Advanced Clinical Concepts

Question 1

What is ARDS?

Answer 1

The exchange of oxygen for carbon dioxide in the lungs is inadequate for oxygen consumption and carbon dioxide production within the body’s cells. ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. Clients are critically ill and are managed in an intensive care setting. The mortality rate is high (50%).

Question 2

What are interventions to prevent complications of clients on mechanical ventilation with ARDS?

Answer 2

Interventions to prevent complications of clients on mechanical ventilation with ARDS: • Elevate head of bed (HOB) to at least 30 degrees. • Assist with daily awakening (“sedation vacation”). • Implement a comprehensive oral hygiene program. • Implement a comprehensive mobilization program.

Question 3

When do you suction a patient with ARDS?

Answer 3

Suction only when secretions are present.

Question 4

When and how do you perform the Allen test?

Answer 4

Before drawing a sample for ABGs from the radial artery, perform the Allen test to assess collateral circulation. Make the client’s hand blanch by obliterating both the radial and the ulnar pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is good, flushing will be seen immediately. The Allen test is then positive, and the radial artery can be used for puncture. If the Allen test is negative, repeat on the other arm. If this test is also negative, seek another site for arterial puncture. The Allen test ensures collateral circulation to the hand if thrombosis of the radial artery should follow the puncture.

Question 5

What are the 4 cardinal signs of ARDS in children?

Answer 5

Cardinal signs of Acute Respiratory Failure in children are: 1. restlessness 2. tachypnea, 3. tachycardia 4. diaphoresis.

Question 6

What PCO2 or PO2 level on what % of O2 signifies respiratory failure?

Answer 6

PCO2 >45 or PO2 <60 on 50% O2 signifies respiratory failure.

Question 7

What % of O2 should a child in severe distress receive?

Answer 7

100% O2

Question 8

What PO2 value indicates respiratory failure in adults?

Answer 8

PO2 <60mm Hg

Question 9

What blood value indicates hypercapnia?

Answer 9

PO2 >45mm Hg

Question 10

Identify the condition that exists when the PO2 is 60%.

Answer 10

Hypoxemia

Question 11

List 3 symptoms of respiratory failure in adults.

Answer 11

1. dypsnea/tachypnea 2. intercostal and sternal retractions 3. cyanosis

Question 12

List 4 common causes of respiratory failure in children.

Answer 12

1. congenital heart disease 2. infection or sepsis 3. respiratory distress syndrome 4. fluid overload or dehydration

Question 13

ARDS: Nursing Assessment

Answer 13

A. Dyspnea, hyperpnea, crackles (or rales) B. Intercostal retractions C. Cyanosis, pallor D. Hypoxemia: Po2 60% E. Diffuse pulmonary infiltrates seen on chest radiograph as “white-out” appearance F. Verbalized anxiety, restlessness

Question 14

ARDS: Nursing Interventions

Answer 14

A. Position client for maximal lung expansion. B. Monitor client for signs of hypoxemia and oxygen toxicity. C. Monitor breath sounds for pneumothorax. D. Provide emotional support to decrease anxiety and allow ventilator to “work” the lungs. E. Monitor client hemodynamically with essential vital signs and cardiac monitor. F. Monitor arterial blood gases (ABGs) routinely. G. Monitor vital organ status: central nervous system (CNS), level of consciousness, renal system output, and myocardium (apical pulse, blood pressure [BP]). H. Monitor fluid and electrolyte balance. I. Monitor metabolic status through routine lab work.

Question 15

ABGs: pH PCO2 HCO3 PO2 O2% O2 Content (Arterial, Venous) Base Excess

Answer 15

pH: 7.35-7.45 PCO2: 35-45mm Hg HCO3: 21-28mEq/L PO2: 80-100mm Hg O2%: 95-100% O2 Content: Arterial 15-22%, Venous 11-16% Base Excess: 0 +-2mEq/L

Question 16

What is shock?

Answer 16

Widespread, serious reduction of tissue perfusion (lack of O2 and nutrients) that, if prolonged, leads to generalized impairment of cellular functioning. Severe shock leads to widespread cellular injury and impairs the integrity of the capillary membranes. Fluid and osmotic proteins seep into the extravascular spaces, further reducing cardiac output. A vicious circle of decreased perfusion to all cellular level activities ensues. All organs are damaged, and if perfusion problems persist, the damage can be permanent.

Question 17

What are the 4 stages of hypovolemic shock?

Answer 17

1. Blood loss <10% Apprehension, restlessness; increased HR; cool, pale skin; fatigue. Arteriolar constriction; incr ADH production; art pressure maintained; CO usually normal; selective reduction in blood flow to skin and muscle beds. 2. Blood loss 15-25% Flat neck veins w/ delayed cap refill; incr HR and RR; pallor, diaphoresis, cool skin; decr UO; sunken, soft eyeballs; confusion. Marked reduction in CO; art pressure decline; adrenergic comp response resulting in tachycardia, tachypnea, cutaneous vasoconstriction, and oliguria; decr cerebral perfusion. 3. Progressive Stage Edema; incr blood viscosity; excessively low BP; dysthymia, ischemia, and MI; weak, thready, or absent peripheral pulses. Rapid circ deteroiration; decr CO; decr tissue perf; reduced blood vol. 4. Irreversible Stage Profound hypoTN, unresponsive to vasopressors; severe hypoxemia, unresponsive to O2 admin; anuria, renal shutdown; HR slows with cardiac/respiratory arrest. Inevitable death d/t cell destruct; multiple organ system failure.

Question 18

What is distributive shock?

Answer 18

Distributive Shock (Anaphylactic, Neurogenic, and Septic Shock)—results from excessive vasodilation and the impaired distribution of blood flow.

Question 19

Relationship between shock, SIRS, and MODS?

Answer 19

All types of shock can lead to systemic inflammatory response syndrome (SIRS) and result in multiple organ dysfunction syndrome (MODS).

Question 20

How do you position a patient with cardiogenic shock with pulmonary edema?

Answer 20

If cardiogenic shock exists in the presence of pulmonary edema (i.e., from pump failure), position client to reduce venous return (high Fowler position with legs down) to decrease further venous return to the left ventricle.

Question 21

Shock: Nursing Assessment

Answer 21

A. Vital signs 1. Tachycardia (pulse >100 bpm) 2. Tachypnea (respirations >24 min) 3. BP decrease (systolic 1.020 indicates hypovolemia.

Question 22

Shock: Nursing Interventions

Answer 22

A. Monitor arterial pressure by understanding the concepts related to arterial pressure (Table 3-3). B. Monitor BP, pulse, respirations, and arrhythmias every 15 minutes or more often, depending on stability of client. C. Assess urine output every hour to maintain at least 30 mL/hr. D. Notify health care provider if urine output drops below 30 mL/hr (reflects decreased renal perfusion and may result in acute renal failure). E. Administer fluids as prescribed by provider to improve preload: blood, colloids, or electrolyte solutions until designated CVP is reached (Table 3-4). F. Remember client’s bed position is dependent on cause of shock. G. Administer medications IV (not intramuscular [IM] or subcutaneous) until perfusion improves in muscles and subcutaneous tissue. H. Keep client warm; increase heat in room or put warm blankets (not too hot) on client. I. Keep side rails up during all procedures; clients in shock experience mental confusion and may easily be injured by falls. J. Obtain blood for lab work as prescribed: complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine (renal damage), lactate (sepsis), and blood gases (oxygenation and ventilation). K. When administering vasopressors or adrenergic stimulants, such as epinephrine (Bronkaid), dopamine (Intropin), dobutamine (Dobutrex), norepinephrine (Levophed), or isoproterenol (Isuprel): 1. Administer through volume-controlled pump. 2. Monitor hemodynamic status every 5 to 15 minutes. 3. Watch intravenous site carefully for extravasation and tissue damage. 4. Ask health care provider for target mean systolic BP (usually 80 to 90 mm Hg). L. When administering vasodilators, such as hydralazine (Apresoline), nitroprusside (Nipride), or labetalol hydrochloride (Normodyne, Trandate) to counteract effects of vasopressors: 1. Wait for precipitous decrease or increase in BP if prescribed together. 2. If drop in BP occurs, decrease vasodilator infusion rate first; then increase vasopressor. 3. If BP increases precipitously, decrease vasopressor rate first; then increase rate of vasodilator. 4. Obtain blood work as prescribed: CBC, electrolytes, BUN, creatinine (renal damage), and blood gases (oxygenation). 5. Glucose levels should be maintained at 140 to 180 mg/dL. M. Provide family support: 1. Notify appropriate support persons for families waiting during crisis—call spiritual advisor, other family members, or anyone the family thinks will be supportive. 2. At intervals, notify family of actions and progress or lack of progress in realistic terms. 3. Collaborate with health care provider before notifying family of medical interventions.

