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Intro To Nursing Care > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Hypo, Hyper, or Iso? In container and in body.
Dextrose 5% in water

A

Isotonic in container
Hypotonic in body

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2
Q

Hypo, Hyper, or Iso? In container and in body.
Dextrose 10% in water

A

Hypertonic in container
Hypotonic in body

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3
Q

Hypo, Hyper, or Iso? In container and in body.
0.225% NaCl (1/4NS)

A

Hypotonic in container
Hypotonic in body

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4
Q

Hypo, Hyper, or Iso? In container and in body.
0.45% NaCl (1/2NS)

A

Hypotonic in container
Hypotonic in body

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5
Q

Hypo, Hyper, or Iso? In container and in body.
0.9%NaCl (NS)

A

Isotonic in container
Isotonic in body

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6
Q

Hypo, Hyper, or Iso? In container and in body.
3% or 5% NaCl

A

Hypertonic in container
Hypertonic in body

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7
Q

Hypo, Hyper, or Iso? In container and in body.
Dextrose 5% in 0.45% NaCl

A

Hypertonic in container
Hypotonic in body

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8
Q

Hypo, Hyper, or Iso? In container and in body.
Dextrose 5% in 0.9% NaCl

A

Hypertonic in container
Isotonic in body

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9
Q

Hypo, Hyper, or Iso? In container and in body.
Lactated ringers (LR)

A

Isotonic in container
Isotonic in body

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10
Q

Hypo, Hyper, or Iso? In container and in body.
Dextrose 6% in LR

A

Hypertonic in container
Isotonic in body

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11
Q

What are sodium containing isotonic solutions used for?

A

For ECV replacement
To prevent/treat ECV deficit

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12
Q

What are hypotonic solutions used for?

A

To dilute body fluids and move water into the cells
Ex: pt with hypernatremia

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13
Q

What are hypertonic solutions used for?

A

To pull water out of cells, causing them to shrivel

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14
Q

What has occurred for a patient to have extracellular fluid volume excess?

A

Body fluids have increased volume but still have normal osmolality
Sodium and water intake greater than output

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15
Q

Initial S/S of a pt with extracellular fluid volume excess

A

Sudden weight gain (over night)
Edema (esp in dependent areas)
Full neck veins when upright
Crackles in lungs

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16
Q

Severe S/S of a pt with extracellular fluid volume excess

A

Confusion
Pulmonary edema

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17
Q

Lab findings in a pt who has extracellular fluid volume excess

A

Decreased hematocrit
BUN <10

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18
Q

What occurs in order for a pt to have extracellular fluid volume deficit?

A

Body fluids have decreased volume but have normal osmolality
Sodium and water intake less than output, causing isotonic loss

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19
Q

Initial S/S of extracellular fluid volume deficit

A

Sudden weight loss (overnight)
Postural hypotension
Tachycardia
Thready pulse
Dry mucous membranes
Poor skin turgor
Slow vein filling
Flat neck veins when supine
Dark yellow urine

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20
Q

Sever S/S of extracellular fluid volume deficit

A

Thirst
Restlessness
Confusion
Hypotension
Oliguria (urine volume <30mL/hr)
Cold, clammy skin
Hypovolemia shock

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21
Q

Lab findings of extracellular fluid volume deficit

A

Increased hematocrit
BUN >20
Urine specific gravity usually >1,020 (unless renal cause)

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22
Q

How does hypernatremia occur?

A

Loss of relatively more water than salt
Or gain of relatively more salt than water
(Body fluids too concentrated)

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23
Q

S/S of hypernatremia

A

Decreased LOC (confusion, lethargy, coma)
Perhaps thirst
Seizures if develops rapidly or is very severe

