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Intro To Nursing Care > Exam 4 > Flashcards

Exam 4 Flashcards

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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
Q

How does hyponatremia occur?

A

Gain of relatively more water than salt
Or loss of relatively more salt than water
(Body fluids too dilute)

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26
Q

S/S of hyponatremia

A

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

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27
Q

Lab findings of hyponatremia

A

Serum Na+ <136
Serum osmolality <285

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28
Q

What is infiltration?

A

When an IV catheter become dislodged or a vein ruptures and IV fluids enter subcutaneous tissue around IV site

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29
Q

What is extravasation?

A

When IV fluid that contained additives that damage tissue and it leaks, entering subcutaneous tissue

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30
Q

S/S of extravasation and infiltration

A

Coolness
Paleness
And swelling of the area

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31
Q

How can you fix the symptoms of extravasation and infiltration?

A

Can apply heat to get blood vessels to reabsorb the fluid

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32
Q

What is phlebitis?

A

Inflammation of a vein resulting from chemical, mechanical, or bacterial causes

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33
Q

S/S of phlebitis

A

Heat
Erythema
Tenderness along course of vein

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34
Q

3 most important safety steps for blood transfusions

A

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

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35
Q

Who must check the label on the blood against the medical record and the pt’s ID number before a blood transfusion?

A

Two RNs or an RN & LPN

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36
Q

What should happen if a blood transfusion reaction begins to occur?

A

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

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37
Q

How long can blood be hung?

A

Ideally a whole unit of blood will be transfused in 2 hrs.
But can be hung up to 4 if needed

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38
Q

What is hypernatremia?

A

Hypertonic condition caused by either losing too much water or gaining too much salt
Makes body fluids too concentrated

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39
Q

What is hyponatremia?

A

Hypotonic condition caused by either gaining too much water or losing too much salt
Makes body fluids too dilute

40
Q

Lab value for osmolality

A

285-295

41
Q

Lab value for sodium

A

136-145

42
Q

Lab value for potassium

A

3.5-5

43
Q

Lab value for chloride

A

98-106

44
Q

Lab value for total CO2

A

22-30

45
Q

Lab value for bicarbonate (arterial)

A

21-28

46
Q

Lab value for bicarbonate (venous)

A

24-30

47
Q

Lab value for total calcium

A

9.0-10.5

48
Q

Lab value for ionized calcium

A

4.5-5.6

49
Q

Lab value for magnesium

A

1.3-2.1

50
Q

Lab value for phosphate

A

3.0-4.5

51
Q

Lab value for anion gap

A

6+/-4

52
Q

Lab value for pH

A

7.35-7.45

53
Q

Lab value for PaCO2

A

35-45

54
Q

Lab value for PaO2

A

80-100

55
Q

Lab value for O2 Sat

A

95%-100%

56
Q

Which foods are potassium found in?

A

Fruits
Potatoes
Instant coffee
Molasses
Brazil nuts

57
Q

Foods calcium is found in

A

Dairy products
Canned fish with bones
Broccoli
Oranges

58
Q

What helps and prevents calcium absorption?

A

Requires Vitamin D
Undigested fat prevents absorption

59
Q

Which foods are magnesium found in?

A

Dark green leafy veggies
Whole grains
Mg containing laxatives and antacids

60
Q

What prevents magnesium from being absorbed?

A

Undigested fat

61
Q

Which foods is phosphate found in?

A

Milk
Processed foods

62
Q

What prevents phosphate from being absorbed?

