Exam 3 Flashcards
How many mL are in one OZ?
30
1 cup of ice is equivalent to how much water?
1/2 cup water
If a patient has an infusion of 150ML/ hr to infuse over 3 hours, how would you measure intake?
450 (150 x 3)
Does liquid stool count as output?
yes
If output is greater than input, the patient is?
fluid volume deficit
If input is greater than output, the patient is?
fluid volume excess
Foods high in calcium include?
dairy, tofu, broccoli
If our client is vegan, or has a dairy allergy, we can tell them to eat what foods to increase calcium?
broccoli and tofu
Foods high in magnesium include?
nuts, seeds, fatty fish (salmon and tuna) ,dark chocolate
Foods high in potassium include?
bananas, potatoes
Foods high in sodium include?
processed foods, junk foods, fast food, canned food
Can potassium be given by gravity drip?
NO ; by infusion pump
How can we confirm our drip of potassium is correct?
second nurse should verify
Hypokalemia and hyperkalemia can cause?
lethal dysrryhtmias
Patients on potassium should be monitored with?
constant cardiac monitoring
Chovostek signs are caused by?
hypocalcemia
Trousseau signs are caused by?
hypocalcemia
How to check chovstek’s sign?
tap the cheek
How to check trousseau’s sign?
use a tourniquet/ blood pressure cuff, wait 5 minutes unless wrist curls sooner
If the clients wrist begins spasms, do we leave the tourniquet on for five minutes?
no
A positive chovstek sign indicates?
(negative) / hypocalcemia
A positive trousseau sign indicates?
(negative) / hypocalcemia
Hypo and hypernatremia puts the client at risk of?
seizures
Symptoms of fluid volume deficit
increased HR, Increased respirations, decreased blood pressure, decreased urine output, flat neck veins, weight loss, poor skin turgor, orthostatic hypotension
Our patient in fluid volume deficit is at risk of falls because of?
orthostatic hypotension and compromised mobility
Will our client in fluid volume deficit have good or poor skin turgor?
poor
Our clients in fluid volume deficit have dry mucous membranes. They require?
frequent oral care
Nursing interventions for fluid volume deficit?
give fluids, protect skin from breakdown with:oral care, lotion, and frequent turns/ positioning. I&Os and daily weights,fall precautions
Symptoms of fluid volume overload?
increased BP, decrease pulse(ATI says tachycardia), increased weight, JVD, SOB, crackles, swelling/edema, falls
why are patients in fluid volume overload at increased risk of falls?
sensations in feet decreased, pain upon standing, fluid shifting upon standing
Nursing interventions for fluid volume overload?
fluid restriction, compression socks, skin protection (lotion, positioning, turning if able), anticipate diuretics, I&Os, daily weights
Are daily weights or I&Os more manageable?
daily weights
Condition requirements for daily weights
same time, same clothes, same scale
If a patient is getting weighed on a bed scale, what are the only items allowed on the bed?
gown, sheet, one pillow only
What are the different types of scales?
bed scales, standing scales, chair scales
What is insensible loss of fluids? Give examples
individual does not perceive loss; perspiration and expiration
What is sensible loss of fluids? Give examples
able to be measured ; urinary output, emesis, etc
Intracellular fluid is _____% of body weight
40
Extracellular fluid is _____% of body weight
20
Patients on nasogastric suctioning are at risk of?
hypokalemia
How should we monitor our clients on nasogastric suctioning?
I&Os, daily weights, CMP or BMP
For patients with hyperkalemia, we may anticipate an order for?
K exudates (gives them diarrhea to excrete the potassium)
A low grade fever (101-103) increases the need for fluids by?
500 ml
A high grade fever (over 103) increases the need for fluids by?
1000ml
Patients with low and high grade fever are at risk of?
fluid volume deficit
A 2KG weight loss is = ______ L
2
When administering a tube feeding, is the flush considered intake?
yes (if it stays inside of the body)
Do liquid medications count as intake?
yes
do IV medications count as intake?
yes
Urine output should be measured in a ___ container and at what level?
rigid container, eye level
How to document wound drainage?
considered output ; document amount and describe consistency/color
What do arterial lines do?
constantly monitor blood pressure
Nursing interventions with arterial lines?
double check with manual blood pressure every hour
In fluid volume deficit, our HCT will be?
high
In fluid volume excess, our HCT will be?
low
How to monitor/ measure orthostatic hypotension?
take blood pressure laying, sitting, and standing with five minutes in between
What is third spacing?
fluid is trapped in places it cannot be used
Clients with 3rd spacing can be both?
FVD and FVE
What is ascites?
fluid trapped in peritoneal cavity
What can our patients with ascites experience? How is it treated?
