Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nursing School Pt 1 > Exam 3 462 > Flashcards

Exam 3 462 Flashcards

1
Q

Clinical Manifestation for PE

A
  1. dyspnea/tachypnea
  2. dry cough
  3. distended neck veins
  4. cyanosis
  5. hypotension
  6. Dysrhymia
  7. Impending doom
  8. chest pain
  9. Blood tinged sputum
  10. sudden death
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
1
Q

What are appropriate nursing considerations for a patient with eye trauma

A
  1. elevate HOB to 45 degrees
  2. administer analgesics
  3. cover eye with dry, sterile gauze
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

An acute metabolic condition, usually is caused by absent or markedly decreased amounts of insulin

A

Diabetic ketoacidosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Long Acting Insulin onset/peak

A

onset 70 minutes, peak none

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

a chemical agent that causes burns and destruction of tissue both internally and externally

A

Vesicant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Name a side effect of the insuline pump?

A

weight gain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what are risk factors with acute closure glaucoma

A
  1. small cornea
  2. hyperopia
  3. advanced age
  4. asian ethnicity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

A blood sugar is well controlled when hemoglobin A1c is what percentage?

A

7%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What angle do you hold the needle for an obese patient for a SubQ injection

A

90 degrees

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

This is the inadvertent administration of a vesicant fluid or solution into the surrounding tissue

A

Extravasation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Type 2 diabetes meal plan

A

calorie reduction, achieving glucose control, blood pressure, high fiber

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

HYPO glycemia

A

cold clammy need candy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is virchow’s triad

A
  1. venous stasis
  2. damage to endothelium
  3. hypercoagulability
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What information should be listed on IV site dressing? x4

A
  1. Guage
  2. Date
  3. Time
  4. Initials
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the prupose of the sliding scale for insulin

A

mimic endogenous (pancreatic) insulin in response to BS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

If a diabetic has ketoacidosis what will potassium be?

A
  • hyperkalemia
  • hypovolemia
  • Renal failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

This type of illness is sudden. It can last 3-6 months. It can also be reversed

A

Acute Illness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Name ways to communicate w/ a person with a hearing impairment x3

A
  1. good eye contact
  2. speak clearly
  3. simple sentences
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Anticoagulant Bleeding Precautions Mneumonic

A

Randi

  • Razor/Electric Blades
  • Aspirin
  • Needles- small gauage
  • Decrease needle sticks
  • Injury (protect)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

This type of illness lasts longer than 6 months. The onset is gradual, and irreversible.

A

Chronic illness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Treatment for HHS

A
  • FLUIDS FIRST
  • serious dehydration
  • normal saline
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the correct way for a nurse to assist an impaired client with ambulation?

A
  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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is Acute Arterial Ischemic Disorder?

A
  • Sudden interruption in arterial blood supply to an organ or tissue
  • May orginiate from aneurism, or left sided heart failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What hand should you use for initial IV site selection?

A

non-dominant hand

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

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.

A

Infiltration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is a good diabetic meal plan

A
  • guidelines for how we are all supposed to eat
  • focused on the amount of carbohydrates.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

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?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Manifestation of hypercoagulability

A
  • dehydration
  • high altitude
  • hormone therapy
  • malignancies
  • nephrotic syndrome
  • sepsis
  • tobacco
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

When is immediate action required for a patient with pneumonia

A

respiratory rate increases above 20/min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Minimizing Risk for DVT/VTE

A
  • Exercise
  • Walk
  • DO NOT cross legs
  • Ted Hose
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Describe the patient with advance COPD and Cor Pulmonale

A
  • Damaged to lung tissue
  • Acute respiratory failure
  • Depression/anxiety.
  • Anger.
  • Pulmonary Hypertension.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is lispro

A

a rapid acting insulin- delivered IV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

When administering an intradermal injection, what angle should the nurse position the needle for insertion?

A

5-15 degrees

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is the problem with exercise and insulin site location?

A

it can metabolize too quickly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

The nurse determines the patient’s IV has infiltrated. What would be the appropriate action by the nurse?

A
  • Stop the infusion
  • Monitor patient
  • apply heat or cold for hypotonic or isotonic
  • apply cold for hypertonic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Define Ventilator Acquired Pneumonia

A
  • 48 hours after intubation, before the onset of the event
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What happens in type 2 diabetes?

A
  • the pancreas produces insulin, but the insulin is insufficient for the body’s needs or the cells do not respond to the insulin appropriately.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Respiratory Acidosis Labs

A
  • pH Low
  • PCO2 High
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

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?

