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PCC2 > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

How many mL are in one OZ?

A

30

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2
Q

1 cup of ice is equivalent to how much water?

A

1/2 cup water

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3
Q

If a patient has an infusion of 150ML/ hr to infuse over 3 hours, how would you measure intake?

A

450 (150 x 3)

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4
Q

Does liquid stool count as output?

A

yes

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5
Q

If output is greater than input, the patient is?

A

fluid volume deficit

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6
Q

If input is greater than output, the patient is?

A

fluid volume excess

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7
Q

Foods high in calcium include?

A

dairy, tofu, broccoli

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8
Q

If our client is vegan, or has a dairy allergy, we can tell them to eat what foods to increase calcium?

A

broccoli and tofu

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9
Q

Foods high in magnesium include?

A

nuts, seeds, fatty fish (salmon and tuna) ,dark chocolate

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10
Q

Foods high in potassium include?

A

bananas, potatoes

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11
Q

Foods high in sodium include?

A

processed foods, junk foods, fast food, canned food

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12
Q

Can potassium be given by gravity drip?

A

NO ; by infusion pump

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13
Q

How can we confirm our drip of potassium is correct?

A

second nurse should verify

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14
Q

Hypokalemia and hyperkalemia can cause?

A

lethal dysrryhtmias

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15
Q

Patients on potassium should be monitored with?

A

constant cardiac monitoring

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16
Q

Chovostek signs are caused by?

A

hypocalcemia

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17
Q

Trousseau signs are caused by?

A

hypocalcemia

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18
Q

How to check chovstek’s sign?

A

tap the cheek

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19
Q

How to check trousseau’s sign?

A

use a tourniquet/ blood pressure cuff, wait 5 minutes unless wrist curls sooner

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20
Q

If the clients wrist begins spasms, do we leave the tourniquet on for five minutes?

A

no

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21
Q

A positive chovstek sign indicates?

A

(negative) / hypocalcemia

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22
Q

A positive trousseau sign indicates?

A

(negative) / hypocalcemia

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23
Q

Hypo and hypernatremia puts the client at risk of?

A

seizures

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24
Q

Symptoms of fluid volume deficit

A

increased HR, Increased respirations, decreased blood pressure, decreased urine output, flat neck veins, weight loss, poor skin turgor, orthostatic hypotension

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25
Q

Our patient in fluid volume deficit is at risk of falls because of?

A

orthostatic hypotension and compromised mobility

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26
Q

Will our client in fluid volume deficit have good or poor skin turgor?

A

poor

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27
Q

Our clients in fluid volume deficit have dry mucous membranes. They require?

A

frequent oral care

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28
Q

Nursing interventions for fluid volume deficit?

A

give fluids, protect skin from breakdown with:oral care, lotion, and frequent turns/ positioning. I&Os and daily weights,fall precautions

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29
Q

Symptoms of fluid volume overload?

A

increased BP, decrease pulse(ATI says tachycardia), increased weight, JVD, SOB, crackles, swelling/edema, falls

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30
Q

why are patients in fluid volume overload at increased risk of falls?

A

sensations in feet decreased, pain upon standing, fluid shifting upon standing

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31
Q

Nursing interventions for fluid volume overload?

A

fluid restriction, compression socks, skin protection (lotion, positioning, turning if able), anticipate diuretics, I&Os, daily weights

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32
Q

Are daily weights or I&Os more manageable?

A

daily weights

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33
Q

Condition requirements for daily weights

A

same time, same clothes, same scale

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34
Q

If a patient is getting weighed on a bed scale, what are the only items allowed on the bed?

A

gown, sheet, one pillow only

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35
Q

What are the different types of scales?

A

bed scales, standing scales, chair scales

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36
Q

What is insensible loss of fluids? Give examples

A

individual does not perceive loss; perspiration and expiration

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37
Q

What is sensible loss of fluids? Give examples

A

able to be measured ; urinary output, emesis, etc

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38
Q

Intracellular fluid is _____% of body weight

A

40

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39
Q

Extracellular fluid is _____% of body weight

A

20

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40
Q

Patients on nasogastric suctioning are at risk of?

A

hypokalemia

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41
Q

How should we monitor our clients on nasogastric suctioning?

A

I&Os, daily weights, CMP or BMP

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42
Q

For patients with hyperkalemia, we may anticipate an order for?

A

K exudates (gives them diarrhea to excrete the potassium)

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43
Q

A low grade fever (101-103) increases the need for fluids by?

