Exam 3 Flashcards
A client is taking a polyethylene glycol lavage prep prior to a colonoscopy. What health problems are contraindicated for this?
Irritable Bowel Syndrome. Intestinal obstruction.
A client presents to the ER with substernal chest pain radiating down his left arm. What is the priority nursing assessment?
EKG
A client with chronic venous insufficiency presents to the ER with chills, swelling and fever in the lower extremities. What are these indicative of?
Cellulitis
A client with primary hypertension presents to the ER with blurred vision and decreased visual (acuity?). What is this indicative of?
Retinal Damage
A patient presents to the emergency room with chest pain. As a nurse, you know that chest pain is the most indicative sign of ___________.
Angina
A patient with CAD is experiencing an increased heart rate. What can result from this?
Myocardial ischemia, which can lead to a myocardial infarction.
Appropriate bowel prep for a lower GI study
Empty and cleanse the bowels
Contributing factors to a decreased Cardiac Output
Blocked artery, Coronary Artery Disease.
Contributing physical factors of angina (3)
CAD, lack of blood flow, insufficient coronary blood flow.
Describe Intermittent Claudication.
Leg cramps caused by narrowing or blocking of the femoral artery, which reduces blood flow to the legs. Causes swelling and loss of hair on the legs. Main symptom of PAD.
Diastole
Relaxation of the heart
Effects of cigarettes and alcohol on PAD
Vasoconstriction: increased HR and BP. Increased risk of clot formation.
Ejection Fraction
Percentage of blood ejected from heart after each heart beat
Exam sequence for abdominal assessment
Inspect, auscultate, percuss, palpate.
How does a PEG tube stay in place?
Mushroom catheter in stomach, goes under the skin. Installed via surgical procedure.
How do you determine the correct tube length prior to NG tube insertion?
Tip of nose, bottom of ear, xiphoid process.
How do you take prescribed nitroglycerin tablets? What adverse effects can occur from taking them?
Put tablet underneath tongue, wait 5 minutes for the drug to kick in. Can take a max of 3 times to produce a therapeutic effect. (Vasodilation)
Adverse Effects: Dizziness, headaches, hypertension.
How would you go about caring for a patient following a radical neck dissection?
Keep head straight; don’t want a lot of pressure or movement; watch for infection.
How would you unclog an NG tube?
Flush with regular water or normal saline. (Like unclogging a toilet)
If a patient’s stool is black or has bright red streaks of blood, this is indicative of:
Hemorrhoids. (The further up the bleed in the GI system, the darker the stool. GI bleeds are darker).
Modifiable risk factors for CAD
Weight, diet, smoking, alcohol, lifestyle
Non-modifiable risk factors for CAD
Age, race, gender, genetic propensity.
Patient teaching after a barium swallow
May cause constipation. Drink plenty of fluids and eat foods high in fiber.
Plaque in the inner lumen arteries is composed of _________ and _________.
Lipids, fibrous tissue.
Primary Hypertension
High BP, unidentified cause.
Repolarization
Return of the heart back to its resting state (recharging)
Secondary Hypertension
High BP, identified cause.
Significance of HDL and LDL.
HDL: good cholesterol (think “HDL-Healthy”)
LDL: Bad cholesterol.
Specific part of brain that regulates swallowing
Medulla Oblongata
Systole
Contraction of the heart
What are health consequences of uncontrolled hypertension?
Myocardial infarction. Renal and heart failure. Hypertrophy of the left ventricle (heart pumps so much it stretches out). Strokes. Impaired vision.
What characteristics would you expect to see in the heart of an elderly patient?
Widening aorta, decreased elasticity, thickening and rigidity of the cardiac valves.
What foods/drugs could cause a false positive in a hemooccult II test?
red meat, aspirin, NSAIDS, turnips
What foods elevate the chance of tooth decay?
Acidic foods, sugary foods and beverages, soda, etc.
What is a major complication of TPN (total Parenteral nutrition) and how would a nurse address the potential complication?
Raise in blood sugar; take blood glucose.
What is associated with GERD, and what part of the GI tract has reduced pressure in a patient with GERD?
Heartburn from spicy foods. Lower esophageal sphincter.
What is the best way to take care of the tube and wound post-gastrostomy?
Wash around it, clean with soap and water.
What is the INR? What is it used for and what is its therapeutic range?
International Normalized Ratio. Used for Warfarin, Coumadin. Therapeutic range: 2-3.
What lifestyle changes could you suggest to an at-risk client to prevent Venous Thromboembolism (VTE)?
Stop smoking. Avoid immobilization. Healthier diet along with exercise. Wear pressure stockings.
What meds should not be given prior to a fecal occult test?
NSAIDS.
What nursing diagnosis is related to using a subclavian catheter to receive parenteral nutrition?
Risk for infection
What physical variables does adequate arterial blood flow depend on? (EAPR)
Efficiency of heart as a pump.
Adequacy of the circulating blood volume.
Patency and Responsiveness of the blood vessels.
What teaching regarding eating habits would you include in the education of a client with hiatal hernia?
(HH: stomach is protruding up through the diaphragm, eating large meals causes pain) Eat small, frequent meals and stay sitting up afterwards.
What vessel is most commonly used as a source for CABG?
Greater saffenous vein
What vitamin can cause a false positive in a hemooccult II test?
Vitamin C
What would be indicated in a client with elevated Troponin I levels? What is the best time frame to check these levels?
They have had a Myocardial infarction; within 24 hours of the MI.
(Note: this cannot be used to predict an MI)
When taking a client’s blood pressure, what should you take into consideration in order to accurately diagnose hypertension?
A high initial reading may be due to nervousness. (White coat syndrome). Never assume it’s HTN, take it again.
When teaching a client about monitoring and controlling their hypertension, what are important points to mention?
Know their own ranges, where they should be. (Diet, exercise)
When would a paralytic ileus be heard?
Post-op
Where is the PMI?
On the midclavicular line at the 5th intercostal space. (Apical pulse)
Which enzyme initiates the digestion of protein?
Pepsin.
Why would you check for residual volume and NG tube placement when caring for a patient with a feeding tube?
Prevent aspiration
You are checking the placement of a patient’s NG tube and aspirate ______ colored fluid, which lets you know the tube has been placed correctly.
Green
You have a client with Venous Insufficiency. What should you include in your client teaching?
Walk around. Don't sit or stand still for too long. Wear pressure stockings. Elevate your legs while laying down. Avoid tight clothing and avoid crossing your legs. Don't smoke.
Your patient is post-op after popliteal bypass graft surgery. What would be your priority assessment for this situation?
Pedal pulses.
How do you calculate pulse pressure?
Systole - Diastole = pulse pressure. Ex) BP: 120/80. Pulse pressure = 40.
You are caring for an elderly patient with primary hypertension who has just been prescribed a beta-blocker. What should be your priority when performing client education?
Risk for falls and orthostatic hypotension. (Getting up/down too quickly)
Your patient has unstable angina, what are three nursing diagnoses you could use for his care plan?
Noncompliance.
Risk for decreased cardiac perfusion.
Risk for deficient knowledge (or Knowledge Deficit)
