FINAL EXAM Flashcards
DUMPING SYNDROME TEACHINGS 7/10)
At his postoperative checkup appt after a gastrojejunostomy (billiroth II), a patient reports that dizziness, weakness and palpitations occur 20 mins after each meal. Which instruction will the nurse include in the teaching plan for the patient? SATA
NI. Low-Fowler’s position after meals to delay stomach emptying
Lie down for 20-30 minutes
Take antispasmodics as prescribed (ex: BACLOFEN)
Diet: ↓ CARBS
MODERATE FAT & PROTEIN
Small, frequent dry meals
AVOID FLUIDS W/MEALS
AVOID SUGAR/SALT/MILK
AVOID CONCENTRATED CARBS (BREAD)
AVOID EXTREME FOOD TEMPERATURES
a. Lie down for about 30mins
b. Eat small frequent meals
Diff. of PUD [GASTRIC/DUODENAL ULCERS]
Which information about peptic ulcer disease should the nurse include when teaching a nursing student? SATA
- PUD (gastric/duodenal) comparison (pyloroplasty, BRI, BRII)
1. Gastric ulcer: gastric = pain when gobbling (women>men. >50yo)
a. Pain high epigastric
b. Food = ↑the pain (1-2 hours after meal)
Burning or gaseous pain
c. Hematemesis > Melena
-More likely than duodenal ulcers to result in hemorrhage, perforation, and obstruction
- Duodenal Ulcer: duodenal = pain delayed after meal
a. Empty stomach ↑ the pain (2-5 hours after the meal)
Pain in mid-epigastric
“Burning or cramp like pain”
Melena > Hematemesis
b. Antacids (alone or combined w/ H2R blockers [Famotidine (Pepcid)] or food usually makes PAIN BETTER/ RELIFS PAIN!
a. Gastric ulcer pain usually starts 1-2 hours after meals
b. Duodenal ulcer pain can be relieved by eating food
c. Gastric ulcers are more likely to result in hemorrhage and hematemesis
complications of liver failure/cirrhosis
The nurse is discussing the impact of cirrhosis on liver function with the family of a dying patient. The nurse explains that when the damage caused by cirrhosis blocks the blood flow through the liver it can lead to which complications? SATA
- Cirrhosis pathophysiology (Chronic Liver Disease/Scarring of liver)
- Diffuse liver fibrosis d/t chronic alcoholism (Alcohol Cirrhosis) or Late Acute Viral Hepatitis (Postnecrotic Cirrhosis) or Biliary Cirrhosis d/t Bile obstruction or infection (cholangitis) in the liver around the bile ducts.
A: ↓ ALBUMIN SYNTHESIS
B: BILE= ↑ CHOLESTEROL (CVD) + ↑ BILLIRUBIN (JAUNDICE)
C: CLOTTING FACTORS/COAGULATION DEFECT → BLEEDING (↓COAGULANTS)
o FAT-SOLUBE VITAMINS (VIT DEKA) treats CLOTTING FACTOR DEFICIENCY
Obstructive d/t Stones or tumor = orange/brown (dark-tea) urine, pale/clay stool
Jaundice/Bleeding w coagulation defect
Portal hypertension→ Ascites, Esophageal/Gastric Varices or Splenomegaly
o Varices→ Increase risk of hemorrhage → RUPTURE
▪ Caput Medusae (ring of Varices around umbilicus) → hemorrhoids
Hepatic encephalopathy or coma → mental changes d/t ↑ Ammonia → COMA
Hepatorenal syndrome – sudden ↓ UO, ↑BUN/Cr
LIVER FAILURE LABS
o Decrease clotting factor ↓
o Increase ascites ↑
o ↓ Protein synthesis → ↓serum oncotic pressure→ ↓ serum protein
o Portal hypertension
o ↓ ALBUMIN (<3.5) → ↓ Ca ↓ Platelets
o ↓ U/O (Urine Output) → ↑ BUN/CRE = Hepatorenal Syndrome
o ↑ AMMONIA → HEPATIC ENCEPHALOPATHY (tx w/ Lactulose → ↓ Ammonia)
o ↑ BILLIRUBIN → ↑ CHOLESTEROL + ↑ JAUNDICE
o ↑ Coagulation Pannel (clotting time) → ↑ PT/PTT/INR bleeding clotting time
o ↑ AST + ↑ ALT = LIVER INJURY
a. Decrease clotting factor
b. Increase ascites
c. Decrease serum protein
d. Portal hypertension
decrease in metabolic processes of the liver.
RISK FACTORS OF CRC (6)
Which of the following will the nurse include in the teaching for risk factors of colorectal cancer? SATA
- Colorectal cancer (CRC) RISK factors:
DIET: high in red meat or processed meat, low in fruits/veggies
High Fat, Low Fiber diet
lifestyle factors; Obesity, physical inactivity, alcohol, smoking
FAP (familial adenomatous polyposis) or Colon cancer
previous Colorectal polyps
Previous IBD (ULCERATIVE COLITIS OR CROHNS)
Age > 50
a. Ulcerative colitis
b. Personal hx of colorectal polyps
c. Family hx of colon ca
COLOSTOMY CARE TEACHINGS
The nurse is providing discharge teaching for a client who has undergone colon resection surgery with a colostomy. Which statement’s by the client indicate that the instruction was understood? SATA
- Colostomy care
Irrigate the colostomy to regulate passage of fecal materials
Performed at a regular time
500-1500mL of lukewarm tap water
Hang 18inches above the stoma (shoulder height)
Insert cath 3-4’’
Perform 1 hour after meal
Use charcoal filters to deodorize
Foods that help decrease odor yogurt and parsley/ avoid fish dairy eggs cabbage
Effective education Post Colostomy (case study)
“I might start bicycling and walking again once my incision has healed”
“I will use warm water and a soft cloth to clean around the stoma.”