SOB, decrease lung expansion, risk for electrolyte imbalances ; Thoracentesis and paracentesis
Generalized edema is known as?
anasarca
Brawny edema symptoms. Why should we be cautious?
shiny, warm, moist skin. Skin is at risk of breaking open and weeping
Patients with edema are at increased risk of?
falls, pressure injuries, cellulitis/infection (especially if edema weeps through skin)
Bounding pulses are symptoms of?
fluid volume overload
if a patient has increased nausea and may vomit, how would we diagnose them?
risk for fluid volume deficit
if a patient has been vomiting for three days and output is greater than intake, how would we diagnose them?
fluid volume deficit
What kind of diet can our patients with fluid volume overload be put on?
renal diet
How long do we use a peripheral catheter IV
up to 7 days
How long do we use a midline catheter IV
one week to 1 month
How long do we use a PICC line catheter?
several months
When selecting an IV site, we start with?
the wrist and work upwards
What medical conditions will prevent us from starting an IV in a certain arm?
mastectomy, lymph node resection, AV graph, stroke/paralyzation, fistula
If our patient has a limb alert, can we put an IV in that limb?
no
Can vesicant drugs be placed in the hand?
no
Vesicant drugs increase the risk of?
extravasation
What is extravasation?
when medication leaks into surrounding tissues and causes necrosis
If we have an extravasation, do we immediately take out the IV?
No
Why do we not immediately take out the IV when it has extravasation?
may need to push antidote ; if no antidote the medication needs to be sucked-out
Extravasation can spread for?
days or weeks, maintains signs of infection
Symptoms of infiltration?
pale, cold, no pain, puffy and very swollen, maintains one spot
Symptoms of phlebitis?
warm, red, painful, streaking up arm, minimal swelling
What causes infiltration?
leakage of non-vesicant medication into surrounding tissues
What causes phlebitis?
irritated veins, may produce blood clot
Grade 0 phlebitis scale
no symptoms
grade 1 phlebitis scale
erythema at access site, with or without pain
Grade 2 phlebitis scale
pain at access site, with erythema
grade 3 phlebitis scale
pain at the access site, erythema, streak formation, palpable venous cord
grade 4 phlebitis scale
pain at access site, erythema, streak formation, palpable venous cord >2.54 cm, purulent drainage
What are the isotonic fluids?
Dextrose 5% in water (D5W), 0.9% NaCl, Lactated Ringers (LR)
What are the hypotonic fluids?
0.45% NaCl (1/2 NS) , 0.33% NaCl,
What are the hypertonic fluids?
Dextrose 5% in 1/2 NS, Dextrose 5% in NS, Dextrose 10% in water, 2%NaCl, 3%NaCl
With hypotonic solution, the cell?
swells
with hypertonic solution, the cell?
shrinks
If we have increase ICP, what kind of solution would the nurse administer?
hypertonic
Are we allowed to push IV potassium?
NO
are we allowed to mix potassium?
NO
How is IV potassium usually given?
40 MeQ over 4 hrs
How can we prevent speed shock when giving iV meds?
give meds at recommended rate
Where do central lines terminate?
in a great vessel such as superior vena cava
Parenteral nutrition is administered through?
PICC lines (peripherally inserted central catheter) /Central line
Why are clients on parenteral nutrition at risk of infection?
easy access to circulation
When inserting a central line, we use?
sterile technique
When changing dressings and tubing for central lines, we use?
sterile technique and through pump
TPN is composed of what substances?
vitamins, electrolytes, minerals, high in dextrose
Is TPN fluid universal or formulated for each patient?
formulated for each patient; mixed by pharmacy
Before administering TPN, we should use a second nurse to?
verify the order and bag
How long is TPN tubing and feed good for?
24 hrs (after 24 hrs change tubing and bag)
Due to its high D10 (dextrose) concentration, TPN increases risk of?
hyperglycemia and infection
Symptoms of hyperglycemia consist of?
polydipsia, polyuria, and polyphagia
While on TPN, we should monitor the client’s?
blood sugar
If TPN is abruptly discontinued, our client is at risk of?
hypoglycemia
Symptoms of hypoglycemia?
dizziness, sweating, confusion, headaches, shakiness
If TPN is abruptly stopped, what should the nurse do?
Give D10 through separate tubing and monitor blood sugar
What color should TPN nutrients be?
lemon lime gatorade (bright yellow)
How can we tell if TPN is rotten?
seperation will occur
Can we delegate central line insertion to LPN or AP?
No, RN only skill
TPN solution is hypertonic? T of F
true
Other than blood sugar, clients on TPN will have increased?
urination
While our client is on TPN, nurses should take?
daily weights
What does the lipids solution look like?
milky
the lipid solution is composed of?
fatty acids
The lipids solution is isotonic? T or F
true
Can lipids be given via regular peripheral IV?
yes
Lipids can be used to aid in?
metabolization
Can we give lipids or TPN solution while they’re cold?
no
Signs our lipid bag is rotten?
pepper looking, separating like lava lamp (throw away)
What kind of client would benefit from TPN?
complete bowel obstruction,
A nurse is caring for a client receiving TPN. They are experiencing polyuria. This is a symptom of what complication?
hyperglycemia
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?
shakiness and diaphoresis (hypoglycemia)
Is it important to monitor the IV site for TPN receivers?
yes; can cause other complications
If pharmacy is late delivering the new bag of TPN, what should the nurse do?
hang a bag of dextrose 10 in water
Other complication of TPN infusion include?
infection, redness at IV site, drainage at IV site, fatigue
Lactated ringers (LR) is harmful to those with what organ dysfunctions?
Liver and Renal (kidneys)
Why is lactated ringers not good for the kidneys?
has high potassium
Why is lactated ringers not good for the liver?
lactate
When is lactated ringers indicated?
burn patients, multiple electrolyte deficits, low potassium