Question 23

Arterial Pressure: MAP CO PR CVP

Answer 23

Arterial Pressure: MAP: level of pressure in central art bed measured indirectly via BP or directly via art cath; MAP = CO x TPR = [SBP + 2DBP] / 3 CO: vol of blood ejected by LV per unit of time; SV x HR = norm 4-6L/min PR: resistance to blood flow CVP: pressure in RA; norm 2-6mm Hg

Question 24

What is DIC? + random case study of woman in automobile accident

Answer 24

Coagulation disorder with paradoxical thrombosis and hemorrhage. You are caring for a woman who was in a severe automobile accident several days earlier. She has several fractures and internal injuries. The exploratory laparotomy was successful in controlling the bleeding. However, today you find that this client is bleeding from her incision, is short of breath, and has a weak, thready pulse, cold and clammy skin, and hematuria. What do you think is wrong with the client, and what would you expect to do about it? These are typical signs and symptoms of DIC crisis. Expect to administer IV heparin to block the formation of thrombin (Coumadin does not do this). However, the client described is already past the coagulation phase and into the hemorrhagic phase. Her care would include administration of clotting factors, along with palliative treatment of the symptoms as they arise. (Her prognosis is poor.)

Question 25

What are the types of blood products administered?

Answer 25

• Packed RBCs
  
  • less danger of fluid overload
  • for acute blood loss
• Frozen RBCs
  
  • must be used within 24hrs of thawing
  • for auto transfusion; used infrequently bc filters out most of WBCs
• Platelets
  
  • “agitate” bag periodically
  • for bleeding c/b thrombocytopenia
• FFP
  
  • being replaced by albumin plasma expanders…
  • for bleeds c/b deficiency in clot factors
• Albumin
  
  • albumin 25g/100mL = 500mL plasma
  • for hypovolemic shock, hypoalbuminemia
• Cryoprecipitates
  
  • for tx hemophelia
  • replacement of clot factors, esp factor VIII and fibrinogen

Question 26

What are the types of transfusion reactions?

Answer 26

• Acute hemolytic
  
  • assess chills, fever, low back pain, flushing, tachycardia, hypotension progressing to acute renal fail, shock, and cardiac arrest
  • STOP TRANSFUSION, change tubing, infuse NS; treat for shock; draw blood samples for testing; monitor hourly UO; diuretics as ordered
• Febrile hemolytic (most common)
  
  • assess sudden chills and fever, headaches, flushing, anxiety, and muscle pain
  • give antipyretics as ordered
• Mild allergic
  
  • assess flushing, utricaria (hives)
  • give antihistamines as ordered
• Anaphylactic / severe allergic
  
  • assess nxiety, utricaria, wheezing, progressive cyanosis leading to shock / cardiac arrest
  • STOP TRANSFUSION. INITIATE CPR.
• Circulatory overload
  
  • assess cough, dyspnea, pulm congest, h/a, HTN
  • place pt in upright position with feet in dependent position and give diuretics, O2, morphine; slow IV rate
• Sepsis
  
  • assess rapid onset chills, high fever, vomiting, hypoTN, or shock
  • ENSURE AIRWAY, obtain blood culture, give abx as ordered, VS q5min until stable

Question 27

What nursing skills are involved in blood product administration?

Answer 27

• Obtain venous access; use central venous catheter or 19-gauge needle.
• Use only blood administration tubing to infuse blood products.
• Run blood products with saline solutions only. Dextrose solutions and Ringer’s lactate solution will induce RBC hemolysis.
• Run infusion at prescribed rate, and remain with client for the first 15-30 minutes of infusion.
• The blood should be administered as soon as it is brought to the client.
• Check vital signs frequently before, during, and immediately following infusion; note any increase in temperature.
• Follow agency policy regarding specific timetable for blood infusion.
• Check and double-check the product before infusing to see that it is the:
• Correct product, as prescribed; double-check with a second licensed person.
• Correct blood type and Rh factor, matched with the client, and note expiration date.

Question 28

DIC: Nursing Assessment

Answer 28

A. Petechiae, purpura, hematomas
B. Oozing from IV sites, drains, gums, and wounds
C. Gastrointestinal and genitourinary bleeding
D. Hemoptysis
E. Mental status change
F. Hypotension, tachycardia
G. Pain

Question 29

DIC: Nursing Interventions

Answer 29

A. Monitor client for bleeding.
B. Monitor vital signs.
C. Monitor PT/INR.
D. Protect client from injury and bleeding.
1. Provide gentle oral care with mouth swabs.
2. Minimize needle sticks; use smallest gauge needle
possible.
3. Turn client frequently to eliminate pressure points.
4. Minimize number of BP measurements taken by
cuff.
5. Use gentle suction to prevent trauma to mucosa.
6. Apply pressure to any oozing site.
E. Administer heparin IV during the first phase to inhibit
coagulation.
F. Provide emotional support to decrease anxiety.

Question 30

1. Define shock.
2. What is the most common cause of shock?
3. What causes septic shock?
4. What is the goal of treatment for hypovolemic shock?
5. What intervention is used to restore cardiac output when hypovolemic shock exists?
6. It is important to differentiate between hypovolemic and cardiogenic shock. How might the nurse determine the existence
   of cardiogenic shock?
7. If a client is in cardiogenic shock, what might result from administration of volume-expanding fluids, and what intervention
   can the nurse expect to perform in the event of such an occurrence?
8. List five assessment findings that occur in most shock victims.
9. Once circulating volume is restored, vasopressors may be prescribed to increase venous return. List the main drugs that are used.
10. What is the established minimum renal output per hour?
11. List four measurable criteria that are the major expected outcomes of a shock crisis.
12. Define DIC.
13. What is the effect of DIC on PT, PTT, platelets, and FSPs (FDPs)?
14. What drug is used in the treatment of DIC?
15. Name four nursing interventions to prevent injury in clients with DIC.

Answer 30

1. Widespread, serious reduction of tissue perfusion, which leads to generalized impairment of cellular function
2. Hypovolemia
3. Release of endotoxins by bacteria, which act on nerves in vascular spaces in the periphery, causing vascular pooling, reduced
   venous return, and decreased cardiac output and result in poor systemic perfusion
4. Quick restoration of cardiac output and tissue perfusion
5. Rapid infusion of volume-expanding fluids
6. History of MI with left ventricular failure or possible cardiomyopathy, with symptoms of pulmonary edema
7. Pulmonary edema; administer medications to manage preload, contractility and/or afterload. For example, to decrease
   afterload, nitroprusside (Nipride) may be administered.
8. Tachycardia; tachypnea; hypotension; cool, clammy skin; decrease in urinary output
9. Epinephrine (Bronkaid), dopamine (Intropin), dobutamine (Dobutrex), norepinephrine (Levophed), or isoproterenol (Isuprel)
10. 30 mL/hr
11. BP mean of 80 to 90 mm Hg; Po2 >50 mm Hg; CVP 2 to 6 mm HG H2O; urine output at least 30 mL/hr
12. A coagulation disorder in which there is paradoxical thrombosis and hemorrhage
13. PT, prolonged; PTT, prolonged; platelets, decreased; FSPs, increased
14. Heparin
15. Gently provide oral care with mouth swabs. Minimize needle sticks and use the smallest gauge needle possible when
    injections are necessary. Eliminate pressure by turning the client frequently. Minimize the number of BP measurements taken
    by cuff. Use gentle suction to prevent trauma to mucosa. Apply pressure to any oozing site.

Question 31

What is cardiopulmonary arrest?

Answer 31

A. Usually caused by MI; necrosis of the heart muscle
caused by inadequate blood supply to heart
B. MIs usually occur at rest or with moderate activity, contrary
to the belief that they occur with strenuous activity.
C. Symptoms immediately preceding MI:
1. Chest pain or discomfort at rest or with ordinary
activity
2. Change in previous stable anginal pain—an increase
in frequency or severity or rest angina occurring for
the first time
3. Chest pain in a client with known coronary heart
disease that is unrelieved by rest or nitroglycerin

Question 32

When do you seek EMS for a client with angina?