“I know that my stoma should look reddish pink and moist.”
X “I should change the appliance daily to prevent odors.”X Empty q 4-6 hours, change bags 5-10 days
“When I change the appliance, I should check the skin for irritation.”
“I should clean around the stoma with mild soap and water and pat dry.”
“I’ll need to alter the appliance opening when the stoma becomes smaller as the area heals.”
X“I will empty the colostomy drainable pouch when it becomes 2/3full.” X 1/2-1/3 full
a. I might start bicycling and walking again once my incision has healed
b. I will use warm water and a soft cloth to clean around the stoma.
“I know that my stoma should look reddish pink and moist.”
“When I change the appliance Q4-6 HOURS+CHANGE BAGS Q5-10 DAYS, I should check the skin for irritation.”
“I should clean around the stoma with mild soap and water and pat dry.”
Preicteric S/sx (6)
A pt has been diagnosed with HEP A 2 days ago. Which symptoms will the nurse expect to observe during PREICTERIC PHASE? SATA
Preicteric →
o Flu-like symptoms
o Headache
o Malaise
o Fatigue
o Anorexia
o Fever
Icteric →
o Dark urine
o Jaundice of skin, sclera
o Tender liver → Fulminant hepatitis → complication that involves complete liver failure
a. Anorexia
b. Fatigue
LIVER BIOPSY PROCEDURES
Which of the following will the nurse include in the teaching plan for a patient who is scheduled for a liver biopsy? SATA
** LIVER BIOPSY **
Preprocedure:
▪ informed consent, MN NPO, Coagulation test, history of meds, sedation, local anesthesia
During procedure:
▪ supine or left lateral with right arm above head, breathing- exhale and hold
Postprocedure:
▪ turn on to the right side with a pillow under the costal Margin x several hours,
▪ NO coughing or straining
▪ NO heavy lifting or strenuous exercise x 1 week (prevents bleeding)
Ultrasonography; CT; MRI
a. Will be placed on LEFT LATERAL position DURING the procedure
b. Will be asked to AVOID heavy lifting and strenuous exercise for ONE WEEK
c. Will be asked to EXHALE AND HOLD BREATH during procedure
d. Will obtain COAGULATION TEST BEFORE procedure
IBD - CROHNS DIET
The nurse is caring for a patient who has been diagnosed with Chron’s disease. When providing educations concerning dietary recommendations, which statement indicates that the nurse teaching has been successful? SATA
-[IBD] Crohn disease DIET teachings-
DIET:
↑ PROTEIN ↑ CALORIES ↑NUTRIENTS.
↓ FIBER ↓FAT ↓ RESIDUE
AVOID HIGH FIBER, GAS FORMING FOOD + MILK
AVOID HIGH FAT DAIRY (MILK) LOW FAT MILK
AVOID SMOKING + CAFFEINE (SMOKING)
a. I should try to eat foods like white rice and lean poultry
b. Reducing dietary fat and fiber will be helpful in managing my condition
c. I should not have milk products
IBS NURSING INTERVENTIONS
Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)? FINAL SATA CHANGED TO FEMALE
a. Encourage the patient to express concerns and ask questions about IBS.
b. Suggest that the patient increase the intake of milk and other dairy products.
c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).
d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.
- IBS management
o Mechanical problem, nothing pathologic
o “Spastic colon”- antispasmodic agent = Dicyclomine [Bentyl]
**Avoid triggering factors: stress, anxiety, high-fat **
Avoid alcohol, smoking Teach relaxation techniques
o Alteration in bowel patterns IBS-D, IBS-C, IBS-M
**Dietary changes: ↑ fiber(psyllium),
adequate fluid intake **
Probiotics (complimentary medicine)
Relaxation techniques
**IBS-D TX Loperamide for diarrhea + Alosetron (BE CAREFUL)
IBS-C TX Alosetron **
(monitor for ischemic colitis, can cause severe constipation)
**Prevention of constipation:
↑ fluids, exercise, ↑ soft fiber (bulk-forming laxative: Psyllium).
No stimulants laxatives (bisacodyl, senna) or mineral oil routinely
No nuts, corn, popcorn/seeds (tomatoes, cucumber, squash, berries)
** Teach the patient to AVOID using NSAIDS**
Encourage the patient to express concerns and ask questions about IBS
a. Teach the patient to avoid using NSAIDS
b. Encourage the patient to express concerns and ask questions about IBS
ANS: A
Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.
IBD MANAGEMENT (TEACHINGS) (6)
The nursing is planning care for a patient with an acute exacerbations of IBD. Which action is/are most important for the nurse to include in the care plan? SATA
**IBD management **
- Assess number and character of stools
- Encourage periods of rest
- Auscultate bowel sounds
- Assess for internal bleeding
- measuring intake and output.
- documenting the patients weekly weight.