A

500 ml

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44
Q

A high grade fever (over 103) increases the need for fluids by?

A

1000ml

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45
Q

Patients with low and high grade fever are at risk of?

A

fluid volume deficit

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46
Q

A 2KG weight loss is = ______ L

A

2

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47
Q

When administering a tube feeding, is the flush considered intake?

A

yes (if it stays inside of the body)

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48
Q

Do liquid medications count as intake?

A

yes

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49
Q

do IV medications count as intake?

A

yes

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50
Q

Urine output should be measured in a ___ container and at what level?

A

rigid container, eye level

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51
Q

How to document wound drainage?

A

considered output ; document amount and describe consistency/color

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52
Q

What do arterial lines do?

A

constantly monitor blood pressure

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53
Q

Nursing interventions with arterial lines?

A

double check with manual blood pressure every hour

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54
Q

In fluid volume deficit, our HCT will be?

A

high

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55
Q

In fluid volume excess, our HCT will be?

A

low

56
Q

How to monitor/ measure orthostatic hypotension?

A

take blood pressure laying, sitting, and standing with five minutes in between

57
Q

What is third spacing?

A

fluid is trapped in places it cannot be used

58
Q

Clients with 3rd spacing can be both?

A

FVD and FVE

59
Q

What is ascites?

A

fluid trapped in peritoneal cavity

60
Q

What can our patients with ascites experience? How is it treated?

A

SOB, decrease lung expansion, risk for electrolyte imbalances ; Thoracentesis and paracentesis

61
Q

Generalized edema is known as?

A

anasarca

62
Q

Brawny edema symptoms. Why should we be cautious?

A

shiny, warm, moist skin. Skin is at risk of breaking open and weeping

63
Q

Patients with edema are at increased risk of?

A

falls, pressure injuries, cellulitis/infection (especially if edema weeps through skin)

64
Q

Bounding pulses are symptoms of?

A

fluid volume overload

65
Q

if a patient has increased nausea and may vomit, how would we diagnose them?

A

risk for fluid volume deficit

66
Q

if a patient has been vomiting for three days and output is greater than intake, how would we diagnose them?

A

fluid volume deficit

67
Q

What kind of diet can our patients with fluid volume overload be put on?

A

renal diet

68
Q

How long do we use a peripheral catheter IV

A

up to 7 days

69
Q

How long do we use a midline catheter IV

A

one week to 1 month

70
Q

How long do we use a PICC line catheter?

A

several months

71
Q

When selecting an IV site, we start with?

A

the wrist and work upwards

72
Q

What medical conditions will prevent us from starting an IV in a certain arm?

A

mastectomy, lymph node resection, AV graph, stroke/paralyzation, fistula

73
Q

If our patient has a limb alert, can we put an IV in that limb?

A

no

74
Q

Can vesicant drugs be placed in the hand?

A

no

75
Q

Vesicant drugs increase the risk of?

A

extravasation

76
Q

What is extravasation?

A

when medication leaks into surrounding tissues and causes necrosis

77
Q

If we have an extravasation, do we immediately take out the IV?

A

No

78
Q

Why do we not immediately take out the IV when it has extravasation?

A

may need to push antidote ; if no antidote the medication needs to be sucked-out

79
Q

Extravasation can spread for?

A

days or weeks, maintains signs of infection

80
Q

Symptoms of infiltration?

A

pale, cold, no pain, puffy and very swollen, maintains one spot

81
Q

Symptoms of phlebitis?

A

warm, red, painful, streaking up arm, minimal swelling

82
Q

What causes infiltration?

A

leakage of non-vesicant medication into surrounding tissues

83
Q

What causes phlebitis?

A

irritated veins, may produce blood clot

84
Q

Grade 0 phlebitis scale

A

no symptoms

85
Q

grade 1 phlebitis scale

A

erythema at access site, with or without pain

86
Q

Grade 2 phlebitis scale

A

pain at access site, with erythema

87
Q

grade 3 phlebitis scale

A

pain at the access site, erythema, streak formation, palpable venous cord

88
Q

grade 4 phlebitis scale

A

pain at access site, erythema, streak formation, palpable venous cord >2.54 cm, purulent drainage

89
Q

What are the isotonic fluids?

A

Dextrose 5% in water (D5W), 0.9% NaCl, Lactated Ringers (LR)

90
Q

What are the hypotonic fluids?

