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Medical Surgical Nursing Lecture > Exam 3 > Flashcards

Exam 3 Flashcards

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1
Q

What is epistaxis?

A

nose bleeding

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2
Q

What are all the nursing interventions for pt. exhibiting epistaxis?

A
  1. upright sitting, high Fowler’s position
  2. keep patient quiet
  3. Apply ice compress
  4. apply direct pressure by pinching the entire soft lower portion of the nose for 10-15 mins
  5. partially insert gauze pads into the bleeding nostril
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3
Q

If epistaxis takes place posteriorly, what is another alternative?

A

epistaxis balloon used for nasal packing

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4
Q

What is allergic rhinitis?

A

inflammation of the nasal mucosa in response to a specific allergen

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5
Q

What are some pt. teaching for allergic rhinitis?

A
  1. identify the allergen by keeping a diary
    * *2. avoidance of environmental triggers**
  2. less exposure to the trigger
  3. med therapy
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6
Q

What is a thoracentesis?

A

is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, removal of pleural fluid, or instill medication

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7
Q

What position should the patient be in for a thoracentesis?

A

the patient should sit on the edge of the bed and leaning forward over a bedside table

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8
Q

What is a bronchoscopy?

A

visualization and biopsy of the airway

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9
Q

What are the nursing actions after a bronchoscopy?

A
  1. keep pt. NPO until gag reflex returns.

2. Monitor for recovery form sedation

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10
Q

If a pt. asks for something to drink or eat after a bronchoscopy, do you give it to your pt?

A

no, the dr. has to order a gag reflex test

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11
Q

What is TB?

A

is an infectious disease caused by Mycobacterium tuberculosis

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12
Q

How do you diagnosis for TB?

A
  1. PPD
  2. Quantiferon Gold
  3. chest x-ray
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13
Q

How do you determine if still has TB in the hospital setting?

A

3 sputum tests consecutively in the am ac

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14
Q

What are the early SI/SX of TB?

A
  1. fatigue
  2. malaise
  3. anorexia
  4. weight-loss
  5. low-grade fevers
  6. night-sweat
  7. chills
  8. productive cough
  9. pleuritic pain
  10. normal or crackles in lungs
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15
Q

What type of isolation should TB patients be in?

A

airborne isolation

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16
Q

What are some nursing interventions for TB patients in the hospital?

A
  1. negative pressure
  2. close door
  3. N95 respiratory
  4. for pt. transferring pt wear a regular mask
  5. anyone less than 14 years old should not visit
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17
Q

What type of med is usually prescribed to a pt with TB?

A

Rifampin

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18
Q

What is some pt. teaching for Rifampin?

A

*1. turns fluids orange (sputum, urine, sweat, and tears)**

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19
Q

What is an acute infection of the lung parenchyma?

A

pneumonia

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20
Q

List the organisms that can cause pneumonia

A
  1. Strep. aureus
  2. Staph. pneumonia
  3. Mycoplasma
  4. Chlaymdia
  5. Haemophilus influenzae
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21
Q

A pneumonia patient is at risk for what?

A
  • *1. aspiration**
    2. atelectasis
    3. bacteremia
    4. acute respiratory failure
    5. sepsis
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22
Q

What are some pt teaching for a pt with pneumonia?

A
  1. frequent hand washing
  2. proper nutrition
  3. adequate rest
  4. regular exercise
  5. coughing or sneezing into the elbow rather than hands
  6. avoidance of cigarette smoking
  7. Avoid people with upper respiratory infections
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23
Q

In what position do we place a pt. at risk for aspiration due to pneumonia?

A
  1. side-lying, upright. turn and reposition q2h
  2. elevate HOB at least 30 degrees and have the pt sit up for all meals
  3. assess for gag reflex
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24
Q

What are some nursing Dxs for those with pneumonia?

