orders for several patients who have risk for fluid volume excess. For which patient condition does the nurse question an order for diuretics?
end stage renal disease
122
The UAP reports to the nurse that a patient being evaluated for kidney problems has produced a large amount of pale yellow urine. What does the nurse do next?
asses the patient for signs of fluid imbalance and check the specific gravity of the urine.
123
On admission, a patient with pulmonary edema weighed 151 lbs; now the patient's weight is 149 lbs. Assuming the patient was weighted both times with the same clothing, same scale, and same time of day, how many milliliters of fluid does the nurse estimate the patient has lost?
1000
124
The nurse is giving discharge instructions to the patient with advance congestive heart failure who is at continued risk for fluid volume excess. For which physical change does the nurse instruct the patient to call the health care provider?
greater than 1 to 2 lbs gained in a 24 hour period
125
The nurse is caring for several patients at risk for fall because of fluid and electrolyte imbalances. Which task related to patient safety and fall prevention does the nurse delegate to the UAP?
help the incontinent patient to toilet every 1 to 2 hours
126
The nurse is assessing a patient's urine specific gravity. The value is 1.035. How does the nurse interpret this result?
dehydration
127
* Main cation is ECF of the cell that maintains ECF osmolarity
* normal plasma value is 136 to 145 mEq
Sodium
128
* normal plasma value is 3.5 to 5.0 mEq/L
* major cation of intracellular fluid (ICF) in the cell
* maintains action potentials in excitable membranes
Potassium
129
* functions include contraction of skeletal and cardiac muscle
* free form is physiologically active in the body
calcium
130
* works in balance with calcium
* normal value is 3.0 to 4.5 mg/dL
* major intracellular anion
phosphorus
131
* has more activity in the cell than in the blood
| * Normal value is 1.3 to 2.1 mg/dL
magnesium
132
* normal value is 98 to 106 mEq/L
| * major anion of extracellular fluid (ECF)
chloride
133
What are the functions of potassium in the body?
a. regulates protein synthesis
b. regulates glucose use and storage
c. helps maintain normal cardiac rhythm
134
Which statements are true about the electrolyte chloride and its role in the cellular environment of the body?
a. it maintains plasma acid-base balance.
b. it provides electroneutrality in relation to sodium
c. chloride imbalances occur with alterations in body water volume.
135
What impacts does sodium have on body function?
a. maintains electroneutrality
b. regulates water balance
c. regulates plasma osmolality
136
What impacts does phosphorus have in the body?
a. activates B-complex vitamins
b. assists in the formation of adenosine triphosphate (ATP)
c. stabilizes excitable membranes
137
The electrolyte magnesium is responsible for which functions?
1. stabilization of excitable membranes
2. contraction of cardiac muscle
3. formation of adenosine triphosphate (ATP
138
____ is a major cation of intracellular fluid (ICF) in the cell
potassium
139
A patient is talking to the nurse about sodium intake. Which statement by the patient indicates an understanding of high-sodium food sources?
" I love Chinese food, but I gave it up because of the soy sauce".
140
Which statement best explains how antidiuretic hormone (ADH) affects urine output?
it increases permeability to water in the tubules causing a decrease in urine output
141
A patient with hyponatremia would have which gastrointestinal findings upon assessment?
a. hyperactive bowel sounds on auscultation, mostly in the left lower quadrant
b. bowel movements that are frequent and watery
c. abdominal cramping
142
The nurse is caring for a patient with severe hyponatremia. What safety measure does the nurse put in place for this patient?
a. turn on a bed alarm when the patient is in bed
b. place the patient on a low bed.
c. ensure three side rails are up when the patient is in bed.
143
Which patients are at risk for developing hyponatremia?
a. postoperative patient who has been NPO for 24 hours with no IV fluid infusing.
b. patient with excessive intake of 5% dextrose solution
c. diabetic patient with blood glucose of 250 mg/dL
d. tennis player in 100 weather who has been drinking water.