DONT INCREASE FIBER (IBS TEACHING)
IBD DIET= [PCN]↑ Protein ↑Calories ↑Nutrients
[FFR] ↓ Fiber ↓ Fat ↓ Residue
a. Assess number and character of stools
b. Encourage periods of rest
c. Auscultate bowel sounds
d. Assess for internal bleeding
A. measuring intake and output.
B. assessing bowel sounds.
C. documenting the patients weekly weight.
D. encouraging periods of rest.
E. assessing for internal bleeding.
HEP A RISK FACTORS
Which of the following individual is considered to have an increased risk for hep A? SATA
**Risk factors: **
young children, institutionalized(prison), laundry workers, HCP, day care workers, food handlers, sanitation workers, travelers to undeveloped countries
-Health care personnel
-Laundry workers
-Day care workers
a. Health care personnel
b. Laundry workers
c. Day care workers
ESOPHAGEAL VARICES PREVENTION MEDS
A patient with advanced cirrhosis develops esophageal varices. The nurse anticipates that these complications will be addressed by which type of medications? SATA
ESOPHAGEAL VARICES PREVENTION MEDS
1. Vasopressin or octreotide (sandostatin)-> vasoconstriction effect
2. Nitroglycerin -> reduce coronary vasoconstriction
3. Use Beta blockers (propranolol and nadolol) -> to decrease portal pressure to reduce the incidence of hemorrhage
- Esophageal varices management
o Manifestations hematemesis, melena, shock
o Prevention patients with cirrhosis should undergo screening endoscopy every 2 years, avoid ETOH, ASA, NSAIDs.
o Use of Beta blockers (propranolol and nadolol) -> to decrease portal pressure to reduce the incidence of hemorrhage
o If acute bleeding occurs: Stabilize patient, manage airway, provide IV therapy and blood
o Combination of drug therapy and endoscopic therapy
-Vasopressin or octreotide (sandostatin)- vasoconstriction effect
-Nitroglycerin to reduce coronary vasoconstriction
o Endoscopic sclerotherapy: injecting sclerosing agent into bleeding varices to promote thrombosis and sclerosis
o Esophageal variceal ligation (banding): tx of choice
o Balloon tamponade (Sengstaken–Blakemore)
a. Vasopressin
b. Beta blockers
c. NTG
Which nursing action will be included in the plan of care for a female patient with bowel irregularity and new Dx of IBS? SATA
a. Teach the patient to avoid using NSAIDS
b. Encourage the patient to express concerns and ask questions about IBS.
c. Suggest that the patient increase the intake of milk and other dairy products.
d. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).
e. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.
- IBS management *
**Avoid triggering factors: stress, anxiety, high-fat **
Avoid alcohol, smoking Teach relaxation techniques
o Alteration in bowel patterns IBS-D, IBS-C, IBS-M
**Dietary changes: ↑ fiber(psyllium),
adequate fluid intake **
Probiotics (complimentary medicine)
Relaxation techniques
**IBS-D TX Loperamide for diarrhea + Alosetron
IBS-C TX Alosetron **
(monitor for ischemic colitis, can cause severe constipation)
**Prevention of constipation:
↑ fluids, exercise, ↑ soft fiber (bulk-forming laxative: Psyllium).
No stimulants laxatives (bisacodyl, senna) or mineral oil routinely
No nuts, corn, popcorn/seeds (tomatoes, cucumber, squash, berries)
** Teach the patient to AVOID using NSAIDS**
Encourage the patient to express concerns and ask questions about IBS
a. Teach the patient to avoid using NSAIDS
b. Encourage the patient to express concerns and ask questions about IBS
ALOSTERON can be used but last treatment! be careful
ACUTE PANCREATITIS ASSESSMENT (4)
The nurse caring for a patient recently admitted with acute pancreatitis. Which actions should the nurse include in the daily assessment? SATA
Monitor/maintain:
1. Maintaining normal respiratory function
2. Having fluid and electrolyte balance
3. Monitor for effectiveness of pain control
4. Developing no ongoing pancreatic disease
5. Monitor U.O
6. Auscultate Bowel Sounds
N.I TCDB ->NPO -> IVF -> NGT -> PAIN MEDS
OPIODS - Morphine, Fentanyl, Dilaudid
H2R/PPI
Calcium Gluconate d/t low Ca (Tetany Monitor)
cardiac monitor
Management:
1. Improve respiratory function: TCDB (semi Fowlers)
2. Relieve pain and discomfort: NGT(suction), NPO(nausea/ distention), bed rest (HOB 45 deg), analgesics
**3. Monitor for fluid and electrolyte balance: symptomatic hypocalcemia **
-> Ca gluconate to treat tetany (hypocalcemia)
->Tetany: chvostek (twitching facial muscles d/t tapping facial nerve) + trousseau sign (carpopedal spasm ~ flexion of wrist/thumb when inflating BP cuff)
a. Monitor urine output
b. Monitor resp. function
c. Auscultate bowel sounds
d. Monitor for effectiveness of pain control
INSULINS USED IN MEALTIMES
A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? SATA
Rapid and short Acting ALWAYS DURING MEALS
(LISPRO/REGULAR (HUMULIN/NOVOLIN-R)
NPH CAN BE MIXED WITH SHORT (R-REGULAR)
DONT SKIP LUNCH INSULIN IS PEAKING (4-12 HOURS)
- Insulin types
1. Rapid acting = injected within 15-30 min of mealtime, duration 4-5 hours
Onset: 10-30min Peak: 30min to 3hr Duration: 3-5hrs
Lispro (humalog)
Aspart (novolog)
Glulisine (apidra) - INHALED INSULIN (AFREZZA)* ($$$)
RAPID ACTING, DO NOT GIVE TO COPD
- Short acting(REGULAR) = injected 30 to 45 min before meal, peak 2-4 hrs
Onset: 30min-1hr Peak: 2-5hrs Duration: 5-8hrs
Regular (humulin R, novolin R) - Intermediate acting (NPH)= can mix with short and rapid acting
Onset: 1.5- 4hrs Peak: 4-12hrs Duration: 12-18hrs
NPH (humulin N, Novolin N) - Long acting = do not mix
Similar to basal insulin = ‘Peakless’
Onset: 0.8-4hr no peak Duration: 16-24hr
o Glargine (lantus)
o Detemir (levemir)
o Degludec (tresiba) - Premixed insulin (NPH/REG)(NPH first number) NO ALLOW FOR ADJUSTMENTS
- 70/30 OR 75/25
a. Lispro
b. Regular
