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Fundamentals > 226 Test 1 > Flashcards

226 Test 1 Flashcards

1
Q

Components of nursing diagnosis

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

Seven guidelines in writing nursing care plan goals

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

Types of interventions

A
  1. Nurse-initiated (Independent)
  2. Physician-initiated (dependent)
  3. Collaborative (interdependent)
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4
Q

What is direct care?

A

treatments performed through interactions with patients

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5
Q

What is indirect care?

A

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

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6
Q

What is collaborative care?

A

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

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7
Q

Nursing sensitive outcome

A

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

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8
Q

What are expected outcomes?

A

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

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9
Q

Normal levels of Sodium (Na)

A

135-145 mEq/L

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10
Q

Function of Sodium (Na)

A

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

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11
Q

Signs and symptoms of hypernatremia (increased sodium)

A

thirst, fever, dry membranes, muscle twitching

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12
Q

What is hypernatremia caused by?

A

dehydration, increased Na

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13
Q

Signs and symptoms of hyponatremia (decreased sodium)

A

lethargy, nausea, headache, confusion, seizures, coma

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14
Q

What is hyponatremia caused by?

A

excessive water intake, increase in Na loss

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15
Q

Normal levels of Potassium (K)

A

3.5-5.0 mEq/L

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16
Q

What is the function of potassium (K)?

A

fluid balance, muscle contraction, acid-base balance

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17
Q

Signs and Symptoms of hyperkalemia (increased potassium)

A

muscle weakness, decreased/absent urine, respiratory distress

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18
Q

What causes hyperkalemia?

A

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

19
Q

Signs and Symptoms of hypokalemia

A

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

20
Q

What causes hypokalemia?

A

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

21
Q

Normal levels of Calcium (Ca)

A

8.4-10.5 mg/dL

22
Q

Function of Calcium

A

Bone & teeth formation, muscle tone, clotting cascade

23
Q

Signs and symptoms of hypercacemia (increased Calcium)

A

Bone pain, muscle weakness, EKG changes, kidney stones

24
Q

What causes hypercacemia?

A

Overactive parathyroid, cancer

25
Q

Signs & symptoms of hypocacemia

A

tetany, hyperreflexia, EKG changes, convulsions

26
Q

What causes hypocacemia?

A

hypothyroidism, decrease intake, increase in Phosphate

27
Q

Normal levels of Phosphate (PO4/Pi)?

A

2.7-4.5 mg/dL

28
Q

Functions of Phosphate?

A

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

29
Q

Normal levels of Magnesium (Mg)?

A

1.5-2.5 mEq/L

30
Q

Function of Magnesium

A

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

31
Q

Signs and symptoms of hypermagnesemia (increased Mg)

A

Muscle weakness, diaphoresis, flushing, bradypnea

32
Q

What causes hypermagnesemia?

A

renal failure, antacids

33
Q

signs and symptoms of hypomagnesemia?

A

neuromuscular ability, difficulty swallowing, arrhythmia

34
Q

What causes hypomagnesemia?

A

malabsorption

35
Q

Normal levels of Chloride (Cl)?

A

98-106 mEq/L

36
Q

Respiratory Alkalosis

A

increased pH, decreased carbonic acid

*Alveolar hyperventilation

37
Q

Respiratory Acidosis

A

Decreased pH, increased carbonic acid

*alveolar hyporventilation

38
Q

Metabolic Alkalosis

A

increased pH, increased bicarbonate

*Decrease in metabolic acid, Loss of gastric juices, overuse of antacids

39
Q

Metabolic Acidosis

A

decreased pH, decreased bicarbonate

*Increase in metabolic acid, diabetic ketoacidosis

40
Q

What is infiltration?

A

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

41
Q

What is phlebitis?

A

inflammation of the inner layer of the vein

42
Q

What is local infection?

A

infection at the catheter point of entry

43
Q

What is extravasation?

A

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

Fundamentals (7 decks)

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