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24
Q

Lab findings of hypernatremia

A

Serum Na+ >145
Serum osmolality >295

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25
How does hyponatremia occur?
Gain of relatively more water than salt Or loss of relatively more salt than water (Body fluids too dilute)
26
S/S of hyponatremia
Decreased LOC (confusion, lethargy, coma) Seizures if develops rapidly or is very severe
27
Lab findings of hyponatremia
Serum Na+ <136 Serum osmolality <285
28
What is infiltration?
When an IV catheter become dislodged or a vein ruptures and IV fluids enter subcutaneous tissue around IV site
29
What is extravasation?
When IV fluid that contained additives that damage tissue and it leaks, entering subcutaneous tissue
30
S/S of extravasation and infiltration
Coolness Paleness And swelling of the area
31
How can you fix the symptoms of extravasation and infiltration?
Can apply heat to get blood vessels to reabsorb the fluid
32
What is phlebitis?
Inflammation of a vein resulting from chemical, mechanical, or bacterial causes
33
S/S of phlebitis
Heat Erythema Tenderness along course of vein
34
3 most important safety steps for blood transfusions
Always verify: 1- that blood components delivered are the ones that were ordered 2- that blood delivered to a pt is compatible with the blood type in their chart 3- that the right pt receives the blood
35
Who must check the label on the blood against the medical record and the pt’s ID number before a blood transfusion?
Two RNs or an RN & LPN
36
What should happen if a blood transfusion reaction begins to occur?
Stop immediately Change out all IV tubing and run 0.9% NS Monitor vital signs and prepare to administer emergency drugs or administer CPR Save the blood container, tubing, etc. to send back to blood bank
37
How long can blood be hung?
Ideally a whole unit of blood will be transfused in 2 hrs. But can be hung up to 4 if needed
38
What is hypernatremia?
Hypertonic condition caused by either losing too much water or gaining too much salt Makes body fluids too concentrated
39
What is hyponatremia?
Hypotonic condition caused by either gaining too much water or losing too much salt Makes body fluids too dilute
40
Lab value for osmolality
285-295
41
Lab value for sodium
136-145
42
Lab value for potassium
3.5-5
43
Lab value for chloride
98-106
44
Lab value for total CO2
22-30
45
Lab value for bicarbonate (arterial)
21-28
46
Lab value for bicarbonate (venous)
24-30
47
Lab value for total calcium
9.0-10.5
48
Lab value for ionized calcium
4.5-5.6
49
Lab value for magnesium
1.3-2.1
50
Lab value for phosphate
3.0-4.5
51
Lab value for anion gap
6+/-4
52
Lab value for pH
7.35-7.45
53
Lab value for PaCO2
35-45
54
Lab value for PaO2
80-100
55
Lab value for O2 Sat
95%-100%
56
Which foods are potassium found in?
Fruits Potatoes Instant coffee Molasses Brazil nuts
57
Foods calcium is found in
Dairy products Canned fish with bones Broccoli Oranges
58
What helps and prevents calcium absorption?
Requires Vitamin D Undigested fat prevents absorption
59
Which foods are magnesium found in?
Dark green leafy veggies Whole grains Mg containing laxatives and antacids
60
What prevents magnesium from being absorbed?
Undigested fat
61
Which foods is phosphate found in?
Milk Processed foods
62
What prevents phosphate from being absorbed?
Aluminum antacids
63
S/S of: - bilateral muscle weakness that begins in quads and may ascend to respiratory muscles - abdominal distention - decreased bowel sounds - constipation - dysrhythmias
Hypokalemia
64
S/S of: - bilateral muscle weakness in quads - transient abdominal cramps - diarrhea - dysrhythmias - cardiac arrest if severe
Hyperkalemia
65
S/S of: - numbness and tingling of fingers, toes, and circumoral region - positive Chvostek’s sign - hyperreactive reflexes - muscle twitching and cramping - carpal and pedal spasms - tetany - seizures - laryngospasm - dysrhythmias
Hypocalcemia
66
S/S of: - anorexia - N & V - constipation - fatigue - diminished reflexes - lethargy - decreased LOC - confusion - personality change - cardiac arrest if severe
Hypercalcemia
67
S/S of: - positive Chvostek’s sign - hyperactive deep tendon reflexes - muscle cramps and twitching - grimacing - Dysphagia - tetany - seizures - insomnia - tachycardia - HTN - dysrhythmias