A

Aluminum antacids

63
Q

S/S of:
- bilateral muscle weakness that begins in quads and may ascend to respiratory muscles
- abdominal distention
- decreased bowel sounds
- constipation
- dysrhythmias

A

Hypokalemia

64
Q

S/S of:
- bilateral muscle weakness in quads
- transient abdominal cramps
- diarrhea
- dysrhythmias
- cardiac arrest if severe

A

Hyperkalemia

65
Q

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

A

Hypocalcemia

66
Q

S/S of:
- anorexia
- N & V
- constipation
- fatigue
- diminished reflexes
- lethargy
- decreased LOC
- confusion
- personality change
- cardiac arrest if severe

A

Hypercalcemia

67
Q

S/S of:
- positive Chvostek’s sign
- hyperactive deep tendon reflexes
- muscle cramps and twitching
- grimacing
- Dysphagia
- tetany
- seizures
- insomnia
- tachycardia
- HTN
- dysrhythmias

A

Hypomagnesemia

68
Q

S/S of:
- lethargy
- hypoactive deep tendon reflexes
- bradycardia
- hypotension
- flushing
- sensation of warmth
- decreased rate and depth of respirations
- dysrhythmias
- cardiac arrest

A

Hypermagnesemia

69
Q

What should you look for when selecting an IV site?

A

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
Q

Which sites should you not choose for an IV site?

A

Site with pain
Side of breast surgery
Distal to previous IV site
Ventral surface of wrist

71
Q

Steps in starting an IV regarding when to use tourniquet

A

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
Q

What is osmosis?

A

Water moving through a membrane that separates fluids with a different particle concentration
(How water moves across cell membranes)

73
Q

What is filtration?

A

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
Q

What is diffusion?

A

Passive movement of electrolytes or other particles down a concentration gradient

75
Q

Most abundant cation in the blood

A

Sodium

76
Q

What causes respiratory acidosis?

A

Alveolar hypoventilation

77
Q

What occurs during respiratory acidosis?

A

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
Q

Which organ compensates during respiratory acidosis and how?

A

The kidneys compensate by increasing excretion of metabolic acids in the urine
Which increases blood bicarbonate

79
Q

Sliding movement of skin and subcutaneous tissue while underlying muscle and bone are stationary

A

Shear

80
Q

Force of 2 surfaces moving across one another

A

Friction

81
Q

Difference between shear and friction

A

Friction = superficial (only affects epidermis)
Shear = deep (affects down to dermis)

82
Q

Stage 1 pressure ulcer

A

Non-blanchable erythema of intact skin

83
Q

Stage 2 pressure ulcer

A

Partial-thickness skin loss with exposed dermis
Does not expose adipose

84
Q

Stage 3 pressure ulcer

A

Full thickness skin loss
Adipose tissue is visible
Rolled wound edges visible

85
Q

Stage 4 pressure ulcer

A

Full thickness skin and tissue loss
Fascia, muscle, tendon, ligament, cartilage, or bone visible

86
Q

Deep tissue pressure injury

A

Persistent, nonblanchable, deep red, maroon, or purple discoloration
Skin may be intact or nonintact

87
Q

Important lab value when assessing potential healing of a pressure ulcer

A

Albumin should be 3.4 - 5.4

88
Q

Partial or total separation of wound layers when an incision fails to heal properly

A

Dehiscence

89
Q

Protrusion of visceral organs through a wound opening

A

Evisceration

90
Q

How does the Braden scale scoring work to assess risk for pressure injuries?

A

Total score ranges from 6-23
Lower score = higher risk for pressure injuries

91
Q

Intrinsic risks during operations for pressure injuries

A

Pt’s tolerance to a pressure injury insult
Ex: decreased mobility, altered nutrition, decreased mental status, infection

92
Q

Extrinsic risks during operations for pressure injuries

A

Variables that increase tissue susceptibility to sustain external pressure
Ex: temperature, friction and shearing forces, moisture

93
Q

Risk factors during operations for pressure ulcers

A

Length of surgery
Position on OR table
Positioning devices used
Warming devices
Anesthetic agents
Intraoperative hemodynamics
Length of time on OR bed

94
Q

Early S/S of malignant hyperthermia

A

Tachypnea
Tachycardia
Heart arrhythmias
Hyperkalemia
Hypercarbia
Muscular rigidity

95
Q

Later S/S of malignant hyperthermia

A

Elevated temperature
Myoglobinuria
Multiple organ failure

96
Q

What is the circulating nurse’s job?

A

RN who does not scrub in
Uses nursing process in management of pt care activities in OR suite

97
Q

What is the scrub nurse’s job?

A

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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