A

metabolic acidosis

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.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Name 3 treatmens for Meniere’s Disease

A
  • antihistamines
  • benzodiazepines
  • diuretics
  • low sodium diet
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

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
A

Potassium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

“The risk factors for type 1 diabetes include all of the following except:
“a. Diet
b. Genetic
c. Autoimmune
d. Environmental”

A

A. Diet

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Describe teaching plan for a diabetic patient that is sick? x4

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Describe a Tunneled CVAD

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

How far should the drip chamber be filled?

A

1/3 -1/2 full

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

The best nursing diagnosis that could be used for a patient that just had cataract surgery is:

A

risk for falls related to vision impairment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Risk factors for type 2 diabetes include all of the following except: “a. Advanced age

b. Obesity
c. Smoking
d. Physical inactivity”

A

C. Smoking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

How do you replace potassium (hypokalemia)?

A
  • Never IV Push
  • Oral
  • Monitor I/O
  • Potatoes, Avocado, Banana
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

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?

A

lay the patient flat and tell them to keep their eye open and fixated on an object

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Normal Value PCO2

A

34-45

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

“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

A

rapid, deep respirations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Normal Value for Chloride

A

95 - 107 mEq/L

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

6 Rights of Medication Administration

A
  1. Patient
  2. Time
  3. Medication
  4. Dose
  5. Route
  6. Documentation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Fats for diabetic

A
  • Less than 200 mg/day
  • less than 7%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

How long can hypoglycemia occur after exercise

A

up to 48 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Signs of COPD

A
  • productive cough for 3 or more months in each of 2 successive years
  • Dyspnea
  • Chronic Fatigue
  • Bluish Red Color Skin
  • Pulmonary Hypertension
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

What is the cornerstone of care for a person with diabetes

A

meal plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

a disease of unknown cause affecting the membranous labyrinth of the ear, causing progressive deafness and attacks of tinnitus and vertigo.

A

Meniere’s Disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Glycemic Index

A
  • how fast blood sugar rises, based on the carbohydrate containing food
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

A normal fasting (no food for eight hours) blood sugar level is

A

between 70 and 99 mg/dL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Types of Insulin

A
  • long acting (basal) once a day
  • rapid/short acting (bolus) before meals
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Normal Value for HCO3

A

22-26

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

This is the term for
inflammation of the walls of a vein.

A

phlebitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

What is the oxygen concentration for a nasal cannula?

A
  • 24-44%
  • 1-6 LPM

Victims w/ difficulty breathing, unable to tolerate mask

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Clinical Manifestation of a patient with Chronic Arterial Disease

A
  • Arteries narrowed
  • Atherosclerosis
  • Inc Risk for Heart Attack/Stroke
  • Pallow
  • Parasthesia
  • Inadequate around boney prominents
  • Gangrene/Amputation
  • Weak Pulses
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

What is the highest priority for a patient with DVT or VTE

A

Skin Integrity b/c of amputation risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

What is the technique for administering IV Bolus (push)

A
  • Flush w/ normal saline first
  • administer medication
  • Flush again
  • Monitor Pt’s tolerance
  • Document any adverse effects
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

What symptoms might an older woman with diabetes mellitus complain?

A

perineal itching

Rationale: Older women might complain of perineal itching due to vaginal candidiasis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Explain Polyuria for diabetes

A

The body tries to remove excess glucose by producing extra urine. The body then requires more water.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Diagnostic Testing for Heart failure

A
  • BNP
  • ANP
  • Creatnine Kinase
  • Troponin
  • Fibronogen
  • Chest Xray
  • EKG
  • Coronary Angiogram
  • Echogram
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Glucose and microvascular complications x3

A
  1. Retinopathy
  2. Neuropathy
  3. Nephropathy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Nursing Diagnoses for patient with VTE

A
  • Ineffective Peripheral Tissue Perfusion
  • Acute Pain
  • Risk for impaired physical mobility
  • Risk for Embolization
  • Impaired Skin Integrity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

“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?

A

Hyperglycemic hyperosmolar non-ketotic coma.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

If someone has diabetes but not ketoacidosis they are

A

hypokalemia

62
Q

Hyperosmolar Hyperglycemic Syndrome

A
  • which high blood sugars cause severe dehydration, increases in osmolarity and a high risk of complications, coma and death.
64
Q

What ahould the nurse do if he/she believes a patient is a hypoglycemic?

