Adult 1 Finale Flashcards
mydriatic medications are for:
dilation of the eye
cycloplegic medications are for:
paralyzing the eye
A client has had hydrochloric acid splashed in their eye. Which of the following are steps the nurse should instruct the client to do? (2 answers)
Assess visual acuity
Flush eye with sterile saline
Primary open-angle glaucoma is less common and can be acute: true or false
false
main s/s of cataracts
glare
main s/s of glaucoma
peripheral vision loss
main s/s of retinal detachment
“curtain” coming across vision
main s/s of age-related macular degeneration (AMD)
central vision loss (black dot in middle of vision)
risks of retinal detachment?
age
eye trauma
for cataracts, the first treatment is surgery: true or false?
false
Scleral buckling
Band placed around the globe and silicone implant sutured against sclera
Pneumatic retinopexy
Gas bubble inserted into the eye to form a bubble to close retinal breaks
Vitrectomy
Removal of vitreous to relieve traction on the retina
Laser photocoagulation
Laser photocoagulation
For retinal tears or holes without detachment; seals with laser and cryotherapy
sensorineural hearing loss what is it and what can cause it?
INNER ear hearing loss
Meniere’s disease
Noise exposure
what is normal intraocular pressure (IOP)?
10-20ish
cause of Cataract:
Caused by accumulation of water and alterations in the lens fiber structure
cause of Retinal detachment:
Caused by the separation of the sensory retina and the underlying pigment epithelium
cause of Glaucoma:
Caused by increased intraocular pressure
cause of Age-related macular degeneration:
Cause of irreversible central vision loss in older adults
cause of Meniere’s disease:
Caused by the accumulation of endolymph inside the membraneous labyrinth
The nurse is caring for a client who is scheduled for surgery with regional anesthesia. The client asks, “Will I be awake during surgery?” Which is the most appropriate statement by the nurse?”
“It will seem like you are awake, however, you will not be aware.”
“During the surgery, you will have a loss of consciousness.”
“You will receive medication that will make you sleepy.”
“There will be a loss of sensation, but you will be awake.”
“There will be a loss of sensation, but you will be awake.”
A nurse is reviewing the laboratory results of a client who is preoperative knee surgery. The nurse should notify which results to the healthcare provider?
WBC count 20,000/mm3
Potassium 3.9 mEq/L
Hematocrit 40%
Creatinine 0.9 mg/dL
WBC count 20,000/mm3
The nurse is assessing a client who is postoperative day 5 and notes the client’s oral temperature is 100.9 F. Which action should the nurse take first?
provide the client with a cooling blanket
request a prescription for an antibiotic
assess the surgical wound site
administer prescribed acetaminophen
assess the surgical wound site
The nurse is collecting the health history from a client who is scheduled for surgery. Which statement by the client would a priority for the nurse to follow up?
“My mother had a reaction during a surgery.”
“I am concerned about the pain after the surgery.”
“My father had an infection after surgery.”
“I got very nauseous the last time I had surgery.”
“My mother had a reaction during a surgery.”
The nurse is educating a client about how to prepare for abdominal surgery. Which statement by the client would require follow up by the nurse?
“I should bathe with the chlorhexidine gluconate solution the morning of the surgery.”
“I need to continue taking my prescribed antiplatelet medication up to the day of surgery.”
“I can practice my breathing exercises the day before the surgery.”
“I will avoid eating and drinking for 8 hours before the surgery.”
“I need to continue taking my prescribed antiplatelet medication up to the day of surgery.”
The preoperative nurse is witnessing a client sign consents for surgery. The client states, “I am not sure I want to have the surgery.” Which statement would be appropriate for the nurse to make?
“This is a hard decision for you to make.”
“Tell me more about what makes you think you do not want the surgery.”
“I will ask your provider to come back to discuss your concerns.”
“You should talk to your family about your concerns.”
“I will ask your provider to come back to discuss your concerns.”
The nurse is monitoring a client who received prescribed fentanyl during a bronchoscopy. The nurse notes the client’s respiratory rate is 10 breaths per minute. Which is the priority action for the nurse to take?
alert the rapid response team
administer IV morphine
reassess the client in 30 minutes
begin rescue breathing with bag-mask-valve
begin rescue breathing with bag-mask-valve
The nurse is teaching a client who had surgery how to cough effectively. Which instructions should the nurse include in the teaching?