A
  1. impaired gas exchange related to fluid and exudate accumulation within the alveoli and surrounding lung tissue
  2. ineffective breathing pattern rt inflammation and chest discomfort
  3. Acute chest pain rt inflammation and ineffective pain management and/or comfort measures
  4. Activity intolerance rt chest discomfort, inflammation, SOB and generalized weakness
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25
Q

What is a tracheostomy?

A

a surgically created stoma in the anterior portion of the trachea

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26
Q

What are the 5 reasons why a pt gets a trache?

A
  • *1. establish a patent airway b/c airway is compromised**
    2. bypass an upper airway obstruction
    3. facilitate removal of secretions
    4. permit long-term mechanical ventilation
    5. facilitate wearing from mechanical
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27
Q

After insertion of a trache what is the nurse role?

A
  1. keep obturator near bedside in case of decannulation
  2. suctioning the airway to remove secretions
  3. cleaning around stoma
  4. changing ties
  5. providing inner cannula care
  6. assess site for infxn
    7 educate the pt if A x O= 0
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28
Q

How often should trache care be performed?

A

qshift (minimum) or PRN

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29
Q

If pt becomes cyanotic during trache suctioning, what is your intervention?

A

stop and give O2

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30
Q

When you are trache suctioning do you suction on the way out or in?

A

on the way out

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31
Q

Before taking a pt to get an MRI what should you assess?

A
  1. assess for a pacemaker. If yes then notify the physician
  2. assess for claustrophobia. If yes then notify physician, they may recommend a sedative. If pt is still uncomfortable after the sedative then MRI may not be done.
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32
Q

What is chronic venous insufficiency and venous leg ulcers?

A

valves are damaged, pooling of blood in the legs and swelling

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33
Q

If pt can’t get shoes on what should you consider?

A

chronic venous insufficiency and venous leg ulcers

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34
Q

What is Raynaud’s Phenomenon?

A

an episodic vasopastic disorder of small cutaneous arteries most often involving finger and toes

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35
Q

Which gender is more common to have Raynaud’s Phenomenon?

A

females

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36
Q

What is VTE?

A

Represents pathology from DVT to PE

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37
Q

What are some nursing actions for VTE?

A
  1. Early and aggressive mobilization
  2. pts who are on bed rest should be turned and repositioned q2h
  3. unless contraindicated, teach pts to flex and extend their feet, knees, and hips q2h or q4h
  4. pts who can get out of bed need to be in a chair for meals and walk at least 4-6x/day
  5. SED and compression stockings
  6. compression devices
  7. anticoagulants
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38
Q

What are some antiHTNsive meds?

A
  1. thizades
  2. ACE Inhibitors
  3. beta blockers
  4. Ca 2+ channel blockers
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39
Q

When administering a beta blocker what should you observe?

A

HR and BP

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40
Q

When administering a thiazde what should you observe?

A

increase in glucose level

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41
Q

When administering an ACE inhibitor what should you observe?

A

hyperkalemia

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42
Q

What is a pt. teaching for a pt. taking hydrochlorothiazde?

A

to change positions slowly due to orthostatic hypotension

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43
Q

What should you assess in a patient taking benezopril?

A
  1. do not apsirin or NSAIDS simultaneously
  2. addition of enhance effectiveness
  3. hyperkalemia so K+ levels
  4. increase Cr
44
Q

What are some nursing interventions for HTN?

A
  1. Lifestyle modifications
  2. weight reduction
  3. DASH eating plan
  4. diet Na+ reduction
  5. moderation of ETHOL intake
  6. physical activity
  7. avoid tobacco products
  8. management of psychosocial factors (i.e. stress)
45
Q

What is Coumadin?

A

Warfarin is an anticoagulant

46
Q

If pt in room 205 is taking Coumadin what would you educate about him regarding his diet?

A
  1. avoid rich K+ foods such as dark greed leafy veggies
  2. no
    - spinach
    - avocado
    - cabbage
47
Q

What is the chemical class of Atenolol?