A
  • 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
Q

Hypoglycemia- Signs and Symptoms

A

TIRED

  • Tachycardia
  • Irritability
  • Restless
  • Excessive hunger
  • Diaphoresis/Depression
66
Q

What is the FIRST action most appropariate for the nurse to perform when a patient presents with impaled object in the eye

A

assess the patient’s pain, visual acuity, and oculomotor nerves

67
Q

What is the term used to clear the tubing of air before administering fluids to a patient?

A

Priming

69
Q

Name the primary veins for peripheral IV insertion

A

cephalic, median, cubital, basilic

69
Q

Complication of Type II Diabetes

A

Hyperosmola hyperglycemic syndrome

70
Q

What is levemir

A

long acting insulin

71
Q

Aspiration Pneumonia Definition

A
  • Aspirated something into their lungs
  • Decreased LOC
72
Q

Insulin Definition

A

allows sugar to go from the blood into the cells for energy.

72
Q

Name interventions for a patient with acute angle closure glaucoma

A
  • lay patient in supine
  • apply eye patch
  • monital vitals
73
Q

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

A

Homan’s Sign

74
Q

This is when you have progressive deterioration of both sensory and motor nerves?

A

diabetic neuropathy

75
Q

If the patient is NOT alert enough to swallow and is hypoglycemic?

A
  • 50% dextrose IV
  • or Glucagon IM, SubQ
    • takes awhile to kick in
77
Q

5 Reasons a nurse would avoid an area of the hand or arm for IV insertion

A
  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
Q

Etiology for Thromboembolism

A
  1. PICC line
  2. Bed Rest
  3. Previous Hx
  4. Heart Failure
  5. COPD
  6. Smoking
  7. Obesity
80
Q

If a person has 301-350 how many units of insulin?

A

8 units

81
Q

What angle do you hold the needle for an average sized subQ injection?

A

45 degrees

81
Q

Reasons for hypovolemia

A
  • ng drainage,
  • burns (3rd spacing),
  • dehydration,
  • shift of plasma into interstitial spaces,
  • peritonitis,
  • ascites (abdomen)
82
Q

Clinical Manifestations for a patient with Venous Insufficienty

A
  • Pooling of blood in the legs
  • Damage to valves in the veins
  • Eczema
  • Edema
  • Leathery brown skin
83
Q

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?

A

1200/6= 200

200x15/60(for minutes)=

50 gtts/min

85
Q

Brown rice is what type of food

A

low glycemic index, a steady increasy in blood sugar

86
Q

Signs (AEB) Hypokalemia

A

6L’s

  1. Lethargy
  2. Lethat cardiac arrhthymia
  3. Leg cramps
  4. Limp Muscles
  5. Low, shallow respirations
  6. Less stool (constipation)
87
Q

What is humalin R or Novolin R

A

Regular insulin, short acting

88
Q

This is related to blindness due to diabetes

A

retinopathy

90
Q

What is a treatment for dawn phenomneon?

A

increase insulin at bedtimes

91
Q

What does alcohol do for diabetic

A
  • high risk for hypoglycemia
  • impaire liver glucose production- glycogen breakdown
    • EAT carbs prior to alcohol consumption
92
Q

“What insulin type can be given by IV?

A

Regular Insulin

92
Q

What is NOT a manifestation of Meniere’s disease

A

high frequency hearing loss

93
Q

“When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask?

A

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
Q

What is the cause of JVD

A
  • Right Sided Heart Failure
  • increase the central venous pressure and the amount of jugular vein distention.
96
Q

What is the oxygen concentration for a Resuscitation mask w/ oxygen inlet (simple mask)?

A
  • 35-55%
  • 6-15 LPM

Victims who are NOT breathing, or difficulty breathing

97
Q

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?

A

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
Q

Describe a Non-tunneled CVAD

A
  • 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
Q

Administration of an intermittent IV medication such as an antibiotic, given in a small IV bag of fluid is called..

A

Secondary IV solution (Piggy Back)

101
Q

Labs for someone with Metabolic Alkalosis

A

High pH High HCO3

103
Q

Describe the purpose of pursed lip breathing in the COPD Patient

A

To reduce overall work of brathing

105
Q

What should diabetic patient due prior to exercise

A

eat a snack. No need for carbohydrate intake when blood glucose lis over 100 before activity.

106
Q

Trauma Assessment Priorities

A
  • Airway
  • Breathing
  • Circulation
  • Disability
  • Examine
  • Fahrenheit
  • Get vitals
  • Head to toe assess
  • Intervention
107
Q

blood urea nitrogen (BUN)

A

8 - 21

8 bun twists x 3

108
Q

If a person has 201-250 how many units of insulin?