A

0.45% NaCl (1/2 NS) , 0.33% NaCl,

91
Q

What are the hypertonic fluids?

A

Dextrose 5% in 1/2 NS, Dextrose 5% in NS, Dextrose 10% in water, 2%NaCl, 3%NaCl

92
Q

With hypotonic solution, the cell?

A

swells

93
Q

with hypertonic solution, the cell?

A

shrinks

94
Q

If we have increase ICP, what kind of solution would the nurse administer?

A

hypertonic

95
Q

Are we allowed to push IV potassium?

A

NO

96
Q

are we allowed to mix potassium?

A

NO

97
Q

How is IV potassium usually given?

A

40 MeQ over 4 hrs

98
Q

How can we prevent speed shock when giving iV meds?

A

give meds at recommended rate

99
Q

Where do central lines terminate?

A

in a great vessel such as superior vena cava

100
Q

Parenteral nutrition is administered through?

A

PICC lines (peripherally inserted central catheter) /Central line

101
Q

Why are clients on parenteral nutrition at risk of infection?

A

easy access to circulation

102
Q

When inserting a central line, we use?

A

sterile technique

103
Q

When changing dressings and tubing for central lines, we use?

A

sterile technique and through pump

104
Q

TPN is composed of what substances?

A

vitamins, electrolytes, minerals, high in dextrose

105
Q

Is TPN fluid universal or formulated for each patient?

A

formulated for each patient; mixed by pharmacy

106
Q

Before administering TPN, we should use a second nurse to?

A

verify the order and bag

107
Q

How long is TPN tubing and feed good for?

A

24 hrs (after 24 hrs change tubing and bag)

108
Q

Due to its high D10 (dextrose) concentration, TPN increases risk of?

A

hyperglycemia and infection

109
Q

Symptoms of hyperglycemia consist of?

A

polydipsia, polyuria, and polyphagia

110
Q

While on TPN, we should monitor the client’s?

A

blood sugar

111
Q

If TPN is abruptly discontinued, our client is at risk of?

A

hypoglycemia

112
Q

Symptoms of hypoglycemia?

A

dizziness, sweating, confusion, headaches, shakiness

113
Q

If TPN is abruptly stopped, what should the nurse do?

A

Give D10 through separate tubing and monitor blood sugar

114
Q

What color should TPN nutrients be?

A

lemon lime gatorade (bright yellow)

115
Q

How can we tell if TPN is rotten?

A

seperation will occur

116
Q

Can we delegate central line insertion to LPN or AP?

A

No, RN only skill

117
Q

TPN solution is hypertonic? T of F

A

true

118
Q

Other than blood sugar, clients on TPN will have increased?

A

urination

119
Q

While our client is on TPN, nurses should take?

A

daily weights

120
Q

What does the lipids solution look like?

A

milky

121
Q

the lipid solution is composed of?

A

fatty acids

122
Q

The lipids solution is isotonic? T or F

A

true

123
Q

Can lipids be given via regular peripheral IV?

A

yes

124
Q

Lipids can be used to aid in?

A

metabolization

125
Q

Can we give lipids or TPN solution while they’re cold?

A

no

126
Q

Signs our lipid bag is rotten?

A

pepper looking, separating like lava lamp (throw away)

127
Q

What kind of client would benefit from TPN?

A

complete bowel obstruction,

128
Q

A nurse is caring for a client receiving TPN. They are experiencing polyuria. This is a symptom of what complication?

A

hyperglycemia

129
Q

A nurse is caring for a client whose TPN was stopped for an hour by mistake. After restarting the infusion pump, what client development should the nurse carefully assess for?

A

shakiness and diaphoresis (hypoglycemia)

130
Q

Is it important to monitor the IV site for TPN receivers?

A

yes; can cause other complications

131
Q

If pharmacy is late delivering the new bag of TPN, what should the nurse do?

A

hang a bag of dextrose 10 in water

132
Q

Other complication of TPN infusion include?

A

infection, redness at IV site, drainage at IV site, fatigue

133
Q

Lactated ringers (LR) is harmful to those with what organ dysfunctions?

A

Liver and Renal (kidneys)

134
Q

Why is lactated ringers not good for the kidneys?

A

has high potassium

135
Q

Why is lactated ringers not good for the liver?

A

lactate

136
Q

When is lactated ringers indicated?

A

burn patients, multiple electrolyte deficits, low potassium

PCC2 (4 decks)

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