226 Test 1

Question 1

Components of nursing diagnosis

Answer 1

1. Diagnostic label
2. “Related to” factors
3. “As evidenced by” - signs & symptoms

Question 2

Seven guidelines in writing nursing care plan goals

Answer 2

1. Patient-centered
2. Singular goal or outcome
3. Observable
4. Measurable
5. Time-limited
6. Mutual factors
7. Realistic

Question 3

Types of interventions

Answer 3

1. Nurse-initiated (Independent)
2. Physician-initiated (dependent)
3. Collaborative (interdependent)

Question 4

What is direct care?

Answer 4

treatments performed through interactions with patients

Question 5

What is indirect care?

Answer 5

treatments performed away from the patient but on behalf of the patient

Question 6

What is collaborative care?

Answer 6

care that combines knowledge, skill, and expertise of multiple health care professionals

Question 7

Nursing sensitive outcome

Answer 7

measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions

Question 8

What are expected outcomes?

Answer 8

end result that is measurable, desirable, and observable and translates into observable patient behaviors

Question 9

Normal levels of Sodium (Na)

Answer 9

135-145 mEq/L

Question 10

Function of Sodium (Na)

Answer 10

Water balance, membrane transport, controls BP and B-volume

Question 11

Signs and symptoms of hypernatremia (increased sodium)

Answer 11

thirst, fever, dry membranes, muscle twitching

Question 12

What is hypernatremia caused by?

Answer 12

dehydration, increased Na

Question 13

Signs and symptoms of hyponatremia (decreased sodium)

Answer 13

lethargy, nausea, headache, confusion, seizures, coma

Question 14

What is hyponatremia caused by?

Answer 14

excessive water intake, increase in Na loss

Question 15

Normal levels of Potassium (K)

Answer 15

3.5-5.0 mEq/L

Question 16

What is the function of potassium (K)?

Answer 16

fluid balance, muscle contraction, acid-base balance

Question 17

Signs and Symptoms of hyperkalemia (increased potassium)

Answer 17

muscle weakness, decreased/absent urine, respiratory distress

Question 18

What causes hyperkalemia?

Answer 18

increased K intake or the body isn’t getting rid of K

Question 19

Signs and Symptoms of hypokalemia

Answer 19

fatigue, muscle weakness & cramping, cardiac dysrhthmia & arrest, alkalosis

Question 20

What causes hypokalemia?

Answer 20

Decrease K intake, increase of K into the cells, loss of K

Question 21

Normal levels of Calcium (Ca)

Answer 21

8.4-10.5 mg/dL

Question 22

Function of Calcium

Answer 22

Bone & teeth formation, muscle tone, clotting cascade

Question 23

Signs and symptoms of hypercacemia (increased Calcium)

Answer 23

Bone pain, muscle weakness, EKG changes, kidney stones

Question 24

What causes hypercacemia?

Answer 24

Overactive parathyroid, cancer

Question 25

Signs & symptoms of hypocacemia

Answer 25

tetany, hyperreflexia, EKG changes, convulsions

Question 26

What causes hypocacemia?

Answer 26

hypothyroidism, decrease intake, increase in Phosphate

Question 27

Normal levels of Phosphate (PO4/Pi)?

Answer 27

2.7-4.5 mg/dL

Question 28

Functions of Phosphate?

Answer 28

necessary for ATP production, energy source for cellular metabolism. When Calcium increases, Phosphate decreases. And when calcium decreases, Phosphate increases.

Question 29

Normal levels of Magnesium (Mg)?

Answer 29

1.5-2.5 mEq/L

Question 30

Function of Magnesium

Answer 30

RNA/DNA synthesis, clotting cascade, bone formation, Na & K transport

Question 31

Signs and symptoms of hypermagnesemia (increased Mg)

Answer 31

Muscle weakness, diaphoresis, flushing, bradypnea

Question 32

What causes hypermagnesemia?

Answer 32

renal failure, antacids

Question 33

signs and symptoms of hypomagnesemia?

Answer 33

neuromuscular ability, difficulty swallowing, arrhythmia

Question 34

What causes hypomagnesemia?

Answer 34

malabsorption

Question 35

Normal levels of Chloride (Cl)?

Answer 35

98-106 mEq/L

Question 36

Respiratory Alkalosis

Answer 36

increased pH, decreased carbonic acid | *Alveolar hyperventilation

Question 37

Respiratory Acidosis

Answer 37

Decreased pH, increased carbonic acid | *alveolar hyporventilation

Question 38

Metabolic Alkalosis

Answer 38

increased pH, increased bicarbonate | *Decrease in metabolic acid, Loss of gastric juices, overuse of antacids

Question 39

Metabolic Acidosis

Answer 39

decreased pH, decreased bicarbonate | *Increase in metabolic acid, diabetic ketoacidosis

Question 40

What is infiltration?

Answer 40

occurs when an IV catheter becomes dislodged or a vein ruptures and IV fluids enter subcutaneous tissue

Question 41

What is phlebitis?

Answer 41

inflammation of the inner layer of the vein

Question 42

What is local infection?

Answer 42

infection at the catheter point of entry

Question 43

What is extravasation?

Answer 43

vesicant (tissue damaging) drug enters tissues - causes coolness, paleness, swelling of area