A

4

110
Q

Lab Value when fully compensated

A

pH will be normal

112
Q

Care for DKa

A
  • Fluid/electrolyte imbalance
  • normal saline 0.45%
  • blood glucose level
  • acidosis
  • IV insulin
113
Q

A nurse is preparing a plan of care for a client with diabetes mellitus who has hyerglycemia. The priority nursing diagnosis would be:

A

Deficient fluid volume. An increased blood glucose level will cause the kidneys to excrete the glucose in the urine

113
Q

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?

A

Hearing

115
Q

Acutal Problem means

A

we have evidence (AEB)

116
Q

what is lipodystrophy

A

scar tissue, if you do not rotate injection sites

117
Q

The best description of cataracts

A

clouding of the lens in the eye that affects vision

118
Q

Blood glucose valuse for hyperglycemia

A

> 200 mg/dl

119
Q

SubQ needle size and guage?

A
  • 5/8”
  • 25G
120
Q

What direction is the bevel facing for an intradermal medication

A

up

121
Q

The nurse is teaching a community class to peole with Type 2 diabetes mellitus. What is the explanation for that?

A

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
Q

What is the oxygen concentration for a non rebreather mask?

A
  • Up to 90%
  • 10-15 LPM

Breathing victims only

123
Q

What is the name of the device which controls the IV flow rate for gravity infusion?

A

Roller Clamp “EID”

124
Q

If a person has 101-150 insulin

A

0 units

125
Q

Why is acute angle closure glaucoma emergent?

A

ange between cornea and iris is closed, raising the intraocular pressure suddenly and causes perm vision loss

125
Q

Appropriate for the nurse to delegate to the UAP with a hearing impared client?

A

help w/ placement of hearing aid (change batteries clean)

127
Q

What are 4 examples of Chronic Illness

A
  1. Diabetes
  2. COPD
  3. Parkinsons
  4. MS
128
Q

Diabetes is balancing what

A

insulin, diet, exercise

129
Q

How can hearing aid therapy be improved

A

continuous use

131
Q

Characteristics of Circulatory Overload

A
  • Excessive amounts of isotonic/hypertonic solution
  • Too Rapid
  • Overload is associated w/ increased risk of death
132
Q

The 6Ps of Acute Arterial Ischemic Disorder

A
  1. Pain
  2. Pallor
  3. Pulselessness
  4. Parasthesia
  5. Poikilothermia (inability to maintain temp)
  6. paralysis
134
Q

Lab values when only partially compensated

A

all three values will be abnormal. One value will be working harder to compensate.

135
Q

When on an anticoagulation for VTE, how should vitamin K be used?

A

even and consistent

136
Q

Protein for diabetic

A

15-20%

138
Q

Non-pharmacological interventions for pain

A
  • Reposition
  • massge
  • Heat/Cold compress
  • Distraction
  • Elevation
  • Humor
139
Q

What are appropriate assessment tools for visual impairment?

A
  • Snellen Chart
  • Confrontation Exam
139
Q

Blood glucose values for hypoglycemia

A

<70

141
Q

What degree angle for an IM injection?

A

90 degrees

142
Q

Hospital Acquired Pneumonia

A
  • Occurring 48 hours or longer after admission
  • Not incubating at time of hospitalization
143
Q

Hyperglycemia

A

dry skin, dehydrated

144
Q

Whenever insulin is peaking what should we be wathcing for?

A

hypoglycemia

146
Q

What are 2 groups of drugs for diabetes

A
  • Insulin- subQ, not given orally b/c destroyed by gastric enzymes
  • antidiabetic agents
147
Q

What is glycosylated hemoglobin

A

the percentage of hemoglobin that is saturated w/ glucose. Excess sugar attaches to hemoglobin

148
Q

What does insulin do to potassium level

A

push potassium back into the cells,

148
Q

Normal Value for Potassium

A

3.5 - 5 mEq/L

149
Q

Left Sided Heart Failure

A
  • 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
Q

Describe Dawn Phenomenon

A
  • occurs for everyone
  • Hyperglycemia all night long
  • An abnormal early-morning increase in blood sugar (glucose) — usually between 2 and 8 a.m.
152
Q

nursing diagnosis for a patient with advanced respiratory diseases.

A
  • 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
Q

What is the timeframe of administering and IM injection?

A

1mL every 10 seconds

154
Q

What is the oxgen concentration for a bag valve mask (BVM)?