Answer 32

When to seek emergency medical
services (EMS):
The American Heart Association recommends that those with known angina pectoris activate an emergency medical system if chest pain does NOT go away immediately with rest or is NOT relieved in 5 minutes after taking nitroglycerin or if additional symptoms such as nausea and sweating are also present with the chest pain. A person with previously unrecognized coronary disease experiencing chest pain persisting for 2 minutes
or longer should seek emergency medical treatment.

Question 33

During CPR, what do you do about arterial acidosis?

Answer 33

When significant arterial acidosis is noted, try to reduce Pco2 by increasing ventilation, which will correct arterial, venous, and tissue acidosis. Bicarbonate may exacerbate acidosis by producing CO2. ACLS guidelines recommend that bicarbonate not be used unless hyperkalemia, tricyclic antidepressant overdose, or pre-existing metabolic acidosis is documented.

Question 34

In pulseless arrest algorithm, what contributing factors should you search for and treat?

Answer 34

In the pulseless arrest algorithm, the search for and treatment of possible contributing factors should include checking for hypovolemia, hypoxia,hydrogen ion acidosis, hypokalemia and hyperkalemia, hypoglycemia, hypothermia, toxins, tamponade (cardiac), tension pneumothorax, thrombosis (cardiac, pulmonary), and trauma.

Question 35

1. What is the first priority when a client with an unwitnessed cardiac arrest is found?
2. Define myocardial infarction.
3. What criteria should alert a client with known angina who takes nitroglycerin tablets sublingually to call EMS?
4. After calling out for help and asking someone to dial for emergency services, what is the next action in CPR?
5. True or false? In feeling for presence of a carotid pulse, no more than 5 seconds should be used.
6. During one-rescuer CPR, what is the ratio of compressions to ventilations for an adult? During one-rescuer CPR, what is the
   ratio of compressions to ventilations for a child?
7. What is the first drug most likely to be used for an in-hospital cardiac arrest?
8. A client in cardiac arrest is noted on bedside monitor to be in pulseless ventricular tachycardia. What is the first action that
   should be taken?
9. How would the nurse assess the adequacy of compressions during CPR? How would the nurse assess the adequacy of
   ventilations during CPR?
10. If a person is choking, when should the rescuer intervene?
11. One should never make blind sweeps into the mouth of a choking child or infant. Why?

Answer 35

1. Begin CPR.
2. Necrosis of the heart muscle due to poor perfusion of the heart
3. Unrelieved chest pain after nitroglycerin
4. For adults check carotid pulse and if no pulse deliver C-A-B.
5. False. Palpate for no more than 10 seconds, recognizing that arrhythmias or bradycardia could be occurring.
6. 30:2; 15:2 for a child or neonate with two rescuers and 30:2 for 1 rescuer.
7. Epinephrine
8. Defibrillation
9. Check for a carotid or femoral pulse. Watch for chest excursion and auscultate bilaterally for breath sounds.
10. When the person points to his or her throat and can no longer cough, talk, or make sounds
11. Because the object might be pushed farther down into the throat

Question 36

Fluid Volume Deficit - Dehydration

Answer 36

• Elevated blood urea nitrogen (BUN): The BUN measures the amount of urea nitrogen in the blood. Urea is formed in the liver as the end product of protein metabolism. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidneys.
• Creatinine, as with BUN, is excreted entirely by the kidneys and is therefore directly proportional to renal excretory function. However, unlike BUN, the creatinine level is affected very little by dehydration, malnutrition, or hepatic function. The daily production of creatinine depends on muscle mass, which fluctuates very little. Therefore, it is a better test of renal function than is the BUN. Creatinine is generally used in conjunction with the BUN test, and they are normally in a
1:20 ratio.
• Serum osmolality measures the concentration of particles in a solution. It refers to the fact that the same amount of solute is present, but the amount of solvent (fluid) is decreased. Therefore, the blood can be considered “more concentrated.”
• Urine osmolality and specific gravity increase.

Question 37

Hyponatremia

Answer 37

Causes:

• Diuretics
• GI fluid loss
• Hypotonic tube feeding
• D5W or hypotonic IV fluids
• Diaphoresis

S/sx:

• Anorexia, nausea, vomiting
• Weakness
• Lethargy
• Confusion
• Muscle cramps, twitching
• Seizures
• Na <135 mEq/L

Tx:

• Restrict fluids (safer).
• If IV saline solutions prescribed, administer very
slowly; use isotonic saline if fluid restriction not
effective.

Question 38

Hypernatremia

Answer 38

Causes:

• Water deprivation
• Hypertonic tube feeding
• Diabetes insipidus
• Heatstroke
• Hyperventilation
• Watery diarrhea
• Renal failure
• Cushing syndrome

S/sx:

• Thirst
• Hyperpyrexia
• Sticky mucous membranes
• Dry mouth
• Hallucinations
• Lethargy
• Irritability
• Seizures
• Na >145 mEq/L

Tx:

• Restrict sodium in the diet.
• Beware of hidden sodium in foods and medications.
• Increase water intake.

Question 39

Hypokalemia

Answer 39

Causes:

• Diarrhea
• Vomiting
• Gastric suction
• Steroid administration
• Hyperaldosteronism
• Amphotericin B
• Bulimia
• Cushing syndrome

S/sx:

• Fatigue
• Anorexia
• Nausea, vomiting
• Muscle weakness
• Decreased GI motility
• Dysrhythmias
• Paresthesia
• Flat T waves on ECG
• K <3.5 mEq/L

Tx:

• Administer potassium supplements orally or IV.
• Oral forms of potassium are unpleasant tasting and
are irritating to the GI tract (do not give on empty
stomach; dilute).
• Never give IV bolus; must be well diluted.
• Assess renal status, i.e., urinary output, prior to
administering.
• Encourage foods high in potassium (e.g., bananas,
oranges, cantaloupes, avocados, spinach, potatoes).

Question 40

Hyperkalemia

Answer 40

Causes

• Hemolyzed serum sample
produces
pseudohyperkalemia
• Oliguria
• Acidosis
• Renal failure
• Addison disease
• Multiple blood transfusions

S/sx:

• Muscle weakness
• Bradycardia
• Dysrhythmias
• Flaccid paralysis
• Intestinal colic
• Tall T waves on ECG
• K >5.0 mEq/L

Tx:

• Eliminate parenteral potassium from IV infusions and
medications.
• Administer 50% glucose with regular insulin.
• Administer cation exchange resin (Kayexalate).
• Monitor ECG.
• Administer calcium gluconate to protect the heart.
• IV loop diuretics may be prescribed.
• Renal dialysis may be required.

Question 41

Hypocalcemia

Answer 41

Causes:

• Renal failure
• Hypoparathyroidism
• Malabsorption
• Pancreatitis
• Alkalosis

S/sx:

• Diarrhea
• Numbness
• Tingling of extremities
• Convulsions
• Positive Trousseau sign
• Positive sign
• Ca <8.5 mEq/L
• At risk for tetany

Tx:

• Administer calcium supplements orally 30 minutes
before meals.
• Administer calcium IV slowly; infiltration can cause
tissue necrosis.
• Increase calcium intake (e.g., dairy products, greens).

Question 42

Hypercalcemia

Answer 42

Causes:

• Hyperparathyroidism
• Malignant bone disease
• Prolonged immobilization
• Excess calcium supplementation

S/sx:

• Muscle weakness
• Constipation
• Anorexia
• Nausea, vomiting
• Polyuria
• Polydipsia
• Neurosis
• Dysrhythmias
• Ca >10.5 mEq/L

Tx:

• Eliminate parenteral calcium.
• Administer agents such as calcitonin to reduce
calcium.
• Avoid calcium-based antacids.
• Renal dialysis may be required.

Question 43

Hypomagnesemia

Answer 43

Causes:

• Alcoholism
• Malabsorption
• Diabetic ketoacidosis
• Prolonged gastric suction
• Diuretics

S/sx:

• Anorexia, distention
• Neuromuscular irritability
• Depression
• Disorientation
• Mg <1.5 mEq/L

Tx:

• Administer MgSO4 IV.
• Encourage foods high in magnesium (e.g., meats, nuts,
legumes, fish, and vegetables).