CUSHING SYNDROME S/SX (3/13)
A patient is being admitted with the diagnosis of Cushing syndrome. Which assessment findings should the nurse correlate with the condition? SATA
Cushing’s syndrome clinical manifestations
-Excessive adrenocortical activity or corticosteroid medications
o ACTH secreting pituitary adenoma
o Adrenal tumors/Ectopic ACTH production by tumors
-Manifestations-
o Hyperglycemia
o Hypernatremia
o Hyperpigmentation
o HTN
Hypokalemia
o Hypocalcemia
o Hirsutism
** PUD**
o Weight gain
o Central type obesity ~ buffalo hump, “moon face,” thin extremities
o Osteoporosis ~ muscle wasting/weakness; MUSCLE ATROPHY
o Menstrual irregularity
Labs:
o Elevated WBC (>11,000) (infection)
o Elevated Cholesterol (LDL>200) (HTN)
a. Hypokalemia
b. Muscle atrophy
c. Peptic ulcer
SIADH tx effectiveness
Which finding will the nurse determine that treatment has been effective for a patient with SIADH? SATA
Treat UNDERLYING cause:
*PRIORITY: Restrict fluids and get rid of fluid (diuretics) hyponatremia ↑ r/o seizures→ seizure precautions
IV fluids (NS or 3% hypertonic saline) + diuretics;
effective result =↑UO (S/SX. of DI)
↑ UO ↑Na(concentrated)
↓USG ↓Wt ↓Bp
DI s/sx:
↑ UO ↑Na(concentrated)
↓USG ↓Wt ↓Bp
Fatigue, Headache
a. Weight decreased
b. Urine output increased
c. Peripheral edema decreased
d. Sodium increased
ANUALLY EXAMS FOR T2DM
To monitor for long term complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually?
- DM long-term complications
- Macrovascular complications
Accelerated atherosclerotic changes
CAD, cerebrovascular disease, peripheral vascular - Microvascular: kidneys and eyes (ANNUALY EXAMS)
▪ Diabetic retinopathy = most common cause of adult blindness/needs annual exam
▪ Nephropathy -> leading cause of end stage kidney disease – assess for microalbuminuria – if present use ACE-I or ARB - Neuropathic changes
Peripheral neuropathy -> major risk for amputation
Autonomic neuropathies- hypoglycemia unawareness, sexual dysfxn, gastroparesis, painless MI, neurogenic bladder (urinary retention)
-Monofilament test of the foot
- Urine for microalbuminuria
- Retinal exam
Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes. Chest x-ray and CBC might be ordered if the patient with diabetes presents with symptoms of respiratory or infectious problems but are not routinely included in screening.
a. Monofilament test of the foot
b. Urine for microalbuminuria/ Blood pressure/ serum creatinine,
c. Retinal exam
HYPERPARATHYROIDISM MANAGEMENT
A patient who is newly diagnosed with hyperparathyroidism is admitted to the hospital. Which of collaborative management would the nurse expect to include in the plan of care? SATA
Manifestations: elevated serum calcium, osteoporosis, renal calculi, apathy, fatigue, muscle weakness, n/v, constipation, HTN, cardiac dysrhythmias
- Hyperparathyroidism intervention
o Tx: rehydrate w/ large IV vol.
Diuretics (furosemide),
calcitonin (Ca into bone),
bisphosphonates, dialysis
Treatment= parathyroidectomy
-Hydration therapy (risk of renal calculi ~ renal failure)
-Furosemide ~ excrete calcium
d/t cardiac dysrhythmias + IVF + meds ->
(put on cardiac monitor)
Encourage mobility -> reduce calcium excretion from bones
Diet:
↑ FLUID ↑FIBER
MODERATE TO LOW Calcium
~ RESTRICT Ca INTAKE
Complication:
Hypercalcemic crisis (>13 mg/dl) = airway obstruction (with severe muscle weakness), severe neuro, CV+renal sxs
a. Restrict calcium intake
b. Continuous cardiac monitor
c. Encourage fluid intake.
Methimazole medication teachings
Which information will the nurse teach a patient who has been newly diagnosed with graves’ disease on methimazole? SATA
Methimazole med teaching
o Medical tx + management of HYPERTHYROID ~ blocks synthesis of thyroid hormone
o Usually given with PTU (propylthyouricil)
Good results in 4 to 8 weeks (full effect in 2-3 months)
o AE: agranulocytosis ~ low granulocytes = ↑risk of infection
May take a few months for its full effect.
** Report to HCP if fever and or sore throat develops**
a. May take a few months (2-3m) for its full effect.
b. Report to HCP if fever and or sore throat develops
Ablation Therapy w/ IODINE PRECAUTIONS (6)
The patient with hyperthyroidism is undergoing ablation therapy with radioactive iodine. Which precaution is most important for the nurse to employ? SATA
Take radioactive precautions with utensils and bedpans
Increase fluids
Enforce avoiding contact with children for 2 days
AVOID CONTACT W/ PREGNANT + KIDS
48 hours Isolation
FLUSH TOILET 2-3 X
USE DISPOSABLE UTENSILS
watch for thyroid storm during ablation therapy
Iodine procedures/related care:
▪ Informed consent
▪ NPO (6-8hrs/midnight)
▪ Check BUN and creatinine (to check kidney function)
▪ Allergies to shellfish → Corticosteroid (prednisone) PO Day before or
→ can take IV antihistamine (Benadryl) during test
▪ Inform pt. of expected s/s: warm flushing, metallic taste
▪ Stop metformin 48hrs before and after
▪ Increase fluids to secrete iodine so check urine output
a. Take radioactive precautions with utensils and bedpans
b. Increase fluids
c. Enforce avoiding contact with children for 2 days
DIET: COPD
A patient with COPD has a nursing dx of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in plan of care? SATA
Diet-teaching
↑ Calories ↑ Protein (COPD=C P)
Eat 5-6 small meals per day to avoid bloating
o Fat rather than carbs (carbs produce more CO2)
Whole milk rather than low fat milk
** Fluids (3L/day) between MEALS**
o Avoid gas producing foods (low residual)
Encourage frequent eating with 5-6 meals a day
Increased fluids between meals
Offer high calorie snack between meals
- Avoid exercise 1 hour b4 and after meals
-rest or use bronchodilator @ least 30 min b4 eating.
a. Encourage frequent eating with 5-6 meals a day
b. Increased fluids between meals
c. Offer high calorie snack between meals
COPD COMPLICATIONS (5)
Which symptom in COPD require immediate intervention? SATA
-COPD complications:
1. Scar tissue in pulmonary vasculature causes thickened vessel lining and hypertrophy of smooth muscle = pulmonary HTN
2.Pulmonary HTN -> increased pulmonary artery pressure-> Cor pulmonale (R-sided HF) =
▪ s/sx: JVD, edema, weight gain
3. Pneumonia -> risk for infections (3-5 days fever)
4. Acute respiratory failure = s/sx
worsening dyspnea(STRIDOR)
▪ mental status changes
5. Cardiac dysrhythmia from acidosis (hyperkalemia) -> cardiac monitoring
Resp. rate of 30/min and restless (DYSPNEA)
Stridor
VENT ALARM SOUNDS
- A nurse caring for a client with acute ARDS who is receiving mechanical ventilation and PEEP. The alarm goes off indicating high pressure alarm in the system. What’s the nurse best action?
Ventilator alarm
▪ High pressure: obstruction
1. Secretions, coughing, gagging
2. Pt fighting vent,
kinked tubing, ↑ resistance
3. Condensation (water in tubing);
4. Decreased compliance
5. (PE (pleural effusion), Pneumothorax)
▪ Low pressure: disconnection
1. Loss of airway
2. Total or partial ventilator disconnect
3. ET tube/trach cuff leak
a. Asses lung sounds.
P.E PREVENTION INTERVENTIONS (5)
The nurse caring for a client who has a high risk for PE. Which preventative measures does the nurse add to the clients care plan? SATA
PE (pulm emb) prevention
PREVENTION IS KEY!
1. ROM
2. Frequent position changes (Turn Q2h)
3. ↑ HOB ambulation
5. Sequential compression devices (SCD)/ antiembolism stocking
6. PPx Anticoagulation
a. Turn Q2h
b. Use antiembolism stocking
BRADYCARDIA TX INTERVENTION (4)
What interventions does the nurse implement FOR BRADYCARDIA? SATA
MANAGEMENT/INTERVENTIONS
* If symptomatic,
1. withhold any meds = causing bradycardia,
2. Oxygen**
3.Atropine 0.5 mg IVP**
4.transcutaneous pacing to permanent pacemaker
a. Atropine
b. Oxygen
ICD N.I. (4/10)
Which intervention by a new nurse who is caring for a patient who has just had an ICD inserted indicates a need for more education about care of patients with ICD’s? [ THIS Q ASKING ABOUT NEEDING MORE EDUCATION]
ICD intervention
Arm restrictions: avoid lifting arm on ICD side above shoulder
Sexual activity ok to resume once incision is healed (2 flight of stairs)
* avoid driving until cleared by cardiologist
* Avoid large magnets (MRI)
* Wear loose fitting over the generator
* Caregivers to learn CPR
* Air travel is not restricted but must inform airport security b/c of metal detector (in person)
* Avoid anti-theft devices
**When ICD fires ONCE call cardiologist right away; when it fires more than once call 911 **
Medic Alert ID and ICD identification card
a. The nurse teaches the patient that sexual activity can be resumed once the surgical incision is healed
b. The nurse assists the patient to fill out the application for obtaining a medic alert ID
PERICARDITIS S/SX (12)
A client with pericarditits is admitted to the cardiac unit. What assessment findings does the nurse expect in this client? SATA
PERICARDITIS S/SX
1. Fever
2. Chills
3. fatigue
4. increased WBC
5. increased ESR
6. HF
7. cardiac murmur
8. Osler nodes(painful, tender, red, or purple, pea sized lesions may be found on the FINGERTIPS/TOES)
9. Janeway lesions (flat, painless, small red spots may be seen on the PALMS & SOLES](macules/papules)
10. Roth spots (hemorrhagic retinal lesions)
11. petechiae (clusters of small red round spots d/t bleeding)
12. splinter hemorrhages in nailbeds
13. Embolic complications:
[1. strokes (dysarthria, confusions)
+ 2. pulmonary embolism]
- Pericarditis: Inflammation of the pericardium
Potential complications:
pericardial effusion and
cardiac tamponade
**Cardiac Tamponade s/sx: pulsus paradoxus (>10mmhg decrease in systolice BP during inspiration) - JVD, SOB, Muffled heart sounds (cardiac tamponade) -> Chest Pain + Increase HR **
Pain worsened by supine position;
relieved by sitting up and leaning forward; friction rub at left lower sternal border
- Treat the underlying causes/ NSAIDs or corticosteroids
a. Janeway lesions
b. Pulsus paradoxus
c. Friction rub at the left lower sternal border
PPX ATB w/ DENTAL PRECEDURE PT. PROBLEMS
The nurse will plan discharge teaching about the need for prophylactic atibiotics when having dental procedures done for which patients? SATA
Infective Endocarditis intervention/prevention
1. (inflammation + valve replacements) & people w:
-prosthetic heart valve or structural cardiac defects
-IV drug abusers
-those with debilitating diseases
-indwelling catheters
-Dialysis
-prolonged IV therapy
Prevention:
Pt education on prophylactic abx therapy before any invasive procedure
(heart valve replacement surgeries, patients that have I.E.
