Competency retake Flashcards
Glucose: normal value & effects of balance
Normal value: 70-110
High glucose: 3 p’s (polydipsia, polyuria, polyphagia)
Low glucose: confusion, irritability, diaphoresis
Na+ : normal value & effects of balance
Normal value: 135-145
High or Low sodium = confusion (change in neuro status) - affected by fluid balance
K+ :normal value & effects of balance
Normal value: 3.5-5
High or low dysrhythmia
High: diarrhea, cramping - acidotic states
Low: constipation, leg cramps - alkalotic states
Ca+ : normal value & effects of balance
Normal value: 8.5-10.5
High: constipation, slowed reflexes, kidney stones
Low: tetany, increased reflexes, Chvosteks & Trousseau sign, diarrhea
BUN: normal value & effects of balance
Normal value: 10-20
affected fluid balance and diet (protein intake - if eat a lot of protein then high if little protein intake then low.) Kidney function but not specific
Creatinine: normal value & effects of balance
Normal value: 0.5-1.5
Specific to kidney function
WBC: normal value & effects of balance
Normal value: 5,000-10,000
Low= sepsis
High = infection
Very high= leukemia
Platelets: normal value & effects of balance
Normal value: 150k-400k
High: clotting
Low: bleeding
Hgb: normal value & effects of balance
Normal value: 10-15
Low: anemia (sob, lethargic, pallor)
Hct: normal value & effects of balance
Normal value: 35% > up 48%
Low: anemia (sob, lethargic, pallor)
High: clotting
Bilirubin: normal value & effects of balance
<1
High: jaundice, abdominal pain, clay stools, brown urine,
State 2 differences between an ileostomy and colostomy
Consistency:
Ileostomy= watery, continuous output.
Colostomy= more formed- not continuous
Location:
ileocecal (right lower quadrant - ileostomy)
colostomy ascending, transverse
How often should an ostomy pouch/wafer be changed?
Bag emptied?
7-10 days or prn if there is a leak.
2/3 full
A client calls the clinic stating they have not had any output from their ileostomy for 2hrs. What is the best response by the nurse?
knee chest, ambulate, change the wafer, warm shower,
State 3 reasons a nurse would clamp a chest tube?
- leaks (intermittently)
- Changing the drainage container
- Getting ready to remove it.
MRI Pre and Post
Pre- Make sure there is no metal in the client e.g. welders may have fragments in their eyes and not know it, older pace-makers, rods, etc. Also, are they claustrophobic?
Post- It depends if it’s just a MRI (don’t need to do anything);
CT with contrast: Pre and Post
Pre- check for allergies for shellfish or iodine. Hold Glucophage the day of the procedure and 48 hours after
Post- Hold Glucophage 48hrs after the procedure. Increase hydration to excrete dye
Arterial Blood Gas Pre and Post
Pre- Allen’s test, check bleeding profile (PT/INR, PTT, Liver function)
Post- Hold pressure for 5 minutes or even longer if on meds that cause bleeding.
Endoscopy Pre and Post
Pre- NPO 4-6 hours before to prevent aspiration
Post- Gag reflex before anything PO
Cardiac Catherization
Pre- NPO 4-6 hours prior, check allergies shellfish
Post- HOB less 30 degrees; maintain pressure, check site q15 minutes and distant pulses, bp/hr for internal bleeding. Hydration to remove dye from body
Thoracentesis
Pre- remain still, assess their lungs, vital signs prior, consent, bleeding time, meds that may increase risk of bleeding
Post- CXR immediately after, assessment of lungs, vital signs immediately
State 3 factors that increase a client’s risk for falls
Age, medication, previous fall, uses equipment to ambulate (cane, walker), lines
How are crutches measured?
2-3 fingerbreadths below axillary, 20 degree angle wrist pressure on wrists not axillary
A client is being discharged home after hip surgery, what “hip precaution” teaching will you provide?
do not cross legs, do not bend over 90 degrees, chair height (upside down stop light), raised toilet seat. chairs with arms
What do nurses need to know about traction e.g. bucks or cervical?
- continuous never release
- never change weights
State 2 nursing considerations when communicating with a client who is hearing impaired
quiet environment, face them, lighting, hearing aids in if they have them, set aside enough time to speak with client
A nurse is discharging home a client with a visual deficit. State 3 home safety interventions:
no extension cords, good lighting, no scatter rugs
What can be delegated to an LPN?