A
  • 90% or more
  • 15LMP or HIGHER

Victims who are not breathing/having A LOT of difficulty breathing

155
Q

Diabetes Mellitus Type 1- Signs & Symptoms

A

3P’s

  • Polydipsia (thirst)
  • Polyuria (urine)
  • Polyphagia (hunger)
156
Q

What is intermittent claudication

A

lactic acid buildup from anearobic metabolism. Muscle pain that resolves w/ rest

157
Q

What is the core problem a patient would have with PE

A

perfusion

158
Q

Name some SubQ injection sites?

A
  1. outser aspect of the upper arm,
  2. Abdomen below costal margin
  3. Anterior aspect of the thigh
159
Q

IV calcs for regulating an IV pump are usually measured in…

A

hours

160
Q

IM / Z-Track needle size and gauge?

A
  • 1-1/2”
  • 21-23G

2” if patient is obese

161
Q

Signs and symptoms of DKA

A
  • dehydration
  • tachycardia
  • dry loose skin
  • eyeballs soft/sunken
  • anorexia
  • kushmal respirations
  • orthostatic hypotension.
162
Q

Short Acting Onset/Peak

A

onset 30-60 min, peak 1 to 5 hours

163
Q

Explain polyphagia for diabetes

A

We get hungry because our cells are starving for energy.

165
Q

HYPER- glycemia mneumonic

A

hot/dry sugar high

166
Q

Techniques for increasing venous distention in preparation for needle insertion

A
  • apply tourniquet 6-12” above chosen site
  • apply warmth to extremity for several min.
167
Q

Intradermal Needle Size and Gauge

A
  • 3/8 -1/2”
  • 26-28G
168
Q

The guidelines for Carbohydrate
Counting as medical nutrition therapy for diabetes mellitus includes

A
  • 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
Q

Benefits of using an insulin pump

A
  • fewer swings
  • increased flexibility in diet
  • accuracy of insulin doses and delivery;
    *
171
Q

What is lantus

A

long acting insulin (SUBQ)

173
Q

Rapid Acting

A

onset 10-15mintues

peak 30 to 90 minutes.

174
Q

A patient with retinitis pigmentosis would exhibit all of the following:

A
  1. night blindness
  2. tunnel vision
  3. slow adjustment to change in light
175
Q

Name 4 examples of an acute illness?

A
  1. Pneumonia
  2. Delirium
  3. Shingles
  4. Apendicitis
176
Q

The patient understand their diagnosis of Retinitis Pigmentosis when the patient states what?

A

Its likely I inherited this from my grandma

177
Q

Glucose Value 2 hours after eating

A

Up to 140

178
Q

What food should be avoided for a diabetic patient b/c of its high glycemic index?

A

potatoes

180
Q

Name 3 location sites for IM injection

A
  1. Vastis Lateralis
  2. Deltoid
  3. Ventrogluteal
181
Q

This is a pathological change in the kidneys that reduce kidney function and lead to renal failure

A

Nephropathy-

Sign is protein in the urine (microalbuminuria)

183
Q

What are symptoms of acute angle closure glaucoma

A
  1. pain in the eye
  2. vomiting
  3. halos around object
  4. blurry vision
184
Q

Create labs for someone with metabolic acidosis

A

low pH low HCO3

185
Q

Intermediate Acting Insulin Onset/Peak

A

onset 1 to 2 hours, peak 6 to 14 hours

186
Q

PE interventions?

A
  • Rotate patient
  • High fowlers
  • oxygen (non-rebreather)
  • Continuous vital signs
  • I/O’s
  • Anticoagulants/Thrombolytics
188
Q

A patient w/ cataracts may have

A

decreased vision acuity and light sensitivity

189
Q

Most appropriate nursing diagnosis for eye trauma

A

disturbed visual sensory perception

191
Q

When giving eye drops it is important to

A

make sure the tip of the eye drops botts is not directly touching the eye

192
Q

Acute pain is directly related to…

A

tissue damage

193
Q

Describe a port CVAD?

A
  • 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
Q

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?

A

The Somogyi Effect

195
Q

Greater than 401 of insulin what is your action

A

call the physician

196
Q

Discharge instructions for a patient with peripheral vascular disease

A
  • look at feet every night
  • avoid exposure to cold or hot
  • wear loose clothing
  • stop smoking
  • avoid caffeine
  • Monitor blood glucose
197
Q

A well written nursing diagnosis contains 3 components

A

Diagnosis,

Related To

As Evidence By

198
Q

Describe a PICC line

A
  • 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
Q

Patient is diagnosed with Meniere’s disease. What should the nurse provide (x3)

A
  1. avoid alcohol/caffeine
  2. low sodium diet
  3. relaxing activities to reduce anxiety (exacerbate vertigo)

Nursing School Pt 1 (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions