Exam 1 Flashcards
A nurse is teaching a client who has type 1 DM about the use of an insulin pump. Which of the following information should the nurse include in the teaching?
The risk for developing DKA can be increased with the use of an insulin pump
What number indicated a fasting blood glucose measurement that is outside the expected reference range?
118 mg/dL
What are assessment findings for hypokalemia?
• May have no symptoms if loss is gradual
• Dramatic function changes if loss is rapid
What are assessments findings of hyperkalemia?
• Palpitations
• Skipped heartbeats
• Muscle twitching
• Leg weakness
• Tingling
• Numbness
• Diarrhea
What are assessment findings for hypocalcemia?
• Frequent, painful muscle spasms in calf or foot
• Paresthesia
• Cardiac, intestinal or skeletal changes
What are assessment findings for hypercalcemia?
• Severe muscle weakness
• Decreased deep tendon reflexes
• Decreased peristalsis
What are assessment findings for hypomagnesemia?
• Inhibited nerve impulse transmission
• GI symptoms
What are some assessment findings for hypermagnesemia?
• Depressed nerve impulse transmission
• Respiratory insufficiency
• Could lead to coma
What are interventions for hypokalemia?
• Increase serum potassium
• Give potassium (IV or SQ)
What are some interventions for hyperkalemia?
• Reduce serum potassium
• Cardiac monitoring
• Restore potassium balance through excretion and movement of potassium
What are some interventions for hypocalcemia?
• Direct calcium replacement (oral or IV)
• Vitamin D
• Calcium rich foods
What are some interventions for hypercalcemia?
• Stop IV solutions and oral drugs containing calcium
• Stop vitamin D
• Give fluid volume replacement (normal saline)
• Diuretics that help excrete calcium
• Cardiac monitoring
What are some interventions for hypomagnesemia?
• Drugs promoting magnesium loss should be d/c
• Magnesium sulfate
What are some interventions for hypermagnesemia?
• Reduce serum level
• Oral and parenteral magnesium should be d/c
• Magnesium (free IV fluids)
• Loop diuretics
pH normal value
7.35-7.45
PaCO2 normal value
35-45
HCO3 normal value
21-28
What causes metabolic acidosis?
Overproduction of hydrogen ions
What causes metabolic alkalosis?
Caused by either an increase of bases or decrease of acids
What causes respiratory acidosis?
It is the retention of CO2, causing increased production of free hydrogen ions
What causes respiratory alkalosis?
Caused by excessive loss of CO2 through hyperventilation
What are assessment findings of metabolic acidosis?
Pt takes long breaths
Severe diarrhea
Weakness
Lethargy
Confusion
Stupor
Coma or death
What are some assessment findings for metabolic alkalosis?
Irritability
Disorientation
Lethargy
Muscle twitching
Numbness and tingling
What are some assessments findings for respiratory acidosis?
Increasingly difficult breathing
Dyspnea
Weakness
Dizziness
Sleepiness
Change in alertness
What are some assessment findings for respiratory alkalosis?
Deep, rapid breathing
Tingling of fingers
Pallor around mouth
Dizziness
Muscle spasms of hands
What are interventions for metabolic acidosis?
Identify and treat the underlying cause
Insulin
Dialysis
IV bicarb and lactate
What are interventions for metabolic alkalosis?
IVF’s
Electrolyte replacement
What are interventions for respiratory acidosis?
Establish & maintain airway
Oxygen
Deep breathing exercises
Bronchodilators
Antibiotics
What are interventions for respiratory alkalosis?
Breathing through re-breather mask or paper bag
S/S of phlebitis
Pain at sight
Skin = red, inflamed and potentially hard
Interventions for phlebitis
Remove site, if possible
Heat and elevate extremity
S/s of infiltration
Skin = cool, tight and tender
Fluid leaking from puncture site
Severely swollen
Interventions for infiltration
Stop infusion, remove sire
Elevate extremity
Cold/warm compress
S/s of extravasation
Skin = cool, tight and tender
Fluid leaking from puncture site
Severely swollen
Blistering/tissue sloughing
Interventions for extravasation
Stop infusion
Surgical intervention may be necessary
S/s of thrombosis
Swollen extremity
Tenderness/redness
Slowed/stopped infusion
Interventions for thrombosis
Stop infusion, apply cold compress
Elevate extremity
Potential need for surgical intervention
S/s of site infections
Site = red, swollen and warm
Potential purulent or odoris exudate
Interventions for site infection
Clean exit site, remove catheter, send for culture, cover with dry sterile dressing
What are some adverse effects for a pt taking Digoxin?
o Fatigue
o Bradycardia
o Anorexia
o N/V
o Dysrhythmias
o CNS effects
o GI effects
What are some adverse effects due to talking Lasix?
o Hypokalemia
o Hypotension
o hyponatremia
o dehydration
S/s of left sided heart failure
o Weakness
o Fatigue
o Cough
o Chest pain/palpitations
o Small amounts of urine
o Dyspnea
o Arm heaviness
S/s of right sided heart failure
o Distended jugular veins
o Abdomen girth
o Edema in upper and lower extremities
o Hepatomegaly
o Hepatojugular reflux
o Ascites
Diet for pt’s with heart failure:
Low sodium
Fruits and veggies
Low fat
What are some adverse effects of Warfarin?
Red/brown urine
Abdominal pain
Black tarry stool
Vomiting/coughing up blood
Hepatitis
Hypotension
Syncope
Interactions for warfarin
Anticoagulants
Oral contraceptives
Herb supplements
Contraindications for warfarin
Diverticulitis
Uncontrolled high BP
Severe hepatic or renal disease
Meds for PVD include:
- Anticoagulants
- Antiplatelets
- Thrombolytics
Example of antiplatelet meds
ASA and Plavix
What are some assessment findings for PAD
o Rubor (redness) of extremity
o Thick toenails
o Dry, scaled, mottled skin
o Decreased/non-palpable pulses
How can you prevent dislodgment of VTE
o Do NOT massage the affected limb
o Encourage ambulation after anticoagulation therapy initiated
o Warm moist compress
Treatment for varicose veins include:
o Exercise
o Elevation
o Elastic compression hose
What is the priority intervention for chest pain?
A cardiac assessment
What is some pt education on foot care for DM?
o Do NOT soak feet
o Inspect feet daily
o Wear breathable shoes
o Wear socks to keep your feet warm
o Do not go barefooted or sandals with open toes/straps between the toes
S/s of hypoglycemia
o Cool, clammy, sweaty
o Anxious
o Nervous
o Mental confusion
o Seizures
o Coma
o Weakness
o Double vision
o Blurred vision
o Hunger
o Tachycardia
o Palpitations
o Irritable
Diet for pt’s with diabetes include:
o Fruits and veggies
o Whole grains
o Low fat/sodium
o Carbs (complex carbs)
When should you take lispro insulin?
Before or with meals
When should you take long acting insulin?
Once a day
Type 1 diabetes is…
insulin dependent
- juvenile-onset diabetes
Type 2 diabetes is…
non-insluin dependent
- adult-onset
Priority assessments for someone with heart failure include…
- cardio (edema)
- resp (listen for crackles/wheezing in the lungs)
- vitals
- neuro (disorientation/confusion)
Meds for right sided heart failure include…
- diuretics
- inotropics
- nitrates
Normal potassium level
3.5 - 5.0
Normal calcium level
8.5 - 10.5
Normal magnesium leve
1.8 - 3.0
Normal sodium level
135 - 145
What does a pt do when they have respiratory alkalosis?
over ventilation
What does a pt do when they have respiratory acidosis?
Underventilation
What does a pt experience when they have metabolic alkalosis?
prolonged vomiting and suction
During your morning assessment of a patient with heart failure, the patient complains of sudden vision changes that include seeing yellowish-green halos around the lights. What medication do you suspect is causing this issue?
Digoxin
A patient is taking Digoxin. Prior to administration you check the patient’s apical pulse and find it to be 61 bpm. Morning lab values are the following: K+ 3.3 and Digoxin level of 5 ng/mL. What is the correct nursing action?
Hold the dose and notify the physician of the digoxin level
What is a common side effect of Spironolactone?
Hyperkalemia
What type of heart failure does this statement describe? The ventricle is unable to properly fill with blood because it is too stiff. Therefore, blood backs up into the lungs causing the patient to experience shortness of breath.
Left ventricular diastolic dysfunction
A patient reports during a routine check-up that he is experiencing chest pain and shortness of breath while performing activities. He states the pain goes away when he rests. This is known as:
Stable angina
A patient calls the cardiac clinic you are working at and reports that they have taken 3 sublingual doses of Nitroglycerin as prescribed for chest pain, but the chest pain is not relieved. What do you educate the patient to do next?
Call 911 immediately
A patient who has diabetes will be started on Metoprolol for medical management of coronary artery disease. What will you include in your discharge teaching about this medication?
Check your glucose regularly because this medication can mask the typical signs and symptoms of hypoglycemia
What do you want to do with pts legs if they have PVD?
Elevate them
What do you want to do with pts legs if they have PAD?
“Hang” them
What can you not drink with a statin?
Grapefruit juice
What labs do you look at with a pt with HF?
- K+
- BUN
- Creatinine
- BNP
- Troponin’s