Question 44

Hypermagnesemia

Answer 44

Causes:

• Renal failure
• Adrenal insufficiency
• Excess replacement

S/sx:
• Flushing
• Hypotension
• Drowsiness, lethargy
• Hypoactive reflexes
• Depressed respirations
• Bradycardia
• Mg >2.5 mEq/L

Tx:
• Avoid magnesium-based antacids and laxatives.
• Restrict dietary intake of foods high in magnesium.

Question 45

Hypophosphetemia

Answer 45

Causes:

• Refeeding after starvation
• Alcohol withdrawal
• Diabetic ketoacidosis
• Respiratory alkalosis

S/sx:
• Paresthesias
• Muscle weakness
• Muscle pain
• Mental changes
• Cardiomyopathy
• Respiratory failure
• pH <2.0 mEq/L

Tx:
• Correct underlying cause.
• Administer oral replacement of phosphates with
vitamin D.

Question 46

Hyperphosphatemia

Answer 46

Causes:

• Renal failure
• Excess intake of phosphorus

S/sx:
• Short-term: tetany symptoms
• Long-term: phosphorus
precipitation in nonosseous
sites
• pH >4.5 mEq/L

Tx:
• Administer aluminum hydroxide with meals to bind
phosphorus.
• Dialysis may be required if renal failure is underlying
cause.

Question 47

Isotonic IV solutions

Answer 47

• Have an osmolality close to the extracellular
fluid (ECF)
• Do not cause red blood cells to swell
or shrink
• Indicated for intravascular dehydration
• Isotonic solutions
→Normal saline (0.9% NS)
→Lactated Ringer’s solution (LR)
→5% dextrose in water
(D5W is on the low end of isotonic;
some sources classify it as
hypotonic)
• Used to treat intravascular dehydration
(not enough fluid in vascular system)
• Common type of dehydration
• Examples: dehydration caused by
running,
labor, fever, etc.

Question 48

Hypotonic IV Solutions

Answer 48

• Have an osmolality lower than the ECF
• Cause fluid to move from ECF to
intracellular fluid (ICF)
• Indicated for cellular dehydration
• Used in the management of the patient
who is both volume-depleted and
hyperosmolar (e.g., in cases of hypernatremia
or hyperglycemia).
• Hypotonic solutions
→0.5% normal saline (HNS or 0.45%
NS)
→2.5% dextrose in 0.45% saline (D2.5
45% NS)
• Used to treat intracellular dehydration
(cells have too many osmoles, need to
drive fluid into the cells)
• Not a common occurrence
• Examples: dehydration caused by prolonged
dehydration (may also see in
clients who are on TPN for prolonged
periods)

Question 49

Hypertonic IV Solutions

Answer 49

• Have an osmolality higher than the
ECF.
• Indicated for intravascular dehydration
with interstitial or cellular
overhydration.
• To be used with extreme caution.
• High concentrations of dextrose are
given for caloric replacement such as
intravenous hyperalimentation into a
central vein for rapid dilution.
• Hypertonic saline solutions are
available but used only when serum
osmolality is dangerously low.
• Hypertonic solutions
→5% dextrose in lactated Ringer’s
(D5LR)
→5% dextrose in 0.45% saline
→5% dextrose in 0.9% saline (D5NS)
→10% dextrose in water (D10W)
• Used to treat intravascular dehydration
with cellular or interstitial
overhydration.
• Examples: dehydration resulting
from surgery; blood loss causes
intravascular
dehydration, but the
tissue cuts inflame and pull fluid into
the area, causing interstitial overhydration;
may also see with ascites and
third-spacing.

Question 50

IV Occlusion / Cath Damage

Answer 50

A. Occlusion/catheter damage
1. Assess for:
a. Pinholes, leaks, and tears
b. Drainage after flushing
c. Blood return
d. Inability to infuse fluid
e. Needle placement, if a port
f. Pain in shoulder, neck, or arm
g. Neck or shoulder edema
h. Suture damage
2. Interventions
a. Do not use syringes that are less than 5 mL to
irrigate.
b. Do not irrigate forcefully.

Question 51

IV Infection / Phlebitis

Answer 51

B. Infection/phlebitis
1. Assess:
a. Site for redness, drainage, edema, or tenderness
b. Vital signs
c. Laboratory findings
2. Interventions
a. Use aseptic and antiseptic techniques when starting
an IV line and when caring for IV site.
b. Inspect all fluids and containers before use to
be sure they have not been opened or otherwise
contaminated.
c. Change administration sets according to hospital
policy (usually every 72 to 96 hours).
d. Change IV bags every 24 hours or according to
hospital policy.
e. Use a catheter that is smaller than the vein.

Question 52

IV Dislodgement / Migration / Incorrect Placement

Answer 52

C. Dislodgment/migration/incorrect placement

1. Assess:
   a. Length of catheter
   b. Edema, drainage, and coiling of catheter
   c. Neck distention or distended neck veins
   d. Client complaints of gurgling sounds
   e. Change in patency of catheter
   f. Chest radiograph
   g. Cardiac dysrhythmias
   h. Hypotension
2. Interventions
   a. Provide enough tubing length for client movement.
   b. Anchor the catheter well.
   c. Measure and record length of catheter.

Question 53

IV Skin Erosion / Infiltration

Answer 53

D. Skin erosion/hematomas/scar tissue formation over
port/infiltration/extravasation
1. Assess:
a. Loss of tissue or separation at exit site
b. Drainage at exit site
c. Erythema and edema at exit site
d. Spongy feeling at exit site
e. Labored breathing
f. Complaints of pain
2. Interventions
a. Dilute medications adequately.
b. Follow institutional protocol for administration
of vesicant drugs.
c. Change IV line within the time frame outlined in
institutional protocol.
d. Provide gentle skin care at exit site.
e. Avoid selecting site over joint.
f. Anchor the catheter well.

Question 54

IV Pneumothorax / Hemothorax / Air Emboli / Hydrothorax

Answer 54

E. Pneumothorax/hemothorax/air emboli/hydrothorax
1. Assess for:
a. Subcutaneous emphysema
b. Chest pain
c. Dyspnea and hypoxia
d. Tachycardia
e. Hypotension
f. Nausea
g. Confusion
2. Interventions
a. Use clot filters when infusing blood and blood
products.
b. Avoid using veins in the lower extremities.
c. Prevent fluid containers from becoming empty.
d. Check valves and micropore filters on vented
Y-type infusions or piggyback infusions, which
allow solutions to run simultaneously. Air may be
introduced into the line if the containers become
empty.
e. If air embolism is suspected place patient in left
lateral Trendelenburg position.

Question 55

What amount of NS is needed to efficiently flush IV tubing / saline locks?

Answer 55

Flushing a saline lock efficiently requires
approximately 1.5 times the amount of fluid the tubing
will hold. Remember to use sterile technique to prevent
complications, such as infiltration, emboli, and infection.

Question 56

Respiratory Acidosis Causes

Answer 56

Primary:

• Hypoventilation

Contributing:
• COPD (primary cause)
• Pulmonary disease
• Drugs
• Obesity
• Mechanical asphyxia
• Sleep apnea

Question 57

Metabolic Acidosis Causes

Answer 57

Primary:

• Addition of large amounts of fixed acids to body fluids

Contributing:
• Lactic acidosis (circulatory failure)
• Ketoacidosis (diabetes, starvation)
• Phosphates and sulfates(renal disease)
• Acid ingestion (salicylates)
• Secondary to respiratory alkalosis
• Adrenal insufficiency

Question 58

Respiratory Alkalosis Causes

Answer 58

Primary:

• Hyperventilation

Contributing:
• Overventilation on a ventilator
• Response to acidosis
• Bacteremia
• Thyrotoxicosis
• Fever
• Hepatic failure
• Response to hypoxia
• Hysteria

Question 59

Metabolic Alkalosis Causes

Answer 59

Primary:

• Retention of base or removal of acid from body fluids

Contributing:
• Excessive gastric drainage
• Vomiting
• Potassium depletion
(diuretic therapy)
• Burns
• Excessive NaHCO3
administration

Question 60

Review of Fluid & Electrolyte Balance:

1. List four common causes of fluid volume deficit.
2. List four common causes of fluid volume overload.
3. Identify two examples of isotonic IV fluids.
4. List three systems that maintain acid-base balance.
5. Cite the normal ABGs for the following:
   A. pH
   B. Pco2
   C. HCO3
6. Determine the following acid-base disorders:
   A. pH 7.50, Pco2 30, HCO3 28
   B. pH 7.30, Pco2 42, HCO3 20
   C. pH 7.48, Pco2 42, HCO3 32
   D. pH 7.29, Pco2 55, HCO3 28

Answer 60

1. Gastrointestinal (GI) causes: vomiting, diarrhea, GI suctioning; decrease in fluid intake; increase in fluid output such as sweating,
   massive edema, ascites
2. Heart failure, renal failure; cirrhosis; excess ingestion of table salt or overhydration with sodium-containing fluids
3. Ringer’s lactate; normal saline
4. Lungs; kidneys; chemical buffers
5. Normal values
   A. 7.35 to 7.45 pH
   B. 35 to 45 mm Hg Pco2
   C. 21 to 28 mEq/L HCO3
6. Disorders
   A. Respiratory alkalosis
   B. Metabolic acidosis
   C. Metabolic alkalosis
   D. Respiratory acidosis

Question 61

What is the order of blood flow through the heart?

Answer 61

Review the order of blood flow through
the heart:
Unoxygenated blood flows from the superior and inferior vena cava into the right atrium, then to the right ventricle. It flows out of the heart through the pulmonary artery, to the lungs for oxygenation. The pulmonary vein delivers oxygenated blood back to the left atrium, then to the left ventricle (largest, strongest chamber), and out the aorta. Review the three structures that control the one-way flow of blood through the heart: Atrioventricular valves, Tricuspid (right side), Mitral (left side), Semilunar valves, Pulmonic (in pulmonary artery), Aortic (in aorta), Chordae tendineae, Papillary muscles

Question 62

What happens if defibrillation occurs during the T-wave of repolarization of the ventricle?

Answer 62

The T wave represents repolarization of the ventricle, so this is a critical time in the heartbeat. This action represents a resting and regrouping stage so that the next heartbeat can occur. If defibrillation occurs during this phase, the heart can be thrust into a lifethreatening dysrhythmia.

Question 63

What do the small and large squares of the ECG paper represent?

Answer 63

1. The small squares represent 0.04 second each; five
   of these small squares combine to form one large
   square.
2. Each large square represents 0.20 second (0.04
   second × 5). Five large squares represent 1 second.
   Calculation of heart rate uses the 6-second rule
   (Box 3-1):
   a. It is the easiest means of calculating the heart rate.
   b. It cannot be used when the heart rate is irregular.
   c. Thirty large squares equal one 6-second time interval.
   d. Count the number of RR intervals in the 30 large squares and multiply by 10 to determine the heart rate for 1 minute (the R is the high peak on the strip; Fig. 3-3).

Question 64

What is the most important assessment for a client with a dysrhythmia?

Answer 64

Observe the client for tolerance of the current rhythm. This information is the most important data the nurse can collect on a client with a [dys]rhythmia.

NCLEX-RN questions are likely to relate to early recognition of abnormalities and associated nursing actions. Remember to monitor the client as well as the machine! If the ECG monitor shows a severe dysrhythmia but the client is sitting up quietly watching television without any sign of distress, assess to determine if the leads are attached properly.

Question 65

1. Identify the waveforms found in a normal ECG.
2. In an ECG reading, which wave represents depolarization of the atrium?
3. In an ECG reading, what complex represents depolarization of the ventricle?
4. What does the PR interval represent?
5. If the U wave is most prominent, what condition might the nurse suspect?
6. Describe the calculation of the heart rate using an ECG rhythm strip.
7. What is the most important assessment data for the nurse to obtain in a client with an arrhythmia?
8. Calculate the rate of this rhythm strip.

Answer 65

1. P wave, QRS complex, T wave, ST segment, PR interval
2. Represented by the P wave
3. QRS complex
4. The time required for the impulse to travel from the atria through the AV node
5. Hypokalemia
6. Count the number of RR intervals in the 30 large squares and multiply by 10 to determine the heart rate for 1 minute.
7. Ability of the client to tolerate the arrhythmia
8. 80 beats per minute (bpm)

Question 66

What is included in the preoperative teaching plan?

Answer 66

A. Regulations concerning valuables, jewelry, dentures
B. Food and fluid restrictions such as nothing by mouth (NPO) after midnight per prescription by health care provider; clear liquids may be given up to 6 hours prior to surgery for the no-risk client per prescription by the health care provider.
C. Invasive procedures such as urinary catheters, IVs, nasogastric (NG) tubes, enemas, douches
D. Preoperative medications
E. Operating room, transportation, skin preparation, postanesthesia
F. Postoperative procedures:
1. Respiratory care, such as ventilator, incentive spirometer, deep breather, splinting
2. Activity, such as range of motion (ROM), leg exercises, early ambulation, turning
3. Pain control, such as IM medications, patient-controlled analgesia (PCA)
4. Dietary restrictions
5. ICU or postanesthesia care unit (PACU) orientation
(recovery room)

Question 67

How should site marking of the operative site be done?

Answer 67

Marking the operative site is required for procedures involving right/left distinctions, multiple structures (fingers, toes), and levels (spinal procedures). Site marking should be done with the involvement of the client.

Question 68

What are the intraoperative nursing responsibilities?

Answer 68

Description: From the time the client is received in the
operative suite until admission to the PACU, an OR nurseis in charge of care.
A. Maintain quiet during induction.
B. Maintain safety:
1. Conduct client identification: right client, right procedure, right anatomic site.
2. Ensure that sponge, needle, and instrument counts
are accurate.
3. Position client during procedure to prevent injury.
4. Apply grounding device to client if electrocautery is
to be used.
5. Strictly adhere to asepsis during all intraoperative
procedures.
6. Ensure adequate functioning suction setups are in
place.
7. Take responsibility for correct labeling, handling, and deposition of any and all specimens.
C. Monitor physical status:
1. If excessive blood loss occurs, calculate effect on
client.
2. Report changes in pulse, temperature, respirations,
and BP to surgeon, in conjunction with anesthesiologist/CRNA.
3. Positioning the patient is a critical part of every procedure and usually follows administration of the
anesthetic.
D. Provide psychological support:
1. Provide emotional support to client and family immediately prior to, during, and after surgery.
2. Arrange with physician to provide information to
the family if surgery is prolonged or complications or unexpected findings occur.
3. Communicate emotional state of client to other health care team members.

Question 69

What are the post-op care nursing responsibilities?

Answer 69

A. Initially, the client goes to the PACU.
B. On arrival, the client is assessed for vital signs (BP, pulse, respirations, temperature), level of consciousness, skin color and condition, dressing location and condition, intravenous fluids, drainage tubes, position, and oxygen saturation levels.
C. When client has been stabilized, and it has been prescribed by the health care provider, the client is then
transferred to the general nursing unit or the ICU.
D. Immediate postoperative nursing care should include:
1. Monitoring for signs of shock and hemorrhage:
hypotension, narrow pulse pressure, rapid weak pulse, cold moist skin, increased capillary filling time
2. Positioning client on side (if not contraindicated) to
prevent aspiration and to allow client to cough out
airway; side rails should be up at all times
3. Providing warmth with heated blanket
4. Managing nausea and vomiting with antiemetic drugs and NG suctioning
5. Managing pain with intravenous analgesics
6. Checking with anesthesiologist about intraoperative
medications before administering pain medications
7. Determining intraoperative irrigations and instillations
with drains to help evaluate amount of drainage on dressing and in drainage collection devices

Question 70

What are the interventions for common post-op complications?

Answer 70

Urinary retention: 8 to 12 hr postoperatively

Int:
• Monitor hydration status and encourage oral intake if allowed.
• Offer bedpan or assist to commode.
Pulmonary problems: 1 to 2 days postoperatively
• Atelectasis
• Pneumonia
• Embolus
Int:
• Assist client to turn, cough, deep breathe every 2 hr.
• Keep client hydrated.
• Enable early ambulation.
• Provide early incentive spirometer.
Wound-healing problems: 5 to 6 days postoperatively

Int:
• Teach splinting of incision when client coughs.
• Monitor for signs of infection, malnutrition, dehydration.
• Provide high-protein diet.
Urinary tract infections: 5 to 8 days postoperatively

Int:
• Oral fluid intake
• Emptying of bladder every 4 to 6 hr
• Monitor intake and output.
• Avoid catheterization if possible.
Thrombophlebitis: 6 to 14 days postoperatively

Int:
• Leg exercises every 8 hr while in bed
• Early ambulation
• Apply antiembolus (TED) stockings or sequential compression devices as prescribed; remove TEDs every 8 hr and reapply.
• Avoid pressure that may obstruct venous flow; do not raise knee gatch on bed; do not place pillows beneath knees; client should avoid crossing legs at knees.
• Low-dose heparin may be used prophylactically.
Decreased gastrointestinal peristalsis, Constipation, Paralytic ileus: 2 to 4 days postoperatively

Int:
• NG tubing to decompress GI tract
• Client to limit use of narcotic analgesics, which decrease peristalsis
• Encourage early ambulation.

Question 71

What is wound dehiscence vs. evisceration?

Answer 71

Wound dehiscence is separation of the wound edges; it is more likely to occur with vertical incisions. It usually occurs after the early postoperative period, when the client’s own granulation tissue is “taking over” the wound, after absorption of the sutures has begun. Evisceration of the wound is protrusion of intestinal contents (in an abdominal wound) and is more likely in clients who are older, diabetic, obese, or malnourished and have prolonged paralytic ileus.

Question 72

Perioperative: A 43-year-old mother of two teenage
daughters enters the hospital to have her gallbladder
removed in a same-day surgery using an endoscope
instead of an incision. What nursing needs will dominate
each phase of her short hospital stay?

Answer 72

Preparation phase: education about postoperative
care, including NPO, assistance with meeting family
needs
Operative phase: assessment, management of the
operative suite
Postanesthesia phase: pain management, postanesthesia
precautions
Postoperative phase: prevention of complications,
assessment for pain management, and teaching about
dietary restrictions and activity levels

Question 73

What is the Time Out, Surgical Care Improvement Project?

Answer 73

Time Out, Surgical Care Improvement Project (SCIP)
protocol implementation, and Hand-Off communication are all best practices implemented to prevent serious medical error during the perioperative period. Time Out occurs before making the incision and the entire surgical team pauses as the surgical site listed on the consent is read aloud. The entire team confirms that this information is correct. SCIP protocols are best practices for safety and quality that are implemented during the preoperative period and followed up on during the postoperative period. The focus of the SCIP protocol is on prevention of infection, prevention of serious cardiac events, and prevention of venous thromboembolism. The Hand-Off communication is the transfer of relevant patient information during the perioperative period, which is standardized and must include an opportunity to ask and to respond to questions.

Question 74

Review of Peroperative Care:

1. List five variables that increase surgical risk.
2. Why is a client with liver disease at increased risk for operative complications?
3. Preoperative teaching should include demonstration and explanation of expected postoperative client activities. What activities should be included?
4. What items should the nurse assist the client in removing before surgery?
5. How is the client positioned in the immediate postoperative period, and why?
6. List three nursing actions that prevent postoperative wound dehiscence and evisceration.
7. Identify three nursing interventions that prevent postoperative urinary tract infections.
8. Identify nursing/medical interventions that prevent postoperative paralytic ileus.
9. List four nursing interventions that prevent postoperative thrombophlebitis.
10. During the intraoperative period, what activities should the OR nurse perform to ensure safety during surgery?

Answer 74

1. Age: very young and very old, obesity and malnutrition, preoperative dehydration/hypovolemia, preoperative infection, use of anticoagulants (aspirin) preoperatively
2. Impairs ability to detoxify medications used during surgery; impairs ability to produce prothrombin to reduce hemorrhage
3. Respiratory activities: coughing, breathing, use of spirometer; exercises: range-of-motion, leg exercises, turning; pain management: medications, splinting; dietary restrictions: NPO evolving to progressive diet; dressings and drains; orientation to recovery room environment
4. Contact lenses, glasses, dentures, partial plates, wigs, jewelry, prostheses, makeup, and nail polish
5. Usually on the side or with head to side to prevent aspiration of any emesis
6. Teaching client to splint incision when coughing; encouraging coughing and deep breathing in early postoperative period when sutures are strong; monitoring for signs of infection, malnutrition, and dehydration; encouraging high-protein diet
7. Avoiding postoperative catheterization; increasing oral fluid intake; emptying bladder every 4 to 6 hours; early ambulation
8. Early ambulation; limiting use of narcotic analgesics; NG tube decompression
9. Teaching performance of in-bed leg exercises; encouraging early ambulation; applying antiembolus stockings; teaching avoidance of positions and pressures that obstruct venous flow
10. Ascertain correct sponge, needle, and instrument count; position client to avoid injury; apply ground during electrocautery use; apply strict use of surgical asepsis

Question 75

HIV Pathophysiology

Answer 75

Description: Infection with human immunodeficiency
virus (HIV).
A. HIV is caused by a retrovirus, which is attracted to
CD4 T cells, lymphocytes, macrophages, and cells of
the CNS.
B. The virus enters the cell and begins to replicate. An
event, such as cofactors (herpes simplex and cytomegalovirus [CMV]), can stimulate this replication.
C. The destruction of the CD4 T cell causes depletion in
the number of CD4 T cells and a loss of the body’s
ability to fight infection. Individuals with fewer than
200 CD4 T cells are at risk for opportunistic infections.
(Normal CD4 T-cell count is 600 to 1200.)
D. Initially, an individual commonly suffers an acute
infection that is quite similar to mononucleosis
(Table 3-12).
E. Initial symptoms usually occur within 3 weeks of first
exposure to HIV, after which the person becomes
asymptomatic. Persons infected with HIV can transmit
the virus to others any time after infection has occurred,
whether they are symptomatic or asymptomatic.
F. Current Centers for Disease Control and Prevention
(CDC) definition of AIDS (end-stage infection)
includes persons with specific serious opportunistic
infections such as Pneumocystis jiroveci pneumonia
(PCP), disseminated CMV, or Kaposi sarcoma.
G. Risk groups include the following:
1. Homosexual or bisexual males
2. IV drug abusers and those who have had tattoos or
acupuncture
3. Heterosexual partners of a risk-group member
4. Recipients of blood products prior to blood product
screening (e.g., those with hemophilia who were
diagnosed and treated prior to 1985)
5. Those taking medications such as steroids or other
agents that cause immunosuppression
6. Infants born to infected mothers
7. Breast-feeding infants of infected mothers

Question 76

Stages of HIV

Answer 76

Primary infection (acute HIV infection or acute HIV
syndrome), CD4 T-cell counts of at least 800 cells/mm3:
• Flu-like symptoms, fever, malaise
• Mononucleosis-like illness, lymphadenopathy, fever, malaise, rash
• Symptoms usually occur within 3 weeks of initial exposure to HIV, after which the person becomes asymptomatic
HIV asymptomatic (CDC Category A), CD4 T-cell counts more than 500 cells/mm3:
• No clinical problems
• Characterized by continuous viral replication
• Can last for many years (10 years or longer)
HIV symptomatic (CDC Category B), CD4 T-cell counts between 200 and 499 cells/mm3:
• Persistent generalized lymphadenopathy
• Persistent fever
• Weight loss, diarrhea
• Peripheral neuropathy
• Herpes zoster
• Candidiasis
• Cervical dysplasia
• Hairy leukoplakia, oral
AIDS (CDC Category C), CD4 T-cell counts less than 200 cells/mm3:
• Occurs when a variety of bacteria, parasites, or viruses overwhelm the body’s immune system
• Once classified as Category C, the patient remains classified as Category C; this has implications for entitlements (e.g., health benefits, housing, food stamps).

Question 77

HIV: Nursing Assessment (Labs, S/sx)

Answer 77

A. Laboratory testing
1. Positive ELISA (enzyme-linked immunosorbent
assay); false-positive results can occur.
2. Confirmation by the Western blot test, which uses
electrophoresis and evaluates virus-specific bands
3. Polymerase chain reaction (PCR) test may be used to
differentiate between HIV infection in the neonate
and antibodies the neonate receives from the mother.
4. Seroconversion to positive on these tests occurs usually within 6 weeks to 3 months but may take as
long as 12 months.
5. Prior to seroconversion to antibody-positive status, a
P24 antigen assay will be positive. (This test detects
the core antigen of the virus.)
B. Symptoms
1. Extreme fatigue
2. Loss of appetite and unexplained weight loss of
more than 10 pounds in 2 months
3. Swollen glands
4. Leg weakness or pain
5. Unexplained fever for more than 1 week
6. Night sweats
7. Unexplained diarrhea
8. Dry cough; may represent PCP
9. White spots in the mouth and throat; may represent
candidiasis
10. Painful blisters; may represent shingles
11. Painless purple-blue lesions on the skin
12. Confusion, disorientation
13. In women, recurrent vaginal infections that are
resistant to treatment

Question 78

HIV Opportunistic Infections

Answer 78

Pneumocystis carinii / Pneumonia :
• Fever
• Dry cough
• Dyspnea at rest
• Chills

Kaposi Sarcoma:
• Purple-blue lesions on skin, often arms and legs
• Invasion of gastrointestinal tract, lymphatic system, lungs, and brain

Cryptosporidiosis:
• Severe watery diarrhea (may be 30 to 40 stools per day)
• Abdominal cramps
• Nausea
• Electrolyte imbalance
• Malaise

Candidiasis of Oral Cavity and Esophagus:
• Thick white exudate in the mouth
• Unusual taste to food
• Retrosternal burning
• Oral ulcers
Cryptococcal Meningitis:
• Headache
• Changes in level of consciousness
• Nausea, vomiting
• Stiff neck
• Blurred vision

Cytomegalovirus (CMV) Retinitis:
• Most common CMV infection in persons with AIDS
• Impaired vision in one or both eyes
• Can lead to blindness

CMV Colitis:
• Diarrhea
• Malabsorption of nutrients
• Weight loss

Disseminated CMV:
• Malaise
• Fever
• Pancytopenia
• Weight loss
• Positive cultures from blood,
urine, or throat
Perirectal Mucocutaneous Herpes Simplex Virus:
• Severe pain
• Bleeding, rectal discharge
• Ulceration in the rectal area

Lymphomas of Central Nervous System (CNS):
• Change in mental status
• Apathy
• Psychomotor slowing
• Seizures

Tuberculosis:
• Pulmonary and extrapulmonary
• Lymphatic and hematogenous TB are common
• Negative skin testing does not rule out TB

HIV Encephalopathy:
• Memory loss and impaired concentration
• Apathy
• Depression
• Psychomotor slowing (most prominent symptom)
• Incontinence
• CT scan findings: diffuse atrophy and ventricular enlargement

Question 79

HIV: Nursing Int

Answer 79

A. Assess respiratory functioning frequently.
B. Avoid known sources of infection.
C. Use strict asepsis for all invasive procedures.
D. Obtain vital signs frequently.
E. Plan activities to allow for rest periods.

F. Elevate HOB.
G. Refer client to nutritionist.
H. Offer small, frequent feedings.
I. Weigh daily.
J. Encourage client to avoid fatty foods.

N. Provide emotional support for grieving client who is
losing all relationships and skills.
O. Provide emotional support for significant others: family,
family of choice, lovers, friends.
P. Administer IV fluids for hydration, as prescribed.
Q. Administer total parenteral nutrition (TPN), as
prescribed.
R. Administer agents that treat specific opportunistic
infections and medications for HIV (Table 3-14).
S. Assist with pain management; administer prescribed
narcotics or analgesics.
K. Monitor for skin breakdown, and offer good skin care.
L. Use safety precautions for clients with neurologic
symptoms or loss of vision.
M. Orient client who is confused.

Question 80

What type of isolation do HIV clients with tuberculosis require?

Answer 80

HIV clients with tuberculosis require respiratory isolation. Tuberculosis is the only real risk to nonpregnant caregivers that is not related to a break in standard precautions (e.g., needle sticks).

Question 81

Standard Precautions

Answer 81

Wash hands, even if gloves have been worn to give care.
Wear exam gloves for touching blood or body fluids or
any nonintact body surface.
Wear gowns during any procedure that might generate
splashes (e.g., changing clients with diarrhea).
Use masks and eye protection during activity that might
disperse droplets (e.g., suctioning).
Do not recap needles; dispose of in puncture-resistant
containers.
Use mouthpiece for resuscitation efforts.

Question 82

HIV Drugs:

NRT-Inhibitors

Non-NRT-Inhibitors

Protease Inhibitors

Combination Products

CCR5 Inhibitors

Fusion Inhibitors

Antiprotozoals

Antivirals

Antifungals

Answer 82

NRTI (nucleoTide) inhibitors:
• Tenofovir (Viread)

NI:

• Monitor for lactic acidosis.

Non-NRT inhibitors
• Efavirenz (Sustiva)
• Delavirdine (Rescriptor)
• Nevirapine (Viramune)
• Etravirine (Intelence)

NI:

• Many drug-drug interactions
• Monitor liver function tests.
• Reduces contraceptive effects
• Do not confuse Viramune with Viracept.

Protease inhibitors
• Indinavir (Crixivan)
• Amprenavir (Agenerase)
• Saquinavir (Invirase)
• Ritonavir (Norvir, Kaletra)
• Nelfinavir (Viracept)
• Lopinavir + ritonavir (Kaletra)
• Fosamprenavir (Lexiva)
• Atazanavir (Reyataz)

NI:

• Many drug-drug interactions
• High-fat, high-protein foods reduce absorption.
• Give most of these with food.
• Reduces contraceptive effects
• Do not confuse ritonavir (Norvir) with trade name zidovudine (Retrovir).

Combination products
• Lamivudine + zidovudine (Combivir)
• Zidovudine + lamivudine + abacavir (Trizivir)
• Emtricitabine + tenofovir (Truvada)
• Tenofovir + emtricitabine + efavirenz (Atripla)

NI:

• Note implications of the individual drugs in the combination product.

CCR5 inhibitors
• Maraviroc (Selzentry)

Use cautiously in patients with underlying liver, renal, and cardiac disease

Fusion inhibitor
• Enfuvirtide (Fuzeon)

NI:

Monitor skin reactions at injection site

Antiprotozoals
• Atovaquone (Mepron)
• Trimethoprim/sulfamethoxazole (Bactrim)
• Pentamidine isethionate (Pentam 300)

NI:

• Enhances effects of oral hypoglycemics
• Increases thrombocytopenia risk if given with thiazide
diuretics
• Check for allergy to sulfonamide.
• IV or aerosol; not oral
• Use careful precautions against potential spread of TB.

Antivirals
• Acyclovir sodium
(Zovirax)
• Valacyclovir (Valtrex)
• Famciclovir (Famvir)
• Ganciclovir (Cytovene)
• Valganciclovir (Valcyte)

NI:

• Give with or without food.
• Many incompatibilities IV PO, IV, topical
• Monitor liver function tests.

Antifungals
• Amphotericin B (Fungizone)
• Caspofungin (Cancidas)
• Fluconazole (Diflucan)
• Flucytosine (Ancobon)
• Anidulafungin (Eraxis)
• Posaconazole (Noxafil)
• Itraconazole (Sporanox)
• Micafungin (Mycamine)

NI:

• Many drug-drug interactions
• Vesicant: Monitor IV site closely; premedicate with
antipyretic; give slowly.
• Swish as long as possible before swallowing PO form.

Question 83

Pediatric HIV: Nursing Assessment

Answer 83

A. Risk groups
1. Infants born to mothers who are HIV-positive
2. Hemophiliacs
3. Infants and children who have received blood
transfusions
B. Symptoms
1. Failure to thrive
2. Lymphadenopathy
3. Organomegaly
4. Neuropathy
5. Cardiomyopathy
6. Chronic recurrent infections such as thrush
7. Unexplained fevers

Pediatric HIV is often evidenced by
lymphoid interstitial pneumonitis, pulmonary lymphoid
hyperplasia, and opportunistic infections.

Question 84

Pedatric HIV: Nursing Int

Answer 84

A. Avoid exposure to persons with infections, especially
chickenpox.
B. Administer no live virus vaccines.
C. Teach the family to:
1. Use gloves when diapering the child.
2. Clean any soiled surfaces (wearing gloves) with a
1:10 bleach to water solution.
3. Identify signs of opportunistic infections.
D. Monitor growth parameters.
E. Administer gamma globulin as prescribed, usually each month.
F. Support use of social services.
G. Support child’s attending school as much as child is
able.
H. Assist in community and school education programs.

Question 85

Review of HIV Infection

1. Identify the ways HIV is transmitted.
2. Vertical transmission (from mother to fetus) occurs how often if the mother is not treated during pregnancy?
3. Describe universal precautions.
4. What are the side effects of amphotericin B?
5. What does the CD4 T-cell count describe?
6. Why does the CD4 T-cell count drop in HIV infections?
7. Describe the ways a pediatric client might acquire HIV infection.

Answer 85

1. HIV is transmitted through blood and body fluids—e.g., unprotected sexual contact with an infected person, sharing needles with drug-abusing persons, infected blood products (rare), breast milk (mother-to-fetus transmission), and breaks in universal precautions (needle sticks or similar occurrences).
2. Vertical transmission occurs 30% to 50% of the time.
3. Protection from blood and body fluids is the goal of standard precautions. Standard precautions initiate barrier protection between caregiver and client through handwashing; using gloves; using gowns and masks; using eye protection as indicated, depending on activity of care and the likelihood of exposure; preventing needle sticks by not recapping needles.
4. Side effects of amphotericin B can be quite severe; they include anorexia, chills, cramping, muscle and joint pain, and circulatory problems.
5. CD4 T-cell count describes the number of infection-fighting lymphocytes the person has.
6. CD4 T-cell count drops because the virus destroys CD4 T cells as it invades them and replicates.
7. Pediatric acquisition may occur through infected blood products, through sexual abuse, and through breast milk.

Question 86

Pain: Nursing Assessment

Answer 86

A. Location: Pain may be localized, radiating, or
referred.
B. Intensity: Ask client to rate pain before and after an
intervention such as medication (use scale such as 0 to
10, with 0 being no pain).
C. Comfort: Often clients can describe what relieves pain
better than they can describe the pain itself.
D. Quality: Pain may be sharp, dull, aching, sore, etc.
E. Chronology: Ask client when pain started, what time
of day it occurs, how often it appears, how long it lasts,
whether it is constant or intermittent, whether the
intensity changes.
F. Subjective experience: Determine what decreases or
aggravates pain, what other symptoms are associated
with pain, what interventions provide relief, what limitations
the pain inflicts.

Question 87

Pain: Nursing Int

Answer 87

A. Pharmacologic interventions (Table 3-15)
1. Nonnarcotics, nonsteroidal antiinflammatory drugs
(NSAIDs; see Table 4-28)
a. Act by means of a peripheral mechanism at level
of damaged tissue by inhibiting prostaglandin and other chemical mediator syntheses involved in pain
b. Show antipyretic activity through action on the
hypothalamic heat-regulating center to reduce
fever
c. Examples: salicylate—aspirin (Bayer), nonsalicylates,
acetaminophen (Tylenol), ibuprofen (Motrin)
2. Narcotic mixed agonists/antagonists
a. Bind to both a receptor that produces pain relief,
which is the agonist portion, and bind to another
receptor that does not produce a physiologic
effect, which is the antagonist portion. Patients
are less likely to have respiratory depression.
b. May cause withdrawal symptoms if administered
after client has been receiving narcotics.
c. Produce side effects, including drowsiness, occasionally, nausea, and psychomimetic effects, such
as hallucinations and euphoria.
d. Examples: butorphanol (Stadol), nalbuphine
(Nubain)
3. Narcotics
a. Act as opioids, binding with specific opiate receptors
throughout the CNS to reduce pain perception.
b. Cause such side effects as nausea and vomiting,
constipation, respiratory depression, and CNS
depression.
c. Examples: hydromorphone (Dilaudid), morphine
sulfate (Table 3-16)

For narcotic-induced respiratory depression, naloxone (Narcan) may be administered as prescribed by the health care provider.

Question 88

Noninvasive Pain Management

Answer 88

Use noninvasive methods for pain management when
possible:
Relaxation exercises
Distraction
Imagery
Biofeedback
Interpersonal skills
Physical care: altering positions, touch, hot and cold
applications

Question 89

Onset of Common Narcotics

Answer 89

Codeine

PO: 30-45 min
IM or SC: 10-30 min
• Do not administer discolored injection solutions.
• May also be prescribed as an antitussive or antidiarrheal
Hydromorphone
(Dilaudid)
PO: 30 min
IM: 15 min
IV: 10-15min
• Fast-acting, potent narcotic
• More likely to cause appetite loss than other narcotics
Morphine sulfate

PO: 60-90 min
IM: 10-30min
IV: 10min
• Drug of choice in relieving pain associated with myocardial infarction
• May cause transient decrease in blood pressure
• Drug of choice for use with chronic cancer pain
Fentanyl citrate
(Duragesic)
IM: 7-15 min
IV: within 5 min
Intradermal: within 12 hr
Intrabuccal: 5-15 min
Intrathecal: immediate
• Synthetic narcotic
• Acts quicker; less duration

Question 90

1. What modalities are associated with the gate control pain theory?
2. How does past experience with pain influence current pain experience?
3. What modalities are thought to increase the production of endogenous opiates?
4. What six factors should the nurse include when assessing the pain experience?
5. What mechanism is involved in the reduction of pain through the administration of NSAIDs?
6. If narcotic agonist/antagonist drugs are administered to a client already taking narcotic drugs, what may be the result?
7. List four side effects of narcotic medications.
8. What is the antidote for narcotic-induced respiratory depression?
9. What is the first sign of tolerance to pain analgesics?
10. Which route of administration for pain medications has the quickest onset and the shortest duration?
11. List the six modalities that are considered noninvasive, nonpharmacologic pain relief measures.

Answer 90

1. Massage, heat and cold, acupuncture, TENS
2. The more pain experienced in childhood, the greater is the perception of pain in adulthood or with current pain
   experience.
3. Acupuncture, administration of placebos, TENS
4. Location, intensity, comfort measures, quality, chronology, and subjective view of pain
5. NSAIDs act via a peripheral mechanism at the level of damaged tissue by inhibiting prostaglandin synthesis and other
   chemical mediators involved in pain transmission.
6. Initiation of withdrawal symptoms
7. Nausea/vomiting; constipation; CNS depression; respiratory depression
8. Narcan (naloxone)
9. Decreased duration of drug effectiveness
10. Intravenous push, or bolus
11. Heat and cold applications; TENS; massage; distraction; relaxation techniques; biofeedback techniques

Question 91

1. Identify the five stages of death and dying.
2. A client has been told of a positive breast biopsy report. She asks no questions and leaves the health care provider’s
   office. She is overheard telling her husband, “The doctor didn’t find a thing.” What coping style is operating at this stage
   of grief?
3. Your client, an incest survivor, is speaking of her deceased father, the perpetrator. “He was a wonderful man, so good and kind.
   Everyone thought so.” What would be the most useful intervention at this time?
4. Your client feels responsible for his sister’s death because he took her to the hospital where she died. “If I hadn’t taken
   her there, they couldn’t have killed her.” It has been 1 month since her death. Is this response indicative of a normal or a
   complicated grief reaction?
5. Mrs. Green lost her husband 3 years ago. She has not disturbed any of his belongings and continues to set a place at the table
   for him nightly. Is this response indicative of a normal or a complicated grief reaction?

Answer 91

1. Denial, anger, bargaining, depression, acceptance
2. Denial
3. Gently point out both the positive and negative aspects of her relationship with her father. Try to minimize the idealization of
   the deceased.
4. This is a normal expression of the anger and guilt that occur. Try to minimize rumination on these thoughts.
5. This is a dysfunctional grief reaction. Mrs. Green has never moved out of the denial stage of her grief work.

Question 92

Death and Grief: NA / NI

Answer 92

NA:

A. Types of death

1. Natural/expected
2. Sudden/unexpected
3. Suicide

D. Complicated grief

1. Unresolved grief
   a. Determine level of dysfunction
2. Physical symptoms similar to those of the deceased
3. Clinical depression
4. Social isolation
5. Failure to acknowledge loss

NI:

A. Encourage client to express anger in a supportive, nonthreatening environment.
B. Discourage rumination.
C. Assist client in giving up idealized perception of
deceased; point out misrepresentations.
D. Encourage interaction with others.
E. Assist client with identification of support systems.
F. Consult spiritual leader as indicated by client need and preference.
G. Assist client toward a comfortable, peaceful death.

Do not take away the coping style used in
a crisis state. Denial is a very useful and needed tool for some at the initial stage. Support, do not challenge, unless it hinders or blocks treatment, endangering the patient.