-Good oral hygiene: brush teeth 2x/day w/ soft toothbrush
ii) No electric toothbrush or flossing
iii) No dental procedures for 6 mo
-Intervention:
Prolong IV therapy periods (4-6 wk) of IV abx
(1) Antibiotic prophylaxis before any invasive procedures
(a) 2g amoxicillin PO 1h before + meticulous oral hygiene
a. Patient who had mitral valve replacement with a mechanical valve.
b. Patient being treated with infective endocarditis after having prolonged IV therapy.
(also people w/):
-prosthetic heart valve or structural cardiac defects
-IV drug abusers
-those with debilitating diseases
-indwelling catheters
-Dialysis
-prolonged IV therapy
Chronic heart failure Nursing d/c teachings (4/10)
Which topics should the nurse include on the discharge teaching plan for a patient who has been hospitalized with chronic heart failure? SATA
Chronic HF Nurse Teachings
1. Diet: low-sodium diet (2 g/day) fluid restriction **
2. Date and time of follow up appt
3. * Recommend (DASH) Dietary Approaches to Stop Hypertension diet
4.* Salt substitutes
5.*Monitoring for signs of excess fluid and symptoms of disease exacerbation including daily weight
6. *Same time, same clothing each day
7.* Weight daily; weight gain of 2 Ibs/day, 3 Ibs/2 days or a 5 lb gain over a week
should be reported to health care provider **
8. * Exercise and activity program/ Stress management *
9. * Prevention of infection*
10. Actions and side effects of prescribed meds
a. Date and time of follow up appt
b. Symptoms indicating worsening heart failure
c. How to take and record daily weight
d. Actions and side effects of prescribed meds
R. HF MANIFESTATIONS (6)
The nurse is performing an initial assessment on a new patient with suspected right sided heart failure. Which finding is consistent with the patients potential diagnosis? SATA
R. HF = RV cannot eject sufficient amounts of blood and blood backs up in the venous system “systemic venous congestions”
Right sided HF = FLUID OVERLOAD
or fluid retained
-Viscera and peripheral congestion “systemic venous congestions”
- JVD
- Hepatospleenomegaly/Splenomegaly
- Ascites
- weight gain
- abdomninal distention
6.Pitting/dependent Edema
a. Abdominal distention
b. Hepatomegaly
c. Weight gain
LEFT SIDE HF MANIFESTATIONS (10)
-LV cannot pump blood effectively to the systemic circulation, pulmonary venous pressures increase and result in pulmonary congestion
Left sided HF = SYSTEMIC CIRCULATION problem d/t PULMONARY CONGESTION + distended PMI (S3 or Cardiomegaly)
-pulmonary congestion=
crackles
Pulm. Edema (pink frothy sputum)
-Dyspnea on exertion (DOE)
-Orthopnea
-Paraxosymal Noc Dyspnea (PND)
-S3 or ventricular gallop at the beginning of diastole
-Dry nonproductive cough initially
-Oliguria, restless, confusion
risk factors for arrythmias
Which factor is potential causative condition for arrhythmias? SATA
arhythmias problem with the heart going too fast or too slow
dysrhythmia: irregular heart beat
Sinus Bradycardia (risks/causes):
Hypothyroidism
Hypothermia
Vagal stimulation
Aerobic athletes
Sinus Tachycardia:
Causes: physical stressors
(HEHEPAF)
Hypovolemia
Exercise
Hypoglycemia
Electrolyte Imbalance
Pain
Anxiety
Fever
Atrial fibrillation
Risk factors:
-Mitral stenosis -(Rheumatic heart disease)
-CAD
-HTN
-Heart failure
-Hyperthyroidism
-electrolyte disturbance
NOT R.F PVC/PAC (Caffeine, ETOH nicotine, anxiety, hypoxia, HYPOkalemia)
a. Valvular disease
b. (MI) Infarct damage
c. Hyperkalemia
d. Hypoglycemia
LEFT HEMISPHERE STROKE S/SX:
When taking care of a patient who had a LEFT HEMISPHERE STROKE which nursing diagnosis can the nurse establish for the patient? SATA
L. HEMISPHERE/HEMORRAGIC/PARALYSIS = L. BRAIN DAMAGE = R. SIDE WEAKNESS/PARALYSIS = R. EYE IMPAIRED
R. Side weakness/paralysis
[SAAADD][3A]
S= Slow Performance, Cautious (impaired physical mobility)
A= Aphasia (speech/language deficits)
A= Aware of Deficits
A= Anxiety
D= Depression
D/T Language and math impairment
LEFT DISCRIMINATION
IMPULSIVE Behavior + poor judgement
a. Impaired physical mobility
b. Impaired verbal communication related to speech language deficits
c. Ineffective coping related to depression and distress about disability
Right Hemispheric Stroke S/Sx:
Left Side weakness/paraysis/stroke
R. brain damage + R. eye impairment
[RSSSTT] [3S]
R= Rapid Performance
S= Short Attention Span
S= Spatial-Perceptual Defects
[Agnosia + Aproxia]
S= SAFETY ISSUES [FALL RISKS]
T= Tends to Deny (minimal problems)
T= Time Impairment Concepts
Left Side Neglect
Impulsive, Impaired Judgement
Manifestation of T5 injury (12 spinal cord Transection Injury)
When taking care of a patient with 12 spinal cord transection injury, what will the nurse explain to the patient? SATA
[T5 INJ] =
-GOOD UPPER BODY CONTROL
-lower body weakness
-self catherization/independent ADLs
-Standing Frame
-Can stand but not walk
Respiratory
C5-T6- paralysis of abd. and intercostal muscles
- ineffective cough= atelectasis or PNA
Cardiovascular: T6 or above
-↓ influence of sympathetic nervous system→
↓HR(Bradycardia), ortho. hypotension(↓BP)
-cardiac monitoring necessary or atropine to raise HR and IV fluids or vasopressor to raise BP
Urinary
-above T12→ spastic or reflex bladder: so incomplete bladder emptying/ urinary incontinence → UTI
Neurogenic bowel → injuries above T12 will have reflex emptying (defacation incontinence)
poikilothermia & skin breakdowns
a. May have urinary incontinence
b. Function of both arms should be retained
PET SCAN PREOP TEACHINGS (6)
The patient scheduled for a PET scan of the brain asks if there is any special preparation for the test. The nurse correctly responds with which statements? SATA
PET SCAN:
computer based nuclear imaging produces images of actual organ functioning/inhale or inject radioactive substance.