“Hold a pillow over the incision.”
“You should cough when you are not experiencing pain.”
“Decrease the amount of fluids you drink before coughing.”
“Get up and walk before you try to cough.”
“Hold a pillow over the incision.”
The post-anesthesia care nurse is monitoring a client following a surgical procedure. Which findings should the nurse report immediately to the healthcare provider?
pain at the incision site
cold, clammy skin
non-productive cough
clear emesis
cold, clammy skin
The perioperative nurse is planning care for a client. Which interventions would be the PRIORITY for the nurse in the operating room?
Verify if the client received teaching.
Provide updates to the client’s family members.
Apply eye patches to client’s eyes for longer procedures
Ensure safe client position.
ensure safe client position
hyponatremia s/s
Nausea/vomiting, lethargy, confusion, muscle cramps, muscle twitching, seizures, coma
hyponatremia nursing interventions
Monitor fluid loss/gains
Assess GI/neuro symptoms
Administer isotonic sodium-containing solutions
Encourage oral intake
Seizure precautions
Avoid “free water”
hypernatremia s/s
Thirst, dry mucous membranes, disorientation, hallucinations, lethargy, irritability, seizures, coma
hypernatremia nursing interventions
Monitor fluid loss/gain
Restrict dietary sodium
Assess neurologic status
Administer sufficient water
Administer IV fluids without sodium
hypokalemia s/s
Fatigue, N/V, muscle weakness, cardiac arrhythmias, nocturia, postural hypotension, paresthesia or muscle tenderness
hypokalemia nursing interventions
potassium chloride IV
a diet high in potassium: beans, bran, squash
hyperkalemia s/s
Muscle weakness, cardiac arrhythmias, paresthesias of face, tongue, feet, and hands, GI symptoms (nausea, colic, diarrhea)
hyperkalemia nursing interventions
Decrease intake (PO and IV)
Increase potassium excretion (medications)
Life-threatening
hypocalcemia s/s
Trousseau’s and Chvostek’s signs, numbness and tingling of fingers/toes, mental changes, seizures, laryngeal muscle spasms, ECG changes, extremity muscle cramps
hypocalcemia nursing interventions
Diet: milk, yogurt, cheese
IV calcium gluconate
hypercalcemia s/s
Muscle weakness, tiredness, constipation, N&V, renal stones, cardiac arrest, neuro changes
hypercalcemia nursing interventions
Increase mobilization
Increase oral fluids
Fluids for renal stones
Medications if severe
Dialysis if severe
hypomagnesemia s/s
Neuromuscular irritability, increased reflexes, seizures, tachyarrhythmia, mental changes
hypomagnesemia nursing interventions
Oral supplements
dietary intake
IV if severe
Seizure precautions
LOC
hypermagnesemia s/s
Flushing of skin, hypotension, depressed RR, drowsiness, hypoactive reflexes, and muscle weakness
hypermagnesemia nursing interventions
Interventions:
Stop and limit dietary intake and Mg containing drugs
Assess neuro, BP, RR
Prevention
hypertonic
h2o out of cells
raisin blood cells
hypotonic
h2o swells cells
too firm of a grape kind of cell
what to assess during fluid imbalance
What do you want to measure?
Daily weights
Intake and output
What body systems do we want to assess? How?
CV
Respiratory
Skin
what should be restricted for a client with end-stage renal disease?
sodium
fluids
s/s fluid volume overload?
Crackles in the lungs
3+ edema in extremities
AV dialysis fistula
A connection between an artery and vein that ensures increased blood flow for dialysis
what is a lithotripsy procedure
non-invasive procedure to break up kidney stones
types of lithotripsy procedures
Ultrasound
Laser
Extracorporeal shock wave
Peritoneal dialysis
done nightly at home
A client comes to the emergency department with a potassium of 6.0. Which of the following are possible interventions to anticipate?
