Unit 3 Flashcards
(149 cards)
Stroke volume is impacted on which specific 3 things
1 myocardial contractility
2 preload
3 SVR-afterload—resistance the ventricles must overcome in order to circulate
What 3 things are comprised in preload, after load, and contractility
Preload—venous return, fluid volume, atrial contraction
After load—resistance to ejected blood—systemic vascular resistance, health of vessels, vasoconstriction
Contractility—sympathetic stimulation—NE, parasympathetic stimulation- AcH, drugs—beta blockers calcium channel blocker
Hat is central perfusion
Ability of heart and large vessels to deliver oxygenated blood to body organ and tissues
—affected by cardiac output
—both mechanical and electrical components of the pump
What is tissue perfusion
Blood that flows through arteries and capillaries into target tissues
—mist have adequate arterial pressure
What are some things that impair central perfusion
Occurs due to altered conduction, reduced myocardial contraction, ineffective heart valves, decreased intramuscular volume. Or systemic vascular resistance
Ex: ventricular fibrillation, endocarditis, severe dehydration, hemorrhage
What happens to occur tissue perfusion
Arterial blockage
Stroke, myocardial infarction
A nurse is caring for a client with a surgical wound healing by secondary intention. Which finding would indicate proper healing during the granulation phase?
A. Approximation of wound edges.
B. Fibroblast activity with capillary formation.
C. Thick scar tissue forming with irregular borders.
D. Platelet aggregation forming a clot.
B
A patient is admitted with erythema, swelling, and warmth around a surgical site. What is the priority nursing intervention?
A. Administer prescribed NSAIDs.
B. Apply a warm compress to reduce swelling.
C. Assess for systemic manifestations of infection.
D. Perform wound care with aseptic technique.
C
A nurse is assessing a patient with a pressure ulcer on the sacrum. The ulcer is full-thickness, has slough present, and exposes subcutaneous tissue but no muscle or bone. What stage should the nurse assign?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
B
A nurse is educating a client about the manifestations of localized inflammation. Which of the following signs should the nurse include?
A. Pain
B. Erythema
C. Pallor
D. Loss of function
E. Fever
A b d
A nurse is implementing interventions to prevent the development of pressure injuries in an immobile patient. Which actions should the nurse take?
A. Reposition the patient every 2 hours.
B. Place a pillow under the patient’s calves to elevate the heels off the bed.
C. Massage reddened areas to improve circulation.
D. Use a lift sheet when repositioning the patient.
E. Keep the patient’s skin clean and dry.
A
Which factors can delay wound healing? (Select all that apply)
A. Smoking
B. Malnutrition
C. Adequate perfusion
D. Diabetes
E. Advanced age
A b d e
A nurse is caring for a patient with atopic dermatitis experiencing intense pruritus. What is the priority nursing intervention?
A. Administer prescribed corticosteroids.
B. Teach the patient to avoid environmental triggers.
C. Apply a topical antihistamine.
D. Encourage the patient to wear loose clothing.
A
A patient presents with a newly formed wound exhibiting erythema, swelling, and exudate formation. What is the nurse’s priority action?
A. Perform a culture of the wound.
B. Apply a moist wound dressing.
C. Encourage the patient to increase protein intake.
D. Administer prescribed antibiotics.
A
A nurse is caring for a bedridden client at high risk for pressure injuries. Which intervention should the nurse prioritize?
A. Monitor the client’s serum albumin levels.
B. Apply a foam dressing to the sacrum.
C. Turn the client every 2 hours.
D. Educate the client about hydration and nutrition.
C
Which finding is most indicative of systemic inflammation in a patient with cellulitis?
A. Localized warmth and redness at the site of infection.
B. Elevated WBC count and fever.
C. Clear exudate draining from the affected area.
D. Thick scar tissue forming over the wound.
B
A nurse is educating a patient about healing by tertiary intention. Which scenario best demonstrates this process?
A. A clean surgical wound closed immediately with sutures.
B. A wound left open due to infection, then later sutured.
C. A pressure ulcer that closes gradually with granulation tissue.
D. A superficial wound that heals with minimal scarring.
B
Which laboratory test result is most relevant for monitoring systemic inflammation in a patient with rheumatoid arthritis?
A. Hemoglobin level.
B. C-reactive protein (CRP).
C. Sodium level.
D. Platelet count.
B
Which of the following factors may delay wound healing? (Select all that apply.)
A. Advanced age
B. Diabetes
C. High protein diet
D. Smoking
E. Low hemoglobin levels
A b d e
A nurse is caring for a patient with a pressure ulcer exhibiting tunneling and slough. What is the priority nursing action?
A. Measure the depth of the wound and document findings.
B. Debride the wound to remove dead tissue.
C. Administer prescribed antibiotics.
D. Apply a hydrocolloid dressing to the wound.
A
A nurse is caring for a patient with localized inflammation after a minor injury. Which is the priority intervention?
A. Administer prescribed NSAIDs.
B. Encourage fluid intake to promote healing.
C. Apply a cold compress to reduce swelling.
D. Perform range of motion exercises to prevent stiffness.
C
T/F inflammation does not mean infection
T
What are three types of inflammation and give an example of each
- Acute—paper cut (no scar)
2 subacute—scab—same as acute but healing weeks to months
3 chronic — months to years (autoimmune disease)
What are the 4 inflammation responses in order
1 histamine and prostaglandins released
2 capillaries dilate clotting begins
3 chemotactic factors attract phagocytic cells
4 phagocytes consume pathogens and cell debris