[INFORMED CONSENT d/t iodine]
-CONTRAINDICATED in pregnant and breastfeeding moms
Preop:
-NO SPECIAL PREPERATIONS [NON-INVASIVE]
[INFORMED CONSENT d/t Iodine]
▪ stop anything affecting blood sugar for 24 hrs
▪ NPO 6hrs
▪ NO coffee, ETOH, steroid, sedatives or tranquilizer
▪ Need patient to be awake or stay awake
Postop:
▪ increase fluid to eliminate contrast
a. There is no special prep for this because its non-invasive
b. You’ll need to sign a consent
c. You should avoid any tranquilizers or sedatives the night and day before the test
SPASTIC BOWEL N.I (4)
A client who experiences a spastic bowel elimination pattern. Which action does the nurse implement to assist in relieving this clients constipation? SATA
Neurogenic Bowel: Spastic bowel
-↑ Fiber ↑ FLUID
-Stool softeners
-Daily RECTAL STIMULATION schedule
- Put pt on toilet 30 min – 1hr after meal
a. Digital stimulation
b. High fiber and high fluid intake
c. Implementing a consistent daily time for elimination
Autonomic Dysreflexia [A.D] N.I. (5/9)
A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking V/S, the nurse notes a BP of 184/95. Which is the nurses action? SATA
A.D. NI
-Place in sitting position
-Empty bladder →(DISTENDED BLADDER #1)→ irrigate or change indwelling cath
-Check for impacted stool (constipation)
-Check skin → restrictive clothing, tight shoes, pressure injuries
-Look for other stimuli → cold air draft
-IV Hydralazine (Apresoline) → ganglionic blocking agent (↓BP)
-Label pt chart/medical record → more likely to repeat
-Prevention management → education to pt and family to monitor –
-prevent constipation and empty bladder
a. Palpate the are over the bladder for distention
b. Remove any constrictive clothing
SCI T4 teachings
After teaching a male client with a spinal cord injury at level t4, the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related effects of this injury? SATA
Sexual dysfunction intervention:
** Men:**
o For above T12 injury- reflex erection
* stroking inner thigh
* rectal stimulation
* Sidenafil (Viagra)
* vacuum device
- Orgasm is possible – different than before
- No/↓ ejaculation or (retrograde ejaculation)
- Infertility (low sperm count, no ejaculation)
o For below the T12 injury- no reflex erection
o Women:
o NO natural lubricating fluids use water-soluble lubricant
o alternative methods for sexual satisfaction
o pregnancy not recommended b/c high risk.
[T4 INJ] =
-GOOD UPPER BODY CONTROL
-lower body weakness
-self catherization/independent ADLs
-Standing Frame
-Can stand but not walk
Respiratory
C5-T6- paralysis of abd. and intercostal muscles
- ineffective cough= atelectasis or PNA
Cardiovascular: T6 or above
-↓ influence of sympathetic nervous system→
↓HR(Bradycardia), ortho. hypotension(↓BP)
-cardiac monitoring necessary or atropine to raise HR and IV fluids or vasopressor to raise BP
Urinary
-above T12→ spastic or reflex bladder: so incomplete bladder emptying/ urinary incontinence → UTI
Neurogenic bowel → injuries above T12 will have reflex emptying (defacation incontinence)
poikilothermia & skin breakdowns
a. Ejaculation may not be as predictable as before
b. I should be able to have an erection with stimulation
c. I may urinate with ejaculation but this will not cause infection
Myasthenia Gravis clinical manifestation
When taking care of a patient with MG, which clinical manifestation will the nurse anticipate? SATA
M.G S/SX (CN 3,5,7,9,10)
* Initially facial muscle weakness and ocular muscles -** diplopia and ptosis (CN III)**
Fatigue, weakness
* With overexertion and in the afternoon
* CN V: difficult chewing
* CN IX & X: dysphagia, drooling
CN X- dysarthria, dysphonia, hoarseness, nasal tone
* Intercostal muscle weakness= resp. Failure
* Paresthesia but no sensory loss
* DTR, coordination, mental=normal
a. Dysarthria and hoarseness
b. Diplopia ptosis
c. Fatigue
Multiple Sclerosis N.I.