Place on cardiac monitor
Educate client on consuming green leafy vegetables
Assess for Chvostek’s sign
Prepare client for dialysis
Place on cardiac monitor
Prepare client for dialysis
risks during peritoneal dialysis
hernias
symptoms of hypoglycemia
sweating
blurred vision
confusion
diabetic ketoacidosis s/s
thirst
fruity breath
Kussmaul respirations
Which of the following blood gases would be expected from a client in diabetic ketoacidosis (DKA)?
pH 7.48, PaCO2 42, HCO3 30, O2 88
pH 7.28, PaCO2 38, HCO3 18, O2 88
pH 7.30, PaCO2 55, HCO3 26, O2 88
pH 7.50, PaCO2 30, HCO3 24, O2 8
pH 7.28, PaCO2 38, HCO3 18, O2 88
what is the only type of insulin that can be administered intravenously.
insulin regular
A nurse is counseling a patient with type 2 diabetes mellitus about nutritional therapy. Which dietary recommendation best aligns with the principles of managing blood glucose levels in this patient?
Consuming simple sugars when experiencing hypoglycemia for rapid energy restoration.
Increasing saturated fat intake to promote satiety and reduce carbohydrate cravings.
Eliminating all fruits due to their natural sugar content to maintain blood sugar control
Choosing whole grains, vegetables, and lean proteins as part of a balanced diet.
Choosing whole grains, vegetables, and lean proteins as part of a balanced diet.
Which of the following should be included in client teaching for administration of insulin?
Sites include the abdomen, arm, and thigh
Insulin should be stored in the fridge until opened
Roll insulin lispro in hands before administering
Administer at a 60 degree angle for smaller patients
Sites include the abdomen, arm, and thigh
Insulin should be stored in the fridge until opene
With diabetic ketoacidosis (DKA), the client typically presents with higher blood glucoses than hyperglycemia hyperosmolar state (HHS): true or false
false
dawn phenomenon
A condition where morning hyperglycemia is caused by the natural release of growth hormone and cortisol in the early morning hours.
cor pulmonale
Cor pulmonale occurs due to the high pressure in the pulmonary vessels, causing the heart to work harder leading to right-sided heart failure.
The nurse is caring for a client with a cor pulmonale due to COPD. Which of the following are priority assessment techniques?
capillary refill
auscultation of the heart
auscultation of the lungs
diagnostic studies for COPD?
spirometry
6 minute walk test
appropriate amount of hydration for a client with pneumonia?
2500 ml/day
exercise that would help a pt. wit pneumonia
A hand patting technique used to help clear mucus from the airways
how are telemetry leads attached?
White on the right
Smoke over fire
Brown- chocolate to the heart
green is last one left (bottom right)
how to read an EKG
every 5 squares = 1 second
right-sided heart failure
JVD
dependant edema
ascites
portal hypertension
left-sided heart failure
dyspnea/cough
crackles
S3 heart sound
decreased perfussion
cardiomyopathy
Dyspnea, fatigue, angina, syncope (LOC), dysrhythmias, S3/S4
clinical manifestations of cardiomyopathy
anorexia
S3/S4
Hepatomegaly
femoral-popliteal bypass surgery
treat blockages in the arteries of the lower extremities by providing collateral blood flow
diagnostic studies to diagnose a deep vein thrombosis
D-dimer
fibrin monomer complex
venous duplex ultrasound
hypertensive crisis priority interventions
obtain base vitals
continuous BP monitoring
assess Heart and chest sounds
IV insertion
Administer IV antihypertensives
4 stages of a seizure
prodromal
aural
ictal
postictal
Which foods are best for a client with iron deficiency anemia?
chicken
whole grains
kale
You are caring for a client with a port. Which of the following are the best ways to best prevent infection?
Hand hygiene
Ensuring only you wear a mask when changing the dressing
Change the dressing everyday
Scrub each clave/hub for at least 15 seconds
Ensure the client bathes each day
Hand hygiene
Scrub each clave/hub for at least 15 seconds
Ensure the client bathes each day
Which of the following lab values would decrease in a plastic anemia client?
hemoglobin
platelet count
WBC count
Thalassemia minor may go unrecognized or undetected because it only causes mild to moderate anemia: true or false
true
A client is undergoing chemotherapy and was identified at risk for tumor lysis syndrome. Which of the following actions is appropriate for the nurse to take?
Restrict fluid intake to 1500mL/day
Ensure the client remains on bedrest.
Administer IV fluids prior to treatment
Hold chemotherapy until lab values return to normal limits
Administer IV fluids prior to treatment
muffled heart sounds, low bp, and distention of jugular veins =
cardiac tamponade
