Exam 3 462 Flashcards
1
Q
Clinical Manifestation for PE
A
- dyspnea/tachypnea
- dry cough
- distended neck veins
- cyanosis
- hypotension
- Dysrhymia
- Impending doom
- chest pain
- Blood tinged sputum
- sudden death
1
Q
Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment?
- A) BP 126/80
- B) A1C 9%
- C)FBG 130mg/dL
- D) LDL cholesterol 100mg/dL
A
B) A1C 9%
1
Q
A nurse is caring for a client with type 1 diabetes mellitus. Which client complaint would alert the nurse to the presence of a possible hypoglycemic reaction ?
A
nervousness, irritability, and tremors.
1
Q
What are appropriate nursing considerations for a patient with eye trauma
A
- elevate HOB to 45 degrees
- administer analgesics
- cover eye with dry, sterile gauze
2
Q
An acute metabolic condition, usually is caused by absent or markedly decreased amounts of insulin
A
Diabetic ketoacidosis
3
Q
Long Acting Insulin onset/peak
A
onset 70 minutes, peak none
3
Q
a chemical agent that causes burns and destruction of tissue both internally and externally
A
Vesicant
3
Q
Name a side effect of the insuline pump?
A
weight gain
4
Q
nursing assessment data which would require immediate medical intervention for a patient with arterial insufficiency.
A
A resting ankle-brachial index less than 1 is abnormal
4
Q
what are risk factors with acute closure glaucoma
A
- small cornea
- hyperopia
- advanced age
- asian ethnicity
5
Q
“The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with Type 1 diabetes at 1600. Which action should the nurse implement?
A
- ensure the client eats the bedtime snack
- Humulin N peaks in 6-8 hours, making the client at risk for hypoglycemia around midnight
- This snack will prevent nighttime hypoglycemia.
6
Q
A blood sugar is well controlled when hemoglobin A1c is what percentage?
A
7%
6
Q
What angle do you hold the needle for an obese patient for a SubQ injection
A
90 degrees
7
Q
This is the inadvertent administration of a vesicant fluid or solution into the surrounding tissue
A
Extravasation
7
Q
Type 2 diabetes meal plan
A
calorie reduction, achieving glucose control, blood pressure, high fiber
8
Q
HYPO glycemia
A
cold clammy need candy
9
Q
What is virchow’s triad
A
- venous stasis
- damage to endothelium
- hypercoagulability
10
Q
What information should be listed on IV site dressing? x4
A
- Guage
- Date
- Time
- Initials
11
Q
Clinical Manifestations for Hypervolemia?
A
- Pulse is bounding JVD
- High BP
- Tachypneic
- dyspnea
- crackles
- headache, confusion, muscle spasms
- Anorexia, weight gain, ascites
- peripheral edema
11
Q
What is the prupose of the sliding scale for insulin
A
mimic endogenous (pancreatic) insulin in response to BS
12
Q
If a diabetic has ketoacidosis what will potassium be?
A
- hyperkalemia
- hypovolemia
- Renal failure
12
Q
This type of illness is sudden. It can last 3-6 months. It can also be reversed
A
Acute Illness
12
Q
Name ways to communicate w/ a person with a hearing impairment x3
A
- good eye contact
- speak clearly
- simple sentences
13
Q
When discontinuting an IV for a paitent who is receiving anticoagulant medication such as heparin, the nurse should hold pressure on the IV site for how many minutes?
A
5-10 minutes
14
Anticoagulant Bleeding Precautions Mneumonic
**Randi**
* Razor/Electric Blades
* Aspirin
* Needles- small gauage
* Decrease needle sticks
* Injury (protect)
15
This type of illness lasts longer than 6 months. The onset is gradual, and irreversible.
Chronic illness
16
Treatment for HHS
* FLUIDS FIRST
* serious dehydration
* normal saline
16
What is the correct way for a nurse to assist an impaired client with ambulation?
1. the client graps the nurses arm while the nurse walk ahead of the clinet
2. the nurse walks slightly behind the patient while walking
17
What is Acute Arterial Ischemic Disorder?
* Sudden interruption in arterial blood supply to an organ or tissue
* May orginiate from aneurism, or **left sided heart failure**
18
What hand should you use for initial IV site selection?
non-dominant hand
19
the leaking of IV fluid into the tissue surrounding the vein. This occurs when IV fluids continue to be delivered even though the tip of the catheter is no longer in the vessel or is blocked.
Infiltration
20
What is a good diabetic meal plan
* guidelines for how we are all supposed to eat
* focused on the amount of carbohydrates.
20
The client, an 18-year-old female, 5'4'' tall, weighing 113 kg, comes to the clinic for a wound on her lower leg that has not healed for the last two (2) weeks. Which diseaseprocess would the nurse suspect that the client has developed?
**Type 2 diabetes** is a disorder that usually occurs around the age of 40, but it is now being detected in children and young adultsas a result of obesity and sedentary life-styles. **Wounds that do not heal are a hall-mark sign of Type 2 diabetes**.
20
Manifestation of hypercoagulability
* dehydration
* high altitude
* hormone therapy
* malignancies
* nephrotic syndrome
* sepsis
* tobacco
21
When is immediate action required for a patient with pneumonia
respiratory rate increases above 20/min
22
Minimizing Risk for DVT/VTE
* Exercise
* Walk
* DO NOT cross legs
* Ted Hose
23
Describe the patient with advance COPD and Cor Pulmonale
* Damaged to lung tissue
* Acute respiratory failure
* Depression/anxiety.
* Anger.
* Pulmonary Hypertension.
23
What is lispro
a rapid acting insulin- delivered IV
24
When administering an intradermal injection, what angle should the nurse position the needle for insertion?
5-15 degrees
24
What is the problem with exercise and insulin site location?
it can metabolize too quickly
25
The nurse determines the patient's IV has **infiltrated**. What would be the appropriate action by the nurse?
* **Stop the infusion**
* Monitor patient
* apply heat or cold for hypotonic or isotonic
* apply cold for hypertonic
26
Define Ventilator Acquired Pneumonia
* 48 hours after intubation, before the onset of the event
27
What happens in type 2 diabetes?
* the pancreas produces insulin, but the insulin is insufficient for the body's needs or the cells do not respond to the insulin appropriately.
28
Respiratory Acidosis Labs
* pH Low
* PCO2 High
28
A client with diabetes melllitus has a blood glucose of 644mg/dl. The nurse intreprets that this client is most at risk of developing which type of acid base imbalance?
metabolic acidosis
## Footnote
*The body breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis."*
28
Name 3 treatmens for Meniere's Disease
* antihistamines
* benzodiazepines
* diuretics
* low sodium diet
29
Which electrolyte replacement should the nurse anticipate being ordered by thehealth-care provider in the client diagnosed with DKA who has just been admitted tothe ICD?
1. Glucose.
2. )Potassium.
3. Calcium.
4. Sodium
Potassium
30
"The risk factors for type 1 diabetes include all of the following except:
"a. Diet
b. Genetic
c. Autoimmune
d. Environmental"
A. Diet
30
Describe teaching plan for a diabetic patient that is sick? x4
* hormones are released when you are sick, meaning you need to take insulin
* take even if you are not hungry
* check urine ketones
* check BS more often
31
Describe a Tunneled CVAD
* inserted into a central vein and the remainder is tunneled subcutaneously to a distant exit site
* tunneling helps secure catheter in place & reduce infection
* inserted in the chest
* placed in a surgical or radiology suite
* may remain in place for several months to years
32
How far should the drip chamber be filled?
1/3 -1/2 full
33
The best nursing diagnosis that could be used for a patient that just had cataract surgery is:
risk for falls related to vision impairment
34
Risk factors for type 2 diabetes include all of the following except: "a. Advanced age
b. Obesity
c. Smoking
d. Physical inactivity"
C. Smoking
34
How do you replace potassium (hypokalemia)?
* Never IV Push
* Oral
* Monitor I/O
* Potatoes, Avocado, Banana
34
A patients presents to their primary care physician complaining of "feeling like the room is psinning and my ears are ringing? What is the FIRST action?
lay the patient flat and tell them to keep their eye open and fixated on an object
35
Normal Value PCO2
34-45
37
"A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. Following assessment of the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of
rapid, deep respirations
39
Normal Value for Chloride
95 - 107 mEq/L
39
6 Rights of Medication Administration
1. Patient
2. Time
3. Medication
4. Dose
5. Route
6. Documentation
40
Fats for diabetic
* Less than 200 mg/day
* less than 7%
41
How long can hypoglycemia occur after exercise
up to 48 hours
42
Signs of COPD
* productive cough for 3 or more months in each of 2 successive years
* Dyspnea
* Chronic Fatigue
* Bluish Red Color Skin
* Pulmonary Hypertension
42
What is the cornerstone of care for a person with diabetes
meal plan
42
a disease of unknown cause affecting the membranous labyrinth of the ear, causing progressive deafness and attacks of tinnitus and vertigo.
Meniere's Disease
43
Glycemic Index
* how fast blood sugar rises, based on the carbohydrate containing food
44
A normal fasting (no food for eight hours) blood sugar level is
between 70 and 99 mg/dL
45
Types of Insulin
* long acting (basal) once a day
* rapid/short acting (bolus) before meals
46
Normal Value for HCO3
22-26
47
This is the term for
inflammation of the walls of a vein.
phlebitis
49
What is the oxygen concentration for a nasal cannula?
* 24-44%
* 1-6 LPM
## Footnote
*Victims w/ difficulty breathing, unable to tolerate mask*
49
Clinical Manifestation of a patient with Chronic Arterial Disease
* Arteries narrowed
* Atherosclerosis
* Inc Risk for Heart Attack/Stroke
* Pallow
* Parasthesia
* Inadequate around boney prominents
* Gangrene/Amputation
* Weak Pulses
50
What is the highest priority for a patient with DVT or VTE
Skin Integrity b/c of amputation risk
50
What is the technique for administering IV Bolus (push)
* Flush w/ normal saline first
* administer medication
* Flush again
* Monitor Pt's tolerance
* Document any adverse effects
52
What symptoms might an older woman with diabetes mellitus complain?
perineal itching
## Footnote
*Rationale: Older women might complain of perineal itching due to **vaginal candidiasis**.*
52
Explain Polyuria for diabetes
The body tries to remove excess glucose by producing extra urine. The body then requires more water.
54
Diagnostic Testing for Heart failure
* BNP
* ANP
* Creatnine Kinase
* Troponin
* Fibronogen
* Chest Xray
* EKG
* Coronary Angiogram
* Echogram
55
Glucose and microvascular complications x3
1. Retinopathy
2. Neuropathy
3. Nephropathy
57
Nursing Diagnoses for patient with VTE
* Ineffective Peripheral Tissue Perfusion
* Acute Pain
* Risk for impaired physical mobility
* Risk for Embolization
* Impaired Skin Integrity
59
"A frail elderly patient with a diagnosis of type 2 diabetes mellitus has been ill with pneumonia. The cliet's intake has been very poor, and she is admitted to the hospital for observation and management as needed. What is the most likely problem with this patient?
Hyperglycemic hyperosmolar non-ketotic coma.
61
If someone has diabetes but not ketoacidosis they are
hypokalemia
62
Hyperosmolar Hyperglycemic Syndrome
* which high blood sugars cause severe dehydration, increases in osmolarity and a high risk of complications, coma and death.
64
What ahould the nurse do if he/she believes a patient is a hypoglycemic?
* Determine if they can swallow, could **aspirate**
* check gag reflex
* Check Blood glucose, if less than 70
* If can swallo, give them carbohydrate, **skim milk. Protein prevents rebound effect**
65
**Hypo**glycemia- Signs and Symptoms
TIRED
* **T**achycardia
* **I**rritability
* **R**estless
* **E**xcessive hunger
* **Diaphoresis**/Depression
66
What is the FIRST action most appropariate for the nurse to perform when a patient presents with impaled object in the eye
assess the patient's pain, visual acuity, and oculomotor nerves
67
What is the term used to clear the tubing of air before administering fluids to a patient?
Priming
69
Name the primary veins for peripheral IV insertion
cephalic, median, cubital, basilic
69
Complication of Type II Diabetes
Hyperosmola hyperglycemic syndrome
70
What is levemir
long acting insulin
71
Aspiration Pneumonia Definition
* Aspirated something into their lungs
* Decreased LOC
72
Insulin Definition
allows sugar to go from the blood into the cells for energy.
72
Name interventions for a patient with acute angle closure glaucoma
* lay patient in supine
* apply eye patch
* monital vitals
73
A positive sign is present when there is pain in the calf on forceful and abrupt dorsiflexion of the patient's foot at the ankle while the knee is extended
Homan's Sign
74
This is when you have progressive deterioration of both sensory and motor nerves?
diabetic neuropathy
75
If the patient is NOT alert enough to swallow and is hypoglycemic?
* 50% dextrose IV
* or Glucagon IM, SubQ
* takes awhile to kick in
77
5 Reasons a nurse would avoid an area of the hand or arm for IV insertion
1. Impede ADL's
2. Tender, Red, Rash, Infected
3. Paralysis, Dialysis, Shunt or Mastectomy
4. Site distal to previous venipuncture
5. Distal to sclerosed, hardened, or phlebitic veins
79
Etiology for Thromboembolism
1. PICC line
2. Bed Rest
3. Previous Hx
4. Heart Failure
5. COPD
6. Smoking
7. Obesity
80
If a person has 301-350 how many units of insulin?
8 units
81
What angle do you hold the needle for an average sized subQ injection?
45 degrees
81
Reasons for hypovolemia
* ng drainage,
* burns (3rd spacing),
* dehydration,
* shift of plasma into interstitial spaces,
* peritonitis,
* ascites (abdomen)
82
Clinical Manifestations for a patient with Venous Insufficienty
* Pooling of blood in the legs
* Damage to valves in the veins
* Eczema
* Edema
* Leathery brown skin
83
Calculate the IV flow rate for 1200 mls of NS to be infused in 6 hours. The infusion set is calibrated for drop factor 15 gtts/mL=_**\_\_\_\_\_**_gtts/min?
1200/6= 200
200x15/60(for minutes)=
**50 gtts/min**
85
Brown rice is what type of food
low glycemic index, a steady increasy in blood sugar
86
Signs (AEB) Hypokalemia
6L's
1. Lethargy
2. Lethat cardiac arrhthymia
3. Leg cramps
4. Limp Muscles
5. Low, shallow respirations
6. Less stool (constipation)
87
What is humalin R or Novolin R
Regular insulin, short acting
88
This is related to blindness due to diabetes
retinopathy
90
What is a treatment for dawn phenomneon?
increase insulin at bedtimes
91
What does alcohol do for diabetic
* high risk for hypoglycemia
* **impaire liver glucose production-** glycogen breakdown
* EAT carbs prior to alcohol consumption
92
"What insulin type can be given by IV?
Regular Insulin
92
What is NOT a manifestation of Meniere's disease
high frequency hearing loss
93
"When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask?
lost any weight? Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy.
94
What is the cause of JVD
* Right Sided Heart Failure
* increase the central venous pressure and the amount of jugular vein distention.
96
What is the oxygen concentration for a Resuscitation mask w/ oxygen inlet (simple mask)?
* 35-55%
* 6-15 LPM
## Footnote
*Victims who are NOT breathing, or difficulty breathing*
97
A patient is admitted with diabetes mellitus, has a glucose level of 380 mg/dl, and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which of the following respiratory patterns would the nurse expect to find?
Kussmaaul Respirations
*the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored.*
99
Describe a Non-tunneled CVAD
* inserted directly into a central vein and is associated with a higher risk of infection
* either the chest or the neck
* can be inserted quickly at the bedside
* Dwell Time less than a month
100
Administration of an intermittent IV medication such as an antibiotic, given in a small IV bag of fluid is called..
Secondary IV solution (Piggy Back)
101
Labs for someone with Metabolic Alkalosis
High pH High HCO3
103
Describe the purpose of pursed lip breathing in the COPD Patient
To reduce overall work of brathing
105
What should diabetic patient due prior to exercise
eat a snack. No need for carbohydrate intake when blood glucose lis over 100 before activity.
106
Trauma Assessment Priorities
* Airway
* Breathing
* Circulation
* Disability
* Examine
* Fahrenheit
* Get vitals
* Head to toe assess
* Intervention
107
blood urea nitrogen (BUN)
8 - 21
8 bun twists x 3
108
If a person has 201-250 how many units of insulin?
4
110
Lab Value when fully compensated
pH will be normal
112
Care for DKa
* Fluid/electrolyte imbalance
* normal saline 0.45%
* blood glucose level
* acidosis
* IV insulin
113
A nurse is preparing a plan of care for a client with diabetes mellitus who has hyerglycemia. The priority nursing diagnosis would be:
Deficient fluid volume. An increased blood glucose level will cause the kidneys to excrete the glucose in the urine
113
An older man comes in for a check up appt. He is cupping his ear to try and understand what the nurse is saying. What should the nurse assess for?
Hearing
115
Acutal Problem means
we have evidence (AEB)
116
what is lipodystrophy
scar tissue, if you do not rotate injection sites
117
The best description of cataracts
clouding of the lens in the eye that affects vision
118
Blood glucose valuse for hyperglycemia
\> 200 mg/dl
119
SubQ needle size and guage?
* 5/8"
* 25G
120
What direction is the bevel facing for an intradermal medication
up
121
The nurse is teaching a community class to peole with Type 2 diabetes mellitus. What is the explanation for that?
Cells become resistant to circulating insulin
*Normally insulin binds to special receptor sites on the cells and initiates a series of reactions involved in metabolism. In Type 2 diabetes these reactions are diminished primarily as a result of obesity and aging.*"
122
What is the oxygen concentration for a non rebreather mask?
* Up to 90%
* 10-15 LPM
## Footnote
*Breathing victims only*
123
What is the name of the device which controls the IV flow rate for gravity infusion?
Roller Clamp "EID"
124
If a person has 101-150 insulin
0 units
125
Why is acute angle closure glaucoma emergent?
ange between cornea and iris is closed, raising the intraocular pressure suddenly and causes perm vision loss
125
Appropriate for the nurse to delegate to the UAP with a hearing impared client?
help w/ placement of hearing aid (change batteries clean)
127
What are 4 examples of Chronic Illness
1. Diabetes
2. COPD
3. Parkinsons
4. MS
128
Diabetes is balancing what
insulin, diet, exercise
129
How can hearing aid therapy be improved
continuous use
131
Characteristics of Circulatory Overload
* Excessive amounts of isotonic/hypertonic solution
* Too Rapid
* Overload is associated w/ increased risk of death
132
The 6Ps of Acute Arterial Ischemic Disorder
1. Pain
2. Pallor
3. Pulselessness
4. Parasthesia
5. Poikilothermia (inability to maintain temp)
6. paralysis
134
Lab values when only partially compensated
all three values will be abnormal. One value will be working harder to compensate.
135
When on an anticoagulation for VTE, how should vitamin K be used?
even and consistent
136
Protein for diabetic
15-20%
138
Non-pharmacological interventions for pain
* Reposition
* massge
* Heat/Cold compress
* Distraction
* Elevation
* Humor
139
What are appropriate assessment tools for visual impairment?
* Snellen Chart
* Confrontation Exam
139
Blood glucose values for hypoglycemia
\<70
141
What degree angle for an IM injection?
90 degrees
142
Hospital Acquired Pneumonia
* Occurring 48 hours or longer after admission
* Not incubating at time of hospitalization
143
Hyperglycemia
dry skin, dehydrated
144
Whenever insulin is peaking what should we be wathcing for?
hypoglycemia
146
What are 2 groups of drugs for diabetes
* Insulin- subQ, not given orally b/c destroyed by gastric enzymes
* antidiabetic agents
147
What is glycosylated hemoglobin
the percentage of hemoglobin that is saturated w/ glucose. Excess sugar attaches to hemoglobin
148
What does insulin do to potassium level
push potassium back into the cells,
148
Normal Value for Potassium
3.5 - 5 mEq/L
149
Left Sided Heart Failure
* Most Common
* Pulmonary Congestion
* Crackles
* Poor Oxygenation
* S3, Increase Afterload
* Irregular Palpitations
* Pulmonary Edema
* Diastolic and systolic dysfunction
* Blood backing up into right atria
151
Describe Dawn Phenomenon
* occurs for everyone
* Hyperglycemia all night long
* An abnormal early-morning increase in blood sugar (glucose) — usually between 2 and 8 a.m.
152
nursing diagnosis for a patient with advanced respiratory diseases.
* Hyperthermia Related to Infectious Illness,
* ineffective airway clearance,
* pneumonia
* pulmonary embolism
* Activity Intolerance
* Inadequate Nutrition
* Social Isolation
* Impaired Gas Exchange.
* Anxiety.
* Risk for Infection
* Ineffective Coping
* Fatigue.
* Ineffective Breathing Pattern
* Insomnia
153
What is the timeframe of administering and IM injection?
1mL every 10 seconds
154
What is the oxgen concentration for a bag valve mask (BVM)?
* 90% or more
* 15LMP or HIGHER
## Footnote
*Victims who are not breathing/having A LOT of difficulty breathing*
155
Diabetes Mellitus Type 1- Signs & Symptoms
3P's
* Polydipsia (thirst)
* Polyuria (urine)
* Polyphagia (hunger)
156
What is intermittent claudication
lactic acid buildup from anearobic metabolism. Muscle pain that resolves w/ rest
157
What is the core problem a patient would have with PE
perfusion
158
Name some SubQ injection sites?
1. outser aspect of the upper arm,
2. Abdomen below costal margin
3. Anterior aspect of the thigh
159
IV calcs for regulating an IV pump are usually measured in...
hours
160
IM / Z-Track needle size and gauge?
* 1-1/2"
* 21-23G
## Footnote
*2" if patient is obese*
161
Signs and symptoms of DKA
* dehydration
* tachycardia
* dry loose skin
* eyeballs soft/sunken
* anorexia
* kushmal respirations
* orthostatic hypotension.
162
Short Acting Onset/Peak
onset 30-60 min, peak 1 to 5 hours
163
Explain polyphagia for diabetes
We get hungry because our cells are starving for energy.
165
**HYPER-** glycemia mneumonic
hot/dry sugar high
166
Techniques for increasing venous distention in preparation for needle insertion
* apply tourniquet 6-12" above chosen site
* apply warmth to extremity for several min.
167
**Intradermal** Needle Size and Gauge
* 3/8 -1/2"
* 26-28G
168
The guidelines for Carbohydrate
Counting as medical nutrition therapy for diabetes mellitus includes
* Flexibility in types and amounts of foods consumed
* Including adequate servings of fruits, vegetables and the dairy group
* Applicable to with either Type 1 or Type 2 diabetes mellitusb. Unlimited intake of total fat, saturated fat and cholesterol"
170
Benefits of using an insulin pump
* fewer swings
* increased flexibility in diet
* accuracy of insulin doses and delivery;
*
171
What is lantus
long acting insulin (SUBQ)
173
Rapid Acting
onset 10-15mintues
peak 30 to 90 minutes.
174
A patient with retinitis pigmentosis would exhibit all of the following:
1. night blindness
2. tunnel vision
3. slow adjustment to change in light
175
Name 4 examples of an acute illness?
1. Pneumonia
2. Delirium
3. Shingles
4. Apendicitis
176
The patient understand their diagnosis of Retinitis Pigmentosis when the patient states what?
Its likely I inherited this from my grandma
177
Glucose Value 2 hours after eating
Up to 140
178
What food should be avoided for a diabetic patient b/c of its high glycemic index?
potatoes
180
Name 3 location sites for IM injection
1. Vastis Lateralis
2. Deltoid
3. Ventrogluteal
181
This is a pathological change in the kidneys that reduce kidney function and lead to renal failure
Nephropathy-
## Footnote
**Sign is _protein_ in the urine (microalbuminuria)**
183
What are symptoms of acute angle closure glaucoma
1. pain in the eye
2. vomiting
3. halos around object
4. blurry vision
184
Create labs for someone with metabolic acidosis
low pH low HCO3
185
Intermediate Acting Insulin Onset/Peak
onset 1 to 2 hours, peak 6 to 14 hours
186
PE interventions?
* Rotate patient
* High fowlers
* oxygen (non-rebreather)
* Continuous vital signs
* I/O's
* Anticoagulants/Thrombolytics
188
A patient w/ cataracts may have
decreased vision acuity and light sensitivity
189
Most appropriate nursing diagnosis for eye trauma
disturbed visual sensory perception
191
When giving eye drops it is important to
make sure the tip of the eye drops botts is not directly touching the eye
192
Acute pain is directly related to...
tissue damage
193
Describe a port CVAD?
* for patients who require long-term, intermittent vascular access
* completely under the skin, there is no need to cover the device while bathing or showering
* less frequent flushing
194
The nurse is caring for a client who has normal glucose levels at bedtime, hypoglycemia at 2am and hyperglycemia in the morning. What is this client likely experiencing?
The Somogyi Effect
195
Greater than 401 of insulin what is your action
call the physician
196
Discharge instructions for a patient with peripheral vascular disease
* look at feet every night
* avoid exposure to cold or hot
* wear loose clothing
* stop smoking
* avoid caffeine
* Monitor blood glucose
197
A well written nursing diagnosis contains 3 components
Diagnosis,
Related To
As Evidence By
198
Describe a PICC line
* inserted in the upper arm but its tip goes past the shoulder and ends in the superior vena cava.
* chest x-ray is done to confirm proper placemen
* less risk for phlebitis/infiltration
* stay in place for a year or more
* IV therapies that continue for 4 wks
199
Patient is diagnosed with Meniere's disease. What should the nurse provide (x3)
1. avoid alcohol/caffeine
2. low sodium diet
3. relaxing activities to reduce anxiety (exacerbate vertigo)