A

beta blocker

48
Q

What is the technique to take blood pressure?

A
  1. have the pt rest for 20 mins
  2. use the proper cuff size
  3. place arm AT heart level
    if bp is not read properly on an extremity than switch to the opposing
    if bp is high or low than ask the pt if that is normal, if not see if they have an hypertensive PRN med if not notify the physician
49
Q

What is CAD?

A

coronary artery disease is a blockage by cholesterol and lipids

50
Q

What are risk factors for CAD?

A 
1. Atherosclerosis 
Modifiable 
- cigarette smoking 
- HTN 
- Obesity 
-Diet/ nutrition ( high cholesterol, glucose, and fat)
- sedentary lifestyle 
- stress 
Nonmodifiable 
- Age 
- Genetics 
- Ethnicity and Race 
Gender
51
Q

What is the chemical class of enoxaparin sodium (Lovenox)? warfarin (Coumadin)?

A

lovenox is an antithrombotic

coumadin is an antigcoagulant

52
Q

Can Lovenox and Coumadin be taken simultaneously? How?

A

Yes. Coumadin is long-term taking a few days for it to take effect. Lovenox works immediately. So by the time Coumadin begins to work lovenox will no longer be in the system

53
Q

Why would you administer lovenox and coumadin simultaneously?

A

DVT prevention

54
Q

What is the normal range for Cr?

A

0.6-1.3

55
Q

What is the normal range for BUN?

A

6-20

56
Q

What is the normal range for C6H1206?

A

70-120

57
Q

What is the normal range for Hct?

A

female: 0.35-0.47
male: 0.39-0.5

58
Q

What is the normal range for Hb?

A

female: 13.2-17.3
male: 11.7-15.5

59
Q

What is the normal range for Na+?

A

135-145

60
Q

What is the normal range for K+?

A

3.5-5.0

61
Q

If pt can’t get shoes on and you consider chronic venous insufficiency what are your nursing considerations?

A
  1. change jobs if it requires a lot of standing
  2. buy comfortable shoes
  3. compression socks
  4. elevate extremities with pillows
  5. ambulate
62
Q

What is Acute Arterial Ischemia?

A

sudden interruption in the blood supply to tissue organ

63
Q

What is the cause of Acute Arterial Ischemia Disorder?

A

embolism, thrombosis or trauma

64
Q

What are the clinical manifestations of Acute Arterial Ischemia?

A
  1. foot drop from nerve damage
  2. anticoagulant therapy-IV heparin
  3. 6 P’s
    - pain
    - pallor
    - pressure
    - pulselessness
    - paralysis
    - parathesia
  4. Poikilothermia- adaptation to evntl temp
65
Q

What are the 2 types of stroke?

A
  1. hemorrhagic

2. ischemia- most common

66
Q

What type of med is given primary to aspirin for a stroke occurrence?

A

TPA- tissue plasminogen activator

67
Q

What is the nurse role if a pt. has a stroke?

A

bedside swallow test

68
Q

What is the most common cause of hemorrhagic stroke?

A

HTN

69
Q

SI/Sx of hemorrhagic stroke

A
  • *1. worst headache of their life**
    2. N/V
    3. decreased/ Altered LOC
    4. HTN
    5. Neurologic deficits
70
Q

Describe a wheeze

A

continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls

71
Q

Describe a stridor

A

continuous musical or crowing sounds of constant pitch `

72
Q

Describe fine crackles

A

discontinuous high-pitched sounds heard just before the end of inspiration. sounds similar to that rolling hair between fingers

73
Q

Describe coarse crackles

A

discontinuous low-pitched sounds caused by air passing through airway intermittently occluded by mucus. similar to sound blowing through straw under water

74
Q

What is tactile fremitus?

A

vibration of the chest wall produced by vocalization

75
Q

How do you assess for tactile fremitus ?

A

placing palmar surface of the hands against the pt’s chest with the fingers hyperextended ask the pt to say 99

76
Q

What is the nursing action for a pt with a respiratory disease?