Anything but EAT (Evaluate, Assess, and Teach)
stable patients, chronic conditions
State 3 nursing ethical principles:
autonomy, veracity (telling truth), fidelity (doing what you say you will do, keep your word), beneficence (doing good); nonmaleficence (not doing harm)
A client is at risk for aspiration (difficulty swallowing) what should the nurse instruct the CNA to do when feeding the client?
90 degrees, chin tuck, no straws, speech and swallow
Which type of cerebrovascular bleed requires immediate surgery (lucid then deteriorates quickly)?
Epidural bleed
State 2 interventions you would do if clear drainage was observed draining from the nares of a client with a basilar skull fracture?
halo test; mustache dressing. High risk for CNS infection = nuchal rigidity
What are the cardinal signs of Parkinson’s Disease? (TRAPI)
Tremors, rigidity, akinesia (bradykinesia slow movement), Postural instability
How is autonomic dysreflexia treated? Who is at risk?
T6 spinal injury or above, high bp caused by a stimulus below the injury usually bladder distention or constipation or tight clothing.
Sit them up, look for the problem. If SBP >170 give BP medication.
State 2 things a nurse needs to know about traction (Gardner wells or Bucks)
continuous traction
Do not change weights
Where is the phlebostatic axis located?
right atrium (4th ICS, mid axillary)
What are signs and symptoms of pericarditis?
friction rub, pain relieved if leaning forward, and NSAIDS
Which type of valve replacement requires life-long anticoagulants?
mechanical
biological do not, but need to get a new biological every 8-10 years whereas mechanical is for life
How does a venous ulcer differ from an arterial ulcer?
Arterial= there is not enough blood, blood is warm and it carries all the nutrients; decreased blood flow to lower extremities will not have edema, will be cool; scarce hair and thick toenails
Venous= blood pools in the feet due to incompetent valves make it difficult for the blood to return to the right side of the heart so edema, warm feet, good pulses, toenails are fine and hair is not patchy. Wounds are shallow with irregular borders
What medication(s) would you use to lower systemic vascular resistance?
vasodilators, antihypertensives
Interpret the following ABG: pH 7.20, pC02 32, Hc03 18, Pa02 70
Metabolic Acidosis, partial compensation, hypoxemia
What would cause a low pressure alarm on a ventilator?
disconnected, pneumothorax, leak, tracheostomy cuff is down.
What is the cardinal sign of ARDs?
refractory hypoxemia needs mechanical ventilation and high PEEP
What labs would the nurse expect for a client admitted with adrenal crisis?
Adrenal crisis= hyperkalemia, hyponatremic, hypotension, hypoglycemic
What are the complications (emergency) of hypothyroid and hyperthyroid?
Hypothyroid emergency/complication: myxedema coma - give synthroid (thyroid hormone)
Hyperthyroid emergency/complication: thyroid storm - treat symptoms High BP, High temperature
Using the rule of nines and Parkland formula calculate fluid resuscitation for first 8 hours:
Burns to the face, entire right arm, entire chest and abdomen, entire right leg and groin. Client weighs 68kg
Total to be infused in the first 8hrs: _____________________
face: 4.5, 9, 18, 18, 1= 50.5 x 4mL x 68= 13,736/2 = 6868 first 8hrs (has to be infused within 8hrs of the when the burn occurred e.g. if burned at 1000, then it must be infused by 1800) then the rest over the next 16 hours
6868/8= 858.5
Compare and contrast
Glomerulonephritis and Nephrotic Syndrome - how are they similar and how are they different?
strep infection undetected/not treated - damaged kidneys, more permeable losing large cells albumin and red blood cells. Low albumin look like pillsbury dough boy (edema) frothy coca cola urine (frothy album and coca cola is red blood cells) ; red blood cells anemic. - treat glomerulonephritis antibiotic, go slow with replacing albumin.
If glomerulonephritis is not treated properly then they will develop nephrotic syndrome - irreversible chronic renal failure - go ahead and replace albumin.
What are 3 types (causes) of acute renal failure?
pre-renal (volume)
intrarenal (drugs aminoglycoside)
post-renal (enlarged prostate or stone)
Frequency and Complications that might occur:
Hemodialysis
Frequency: 3 days a week for few hours
Complications that might occur: hypotension
Frequency and Complications that might occur:
Peritoneal Dialysis
Frequency: several exchanges a day
Complications that might occur: fluid overload