Hypomagnesemia
68
S/S of: - lethargy - hypoactive deep tendon reflexes - bradycardia - hypotension - flushing - sensation of warmth - decreased rate and depth of respirations - dysrhythmias - cardiac arrest
Hypermagnesemia
69
What should you look for when selecting an IV site?
Look for valves and bifurcations Find vein with no curvature Preferred are veins on dorsal and ventral surfaces (Use most distal site in non dominant arm if possible)
70
Which sites should you not choose for an IV site?
Site with pain Side of breast surgery Distal to previous IV site Ventral surface of wrist
71
Steps in starting an IV regarding when to use tourniquet
Prepare gear Hand hygiene Apply tourniquet Select vein Release tourniquet Hand hygiene, gloves, PPEs Antisepsis Apply tourniquet 10-15 cm above insertion site Insert IV
72
What is osmosis?
Water moving through a membrane that separates fluids with a different particle concentration (How water moves across cell membranes)
73
What is filtration?
The net effect of four forces: - two that move fluid out of capillaries and small venules - two that move fluid back into them (How fluid moves in and out of capillaries)
74
What is diffusion?
Passive movement of electrolytes or other particles down a concentration gradient
75
Most abundant cation in the blood
Sodium
76
What causes respiratory acidosis?
Alveolar hypoventilation
77
What occurs during respiratory acidosis?
The lungs are unable to secrete enough CO2 PaCO2 rises, creating excess of carbonic acid in blood, which decreases pH (Decreased pH in spinal cord and brain caused decreased LOC)
78
Which organ compensates during respiratory acidosis and how?
The kidneys compensate by increasing excretion of metabolic acids in the urine Which increases blood bicarbonate
79
Sliding movement of skin and subcutaneous tissue while underlying muscle and bone are stationary
Shear
80
Force of 2 surfaces moving across one another
Friction
81
Difference between shear and friction
Friction = superficial (only affects epidermis) Shear = deep (affects down to dermis)
82
Stage 1 pressure ulcer
Non-blanchable erythema of intact skin
83
Stage 2 pressure ulcer
Partial-thickness skin loss with exposed dermis Does not expose adipose
84
Stage 3 pressure ulcer
Full thickness skin loss Adipose tissue is visible Rolled wound edges visible
85
Stage 4 pressure ulcer
Full thickness skin and tissue loss Fascia, muscle, tendon, ligament, cartilage, or bone visible
86
Deep tissue pressure injury
Persistent, nonblanchable, deep red, maroon, or purple discoloration Skin may be intact or nonintact
87
Important lab value when assessing potential healing of a pressure ulcer
Albumin should be 3.4 - 5.4
88
Partial or total separation of wound layers when an incision fails to heal properly
Dehiscence
89
Protrusion of visceral organs through a wound opening
Evisceration
90
How does the Braden scale scoring work to assess risk for pressure injuries?
Total score ranges from 6-23 Lower score = higher risk for pressure injuries
91
Intrinsic risks during operations for pressure injuries
Pt’s tolerance to a pressure injury insult Ex: decreased mobility, altered nutrition, decreased mental status, infection
92
Extrinsic risks during operations for pressure injuries
Variables that increase tissue susceptibility to sustain external pressure Ex: temperature, friction and shearing forces, moisture
93
Risk factors during operations for pressure ulcers
Length of surgery Position on OR table Positioning devices used Warming devices Anesthetic agents Intraoperative hemodynamics Length of time on OR bed
94
Early S/S of malignant hyperthermia
Tachypnea Tachycardia Heart arrhythmias Hyperkalemia Hypercarbia Muscular rigidity
95
Later S/S of malignant hyperthermia
Elevated temperature Myoglobinuria Multiple organ failure
96
What is the circulating nurse’s job?
RN who does not scrub in Uses nursing process in management of pt care activities in OR suite
97
What is the scrub nurse’s job?
Must have thorough knowledge of each step of surgical procedure and ability to anticipate each instrument and supply needed by the surgeons

Intro To Nursing Care (10 decks)

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