A

apply O2

77
Q

How do you assess lungs?

A
  1. inspect
  2. palpate
  3. perucssion
  4. auscultation
78
Q

How do you screen Tb in immigrants?

A

Bacille Calmette-Guérin vaccine, not recommended in the US.

Not candidates for PPD may result in a false positive result

79
Q

What are patient teachings for a pt. with pulmonary edema?

A
  1. instruct the patient on effective breathing techniques
  2. stress taking medications
  3. the client should measure weight daily at the same time
  4. teach common adverse effects of medications
  5. Instruct the patient on a low-sodium and fluid restriction
  6. Avoid ETHOL
80
Q

If patient exhibits sharp pain, cough, and fever what is your first consideration?

A

pneumonia

81
Q

What is the clinical assessment for pneumonia?

A

history, physical examination and chest x-ray

1. sputum culture and sensitivity test

82
Q

If patient complains of pain near the IV site, what is your nursing intervention?

A

DC the IV

83
Q

What is included in the PreOP teaching to prevent DVT?

A
  1. Demonstrate and teach the importance of ROM and early ambulation for thrombi prevention
  2. instruct the patient about the purpose of antiembolism stockings and pneumatic compression devices to prevent DVT
84
Q

What is the normal range for CO2?

A

35-45

85
Q

What is the normal range for HCO3-?

A

22-26

86
Q

What s the normal range for pH?

A

7.35- 7.45

87
Q

What is respiratory acidosis?

A

pH is low and CO2 is high

88
Q

What is metabolic acidosis?

A

both pH and HCO3- are low

89
Q

What is metabolic alkalosis?

A

both pH and HCO3- are high

90
Q

What is respiratory alkalosis?

A

pH is high and CO2 is low

91
Q

What are some causes of metabolic alkalosis?

A

vomiting, NG suctioning, diuretic therapy, and hypokalemia

92
Q

What are some causes of metabolic acidosis?

A

renal failure, poisonings, and diarrhea

93
Q

What are some causes of respiratory alkalosis?

A

hyperventilation and PE

94
Q

What are some causes of respiratory acidosis?

A

hypoventilation, oversedation, cardiac arrect and CHF

95
Q

What are some interventions if a trace is accidentally dislodged?

A
  1. immediately call for help (MD)
  2. replace tube
  3. insert the obturator in the replacement trache tube
96
Q

If the trache cannot be replaces what are some nursing interventions?

A
  1. Assess level of respiratory distress

2. cover stoma with dressing and ventilate with bag until the MD or RT arrives

97
Q

T/F. Try to avoid suctioning through the newly created trache in the first few hours after procedure

A

T.

98
Q

What should you have at the bedside of a trache pt?

A

trache tube of equal or lesser size for emergency reinsertion

99
Q

Because an inflated cuff exerts pressure on the tracheal mucosa, what is important?

A

inflate the cuff with minimum volume of air required to obtain an airway seal

100
Q

What is the result of an excessive cuff pressure?

A
  1. compress tracheal capillaries
  2. limit blood flow
  3. predispose to tracheal necrosis
101
Q

A patient has had a hemorrhagic stroke and is taking coumadin with history of A-fib? Are they a priority?

A

yes, they are number ONE priority

102
Q

If i assume a patient has influenza what is my nursing action?

A

place the patient on droplet precaution even before I get labs

103
Q

Can a pt with active TB leave the hospital?

A

no if they do call police

104
Q

If a pt has a stroke and they are alone, can they get TPA?

A

no because you don’t know how long the stroke lasted

105
Q

What is a stroke pt at risk for?

A

aspiration

106
Q

Is a stroke pt aspirating a priority?

A

yes number ONE

107
Q

Can a patient go home with a trache?

A

yes, they should be taught how to care for their trache using a clean technique

Medical Surgical Nursing Lecture (4 decks)

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