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ABSN > AH II Exam I > Flashcards

AH II Exam I Flashcards

1
Q

What does the acronym SPICES stand for?

A 
Sleep disorders
Problems with eating and feeding
Incontinence 
Evidence of falls
Skin breakdown
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2
Q

What 2 assessments do we use to observe changes from the baseline in older adults?

A 
ACES
Assess function and expectations for ADLs 
Coordinate and manage care
use Evolving knowledge
makeSituational decisions

-used to Advance Care for the Excellence of Seniors

SPICES
assesses changes to their normal ADLs

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3
Q

What happens to each body system as we age?

A

kidney function, thirst and fluid status all decrease

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4
Q

If an older adult is having problems with swallowing/chewing, what do we want to give them?

A

THICKENED liquids

for example: a shake instead of a lemonade to reduce the risk of aspiration

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5
Q

What is a high risk BRADEN scale? What does it mean? How should a nurse intervene?

A

a low Braden score indicates a high risk for pressure ulcers

the highest risk score you can get is 6

no risk for ulcers is 23

Nursing Action: turn the patient every 2 hours. It only takes 20 minutes for an ulcer to begin developing.

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6
Q

What is a high risk MORSE scale? What does it mean? How should the nurse intervene?

A

a score over 50 indicates a high risk for falls

Nursing Action: get rid of environmental hazards, assess for muscle weakness.

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7
Q

When assessing an older adult’s AAOX3, are they oriented if they are off by just one day?

A

NO- the nurse should be reorienting the patient daily.

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8
Q

What is the “triple S” associated with chronic illness?

A

Sedentary lifestyle
Smoking
Stress

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9
Q

What defines a chronic illness?

A

it is permanent, and caused by a non-reversible pathological alteration.
it has a remission-exacerbation cycle.

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10
Q

What is the difference between the NIC and the NOC?

A

NIC- provides standardized patient interventions

NOC- provides standardized patient outcomes

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11
Q

What are 3 isotonic fluids? When are they indicated? When are they contraindicated?

A

0.9% Normal Saline
D 5% W
Lactated Ringers

Indicated: to increase intravascular volume
can be used in conjunction with blood products

Contraindicated: volume overload
do NOT gives lactated ringers when patient is alkylotic or in liver failure

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12
Q

What are 3 HYPOtonic fluids? When are they indicated? When are they contraindicated?

A

0.45% (half) normal saline
33% (one third) normal saline
2.5% (half) dextrose

Indicated: to draw water into the cell

Contraindicated: anasarca, cerebral edema, HYPOtension

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13
Q

What are 3 HYPERtonic fluids? When are they indicated? When are they contraindicated?

A

D 5% W in 0.45% NS
D 5% W in 0.9% NS
D 5% W in lactated ringers

Indicated: to draw water into the vessels

Contraindicated: heart failure, DKA

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14
Q

What is the pressure called that PULLS (absorbs) fluid from the interstitial space?

A

colloid oncotic pressure

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15
Q

What are the 4 routes too edema?

A
  1. increased capillary permeability r/t burns, allergies, inflammatory reactions, etc.
  2. decreased capillary oncotic pressure r/t loss of plasma proteins
  3. increased capillary hydrostatic pressure r/t vein obstruction, salt/water retention and heart failure
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16
Q

What are the 4 routes too edema?

A
  1. increased capillary permeability
  2. decreased capillary oncotic pressure
  3. increased capillary hydrostatic pressure
  4. lymphatic obstruction
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17
Q

How do decreased blood volume and decreased blood pressure affect osmolarity?

A

They both lead to a decrease in osmolarity.
They tell the atria and great veins that they need more fluid.
That sets off an increase in ADH.
ADH increase causes reabsorption of water into the vessels which decreases the concentration of electrolytes there (decreases osmolarity)

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18
Q

What are the three things that cause the body to increase its ADH production and consequently decrease its osmolarity? (yes. do the big list)

A
  1. decreased blood volume/blood pressure
  2. too high an increase in osmolarity (sensed by the hypothalamus)
  3. extrinsic factors such as:
    HAANNSS
    Heat
    Anesthetics
    Antineoplastics (chemo)
    Narcotics
    Nicotine
    Surgery
    Stress
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19
Q

Describe the RAAS cycle.

A
  1. Triggered by low BP
  2. Kidneys release renin which travels to the liver
  3. Renin converts angiotensin to angiotensin I
  4. Angiotensin I travels to the lungs to be converted by ACE into angiotensin II
  5. Angiotensin II powerfully vasoconstricts vessels and increases BP
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20
Q

What is the best indicator of fluid status?

A

daily weight

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21
Q

What are the 2 most important things to monitor during rehydration?

A

HR

urine output

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22
Q

Dilution of which two electrolytes can lead to seizures, coma and death?

A

sodium and potassium

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23
Q

Urine output below _____ for a kidney patient is cause for concern?

A

500mL/day
or
1lb/day

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24
Q

What is the most common type of fluid loss problem?

A

isotonic dehydration

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25
Q

A patient with acute kidney injury or chronic kidney disease is at risk for fluid volume _____

A

excess

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26
Q

What are the 5 clinical signs of HYPOvolemia?

A 
sudden weight loss
flat neck veins
HYPOtension
tachycardia
weak, thready pulse
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27
Q

What are the 4 clinical LABS for HYPOvolemia?

A

Increased hematocrit
Increased BUN (>25)
Increased urine specific gravity (> 1.03)
Increased serum sodium

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28
Q

What are the 3 clinical signs of HYPERvolemia?

A

sudden weight gain
distended neck veins
lung crackles

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29
Q

What are the 4 clinical LABS for HYPERvolemia?

A

Decreased hematocrit
Decreased BUN (< 10)
Decreased urine specific gravity
Decreased serum sodium

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30
Q

What are 3 nursing management options for HYPOvolemia?

A

check urine output
monitor for bounding pulse/difficulty breathing when rehydrating
give ~100mL/hr PO fluid replacement

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31
Q

What are 4 nursing management options for HYPERvolemia?

A

prevent skin breakdown from edema/oxygen therapy
administer diuretics
restrict fluid
restrict sodium to 2-4g/day

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32
Q

Sodium Range:

A

135-145

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33
Q

HYPOnatremia neuromuscular:

A

decreased mm contraction that leads to shallow respirations

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34
Q

How does the nurse fix HYPOnatremia?

A

if related to excess fluid intake, restrict fluids and administer diuretics

if related to decreased sodium intake, replace with hypertonic solution like 3-5% normal saline

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35
Q

Common causes of HYPOnatremia:

A 
excessive sweating
wound drainage
diuretics
HYPOtonic fluids
HYPERglycemia
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36
Q

Potassium LOSS can be caused by an INCREASE in what hormone?

A

aldosterone

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37
Q

Shifting potassium into cells via what condition can cause HYPOkalemia?

Shifting potassium OUT of the cells via what condition can cause HYPERkalemia?

A

HYPO:
metabolic ALKalosis
treatment of DKA (b/c it may lead to an alkylotic state)

HYPER:
metabolic ACIDosis
trauma

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38
Q

Potassium Range:

A

3.5-5

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39
Q

What the early and late neuromuscular sign of HYPERnatremia?

A

early: Increased mm contraction
late: Decreased mm contraction

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40
Q

How should the nurse treat HYPERnatremia?

A

restrict sodium intake and drink fluids

give 0.9% normal saline to rehydrate AND dextrose 5% in 1/2 normal saline

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41
Q

What is HYPERnatremia commonly caused by?

A

Cushing’s

HYPERtonic fluid administration

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42
Q

mental status for HYPOkalemia versus HYPERkalemia:

A

HYPO:
lethargic
coma

HYPER:
irritable

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43
Q

Respiratory for HYPOkalemia

A

shallow respirations

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44
Q

What is the #1 cause of death in patients with HYPOkalemia?

A

respiratory arrest

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45
Q

HYPOkalemia cardiac

vs.

HYPERkalemia cardiac

A 
HYPO:
Peaked P
Prolonged PR
Normal QRS
Depressed ST
Shallow T
Prominent U 
HYPER: 
Absent P
Prolonged PR (even more than HYPOkalemia)
Widened QRS
Depressed ST
Tall T 
No U
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46
Q

HYPOkalemia GI
vs.
HYPERkalemia GI

A

HYPO: constipation
HYPER: diarrhea

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47
Q

What is the earliest sign of HYPERkalemia? Late sign?

A

early: irritability
late: flaccid paralysis

48
Q

HYPOkalemia neuromuscular vs. HYPERkalemia neuromuscular

A

HYPO: mm weakness, diminished DTRs and flaccid paralysis

HYPER: early- paresthesias, cramps, mm twitches
late-flaccid paralysis

49
Q

How should the nurse fix HYPOkalemia?

A

give IV potassium
always diluted
1mEq potassium to 10mL solution

50
Q

When administering supplemental potassium, what are the rules?

A

NEVER IV push/IM/subQ
infusion should never exceed 20mEq/hour
if the infusion exceeds 10mEq/hour we have to monitor respiratory and cardiac

51
Q

How should the nurse fix HYPERkalemia?

A

Patiromer - decreases potassium absorption
Sorbitol- laxative that draws. potassium out
Potassium wasting (loop) diuretics.
Dialysis

52
Q

What is the emergency treatment for HYPERkalemia?

A

IV fluids with 10-20% glucose and 10-20 units insulin

monitor cardiac

53
Q

Foods high in potassium:

A 
Avocado
Banana
Broccoli 
Cantaloupe
Carrots
Dairy
Dried fruit
Kiwi
Mushrooms
Oranges
Organ meats
Potatoes
Pork, beef, veal
Seaweed
Spinach
54
Q

What drug do we need to be careful with when a patient is in a HYPOkalemic state?

A

Digoxin - it worsens the hypokalemia and therefore the dysrhythmias

55
Q

Calcium Range:

56
Q

HYPOcalcemia vs.

HYPERcalcemia bones:

A

BOTH:
osteoporosis
fractures

HYPO:
calcium deposits throughout the body b/c bones give it away when they sense low l levels throughout the body

57
Q

HYPOcalcemia vs.

HYPERcalcemia cardiac:

A

Both: dysrhythmias/arrest

HYPER: long QT and ST, HYPOtension

HYPO: short QT, HYPERtension, increased HR that progresses to decreased HR

58
Q

HYPOcalcemia vs.

HYPERcalcemia GI

A

HYPO: diarrhea
HYPER: constipation

59
Q

HYPOcalcemia vs.

HYPERcalcemia Neuromuscular:

A

HYPO: tetany, (+) Trousseau’s, (+) Chvostek’s

HYPER: decreased DTR, lethargy, coma

60
Q

How does the nurse fix HYPOcalcemia?

A

IV 10% calcium gluconate (NEVER push)
Slow IV chloride
vitamin D replacement
Reduce stimulation (lights, voice volume)

61
Q

What is the most important nursing consideration with a patient who has HYPOcalcemia?

A

fall prevention

62
Q

How should the nurse fix HYPERcalcemia?

A

increase isotonic fluids
corticosteroids
switch diuretics to Furosemide

63
Q

What is the most important nursing consideration with a patient who has HYPERcalcemia?

A

watch for calcium-containing antacids (AlOH)

assess for poor perfusion

64
Q

Foods high in calcium:

A 
cheese
collard greens
milk
rhubarb
sardines
spinach 
tofu
yogurt
65
Q

Which vitamin increases with calcium increase?

66
Q

Which electrolyte increase leads to a decrease in calcium absorption?

A

magnesium

since magnesium and calcium go together, having more magnesium absorbed leaves “less room” for calcium.

67
Q

Magnesium Levels:

68
Q

HYPOmagnesemia vs. HYPERmagnesemia cerebral:

A

HYPO: agitation
HYPER: drowsiness, coma

69
Q

HYPOmagnesemia vs. HYPERmagnesemia cardiac:

A 
HYPO: 
tachycardia
HYPERtension 
atherosclerosis 
Long QT 
left ventricle hypertrophy 
HYPER: 
bradycardia 
HYPOtension (vasodilation) 
increased PR
shortened QT
T wave changes
70
Q

HYPOmagnesemia vs. HYPERmagnesemia neuromuscular:

A

HYPO:
tetany
(+) Trousseau’s
(+) Chvostek’s

HYPER:
decreased DTR
lethargy
coma

71
Q

How does the nurse treat HYPOmagnesemia vs HYPERmagnesemia?

A

HYPO: IV magnesium replacement

HYPER: diuretics
Dialysis
Calcium Gluconate

72
Q

Nursing action for HYPOmagnesemia:

A

ask if the patient is taking Digoxin or if they drink

73
Q

What is the largest concern for patients with HYPERcalcemia and HYPERmagnesemia?

A

respiratory arrest

when levels are high, nerves and muscles slow down

74
Q

Nursing actions for HYPERmagnesemia:

A

give phosphate

75
Q

Foods high in magnesium:

A 
avocado 
canned tuna
cauliflower
green leafy veggies 
oatmeal
peanut butter
peas
pork
potatoes 
soy beans 
raisins
yogurt
76
Q

What do you do if the patient gets air emboli related to a catheter?

A

place them in Trendelenburg

77
Q

What should the nurse assess for after an IV placement?

A 
redness
swelling
tenderness
blood return 
integrity of dressing 
color
78
Q

When should IV tubing be replaced?

A

72-96 hours

79
Q

IV dressings must be:

A

dry
intact
occlusive

80
Q

What is infiltration vs. extravasation?

A

Infiltration:
leakage of NON-vesicant IV solution into the tissues

Extraversion:
leakage of vesicant IV solution into the. tissues

81
Q

S&S of infiltration and extravasation:

A

cool, tight, blanched skin

numbness and pain

82
Q

Treatment of infiltration:

A

STOP and remove
elevate
apply warm OR cool compress
document

83
Q

Treatment of extravasation:

A

STOP and remove
disconnect tubing
aspirate the medication out
document

84
Q

What is phlebitis? S&S? Tx?

A

venous inflammation

S&S:
veins are hard and cordlike
pain, redness, inflammation
can occur 2-4 days p extubation

Treatment:
STOP. and remove
apply warm compress
document

85
Q

What could cause phlebitis?

A

mechanical trauma or bacterial infection

86
Q

Which catheters can NOT take vesicant medications?

A

Peripheral IV

Midline

87
Q

What are considerations with a PICC line?

A

No heavy lifting
No wheelchairs
No crutches

X ray confirms placement

88
Q

What are considerations with a non-tunneled CVC?

A

assess for blood return

watch for air emboli

89
Q

Which catheter needs a Huber needle to access it?

A

Implanted ports

90
Q

You can’t give anything via IV at the same time as ______.

A

Blood or heparin

91
Q

What is the only thing you can give with TPN?

A

lipids and insulin

92
Q

How should the nurse prevent infection during IV catheter administration?

A

wear a mask and have the patient look away

93
Q

If a patient is allergic to_________, they have a high probability of a latex allergy

A

ABS
Avocado
Banana
Strawberry

94
Q

-rrhapy

95
Q

Surgical Timing:

A

Green: Elective- planned but unessential

Yellow: Urgent- unplanned, requires timely intervention

Red: Emergent- immediate to preserve life/limb

96
Q

What herb is important to note in a preoperative assessment? Why?

A

Ginkgo: impacts clotting

97
Q

Which medications should be noted in a preoperative assessment?

A 
NSAIDs: anti-platelet 
Steroids: infection risk
Antihypertensives
Diuretics
Metformin 
Opioids: higher tolerance 
MAOIs: interactions - stop 13 days before surgery
98
Q

What are the 4 risk factors for pulmonary complications post-op?

A

Smoking
COPD
Respiratory infection
Skeletal deformities that impair ventilation

99
Q

A patient should be NPO _______ hours before surgery.

100
Q

Should patients take prescribed medication before surgery?

A

Yes-unless told otherwise

101
Q

Why would a bowel/intestinal prep be conducted before surgery?

A

it reduces the number of intestinal bacteria

102
Q

Describe how how to use an incentive spirometer (5 steps).

A
  1. sit upright
  2. put in mouth
  3. raise the ball between the 600-900 mark
  4. hold a full breath for 5 seconds before breathing out
  5. repeat 10 times/hour
103
Q

What does using the incentive spirometer prevent?

A

atelectasis

104
Q

What is a non-pharmacological intervention we can use when using the incentive spirometer?

105
Q

When should antibiotics be administered pre-op?

A

30 minutes

106
Q

What medications can be given pre-op?

A 
the -pams
Glycopyrrolate
Hyoscine
Hydrobromide 
PPIs 
Rubinol
Supolamine
107
Q

Scrubbing in:

A

3-5 minutes
elbows to fingertips
water should drip FROM elbows TO fingertips
solution used is broad spectrum and antimicrobial

108
Q

What is malignant hyperthermia?

A 
a common complication of general anesthesia that causes:  
mm rigidity of the jaw/chest
rapid breathing
HYPOtension 
CO2 levels rising
respiratory and metabolic acidosis 
late sign: pt temp into 112F
109
Q

What is the treatment of malignant hyperthermia?

A

Dantrolene

110
Q

What level should you check when patient is getting Heparin?

A

PTT

goal: 45-70

111
Q

What should you do if a patient’s PTT is high (>70)?

A

STOP, they’re taking too long to clot

112
Q

What should you do if a patient’s PTT is low (<45)?

A

prepare to give more heparin, they’re clotting too quickly

113
Q

The _________ gauge catheter should be chosen that suits the prescribed therapy.

114
Q

_________ gauge peripheral catheters increase risk of phlebitis

115
Q

How many times can you attempt to put in a catheter?

A

each clinician can try 2X

max of 4X

116
Q

What is the max flow rate fora Power PICC?

117
Q

What is the most serious complication of a PICC?

A

thrombophlebitis

ABSN (18 decks)

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