Which interventions will the nurse include in the plan of care for a client with MS? SATA
MS interventions: MD BSN
(think ur doctors are the MD and nurses are the BSN and they work together to come up w/ interventions for MS)
M = maintain independence in ADL
D = during acute exacerbation
B= bladder/bowel training
S = safety care
N = nutritious/well balanced meals
MS- NI
(MD BSN / NO FISH/ Prevent CRUP/ ↑PP↑FF)
1) MAINTAIN INDEPENDENT ADLs as long as possible
↓ factors that precipitate exacerbations:
[NO COLD FISH ]
* NO Cold (↑ spasticity)
*. NO Fatigue
* NO Infection
* NO Stress
* NO Hot shower (↑Fatigue)
2) During acute exacerbation, prevent complications of immobility: PREVENT [CRUP] -
PREVENT CONTRACTURES: ROM/Stretching
Resp. complications: PNA
UTI- Fever, flank pain, sepsis
Pressure ulcers
3) Bladder and bowel training:
kegel exercise,
crede method (pressing on bladder),
self catheterization**
4) Safety care:
no heating pad, no hot shower
only warm shower -> ↓ spasticity
NO THROW RUGS
- Nutritious/ well balanced meals
(DIET)
* ↑ [PP] ↑[FF]
* ↑protein, potassium, fiber, fluids
* ↓ caffeine intake
(soft diet sitting position)
a. Remove throw rugs
b. Teach the patient how to use Crede method
c. Offer soft diet in a sitting position
EXPRESSIVE APHASIA N.I. (4)
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. Which nursing intervention is appropriate to help the patient communicate? SATA
Expressive aphasia: Pt understands has trouble speaking
- *Give pt time to respond
- Ask pt to speak clearly
- Pt can use pic. Board or write on board
-Ask close ended (Y/N) questions
-encourage to repeat alphabet d/t single words being used.
- assessing for pain: facial expression, V/S changes, diaphoresis, clenching teeth
Receptive Aphasia: opposite pt has trouble understanding nurse, but can speak although you can’t understand it. Interventions: use gestures, use short sentences, repeat yourself if need and see if patient can read. Use communication board as well.
a. The nurse should allow time for the patient to respond
b. Ask questions that can be answered in yes or no
c. Allow patient to use gesture and a picture board
ALZHEIMERS MANAGEMENT
A patient with Alzheimer’s disease who is being admitted to a LTC has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? SATA
“NEAR NURSE STATION”
-NO L E R R D S-
NO Locked Doors, But locked Facility
No Extention Cords
No Restraints
No Rugs (throw)
NO Driving
No Side Rails
Increase ADLs IN AM (DAY)
Bright colored clothes
a. Place the patient in a room closest to the nursing station
b. Keep the facility doors closed at all times
SHOCK N.I.
The nurse caring for hospitalized clients includes which action on their care plans to reduce the possibility of the clients developing shock? SATA
a. Using technique during procedures
b. Performing proper hand hygiene
c. Removing invasive lines ASAP
d. Assessing and identifying clients at risk
- Collaborative care for all types of SHOCK
- Early identification & treatment of underlying cause
- Support respiratory system
▪ Ensure airway
▪ Maximize oxygen delivery - Protect organs from dysfunction
- Multisystem supportive care
- Fluid replacement/resuscitation ~ septic/hypovolemic/anaphylactic
▪ Crystalloid solutions
▪ Colloid solutions (expand intravascular volume by exerting oncotic pressure
a. Using technique during procedures
b. Performing proper hand hygiene
c. Removing invasive lines ASAP
d. Assessing and identifying clients at risk
The nurse is participating in an educational program concerning nuclear disasters. Which factors determines a victims level of exposure to radiation? SATA
a. Shielding the victim from the nuclear source
b. Length of exposure
c. Distance of the victim from the nuclear source
a. SHIELDING the victim from the nuclear source
b. Length (TIME) of exposure
c. DISTANCE of the victim from the nuclear source
Exposure to radiation is affected by time, distance and shielding
A client presents to the ED after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which intervention will the nurse plan to do? SATA
a. Begin continuous cardiac monitoring
b. Administer warm IV fluids
a. Begin continuous cardiac monitoring
b. Administer warm IV fluids
An emergency dept. nurse moves to a new city where heat-related illness is common. Which action should the nurse anticipate as at high risk for heat related illness? SATA
a. Homeless
b. Older adults
c. Illicit drug users
o At risk:
o Older adults
o Very young ppl
o Ill/debilitated ppl
o Ppl who work outside (construction, agriculture)
o Illicit drug users
o Homeless
o Outdoor athletes
a. Homeless
b. Older adults
c. Illicit drug users
A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? SATA
a. Client on the medical unit for wound care
b. Client who had ORIF of femur fracture 3 days ago
a. Client on the medical unit for wound care
b. Client who had ORIF of femur fracture 3 days ago
The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at higher risk for shock. For what factors would the nurse assess? SATA
a. Diminished immune response
b. Decreased thirst response
c. Altered mobility/immobility
d. Malnutrition
a. Diminished immune response
b. Decreased thirst response
c. Altered mobility/immobility
d. Malnutrition
A wing of a hospital is on fire. Which actions by the nurse promote safe evacuation of clients? SATA
a. Direct ambulatory pts on where to go to be safe
b. Drag clients on blankets if non ambulatory
c. Manually ventilate clients on vents
d. Use ambulatory clients to push pts on W/C
a. Direct ambulatory pts on where to go to be safe
b. Drag clients on blankets if non ambulatory
c. Manually ventilate clients on vents
d. Use ambulatory clients to push pts on W/C
Which of the following statement is true about biological warfare agents? SATA
a. Surgical mask and gown are required when taking care of a patient with pneumonic plague
b. Small pox patient is placed in a negative pressure room
c. Botulism can spread through improperly canned food
d. Inhaled anthrax can be fatal if untreated
Standard= Anthrax, Tularemia (rabbit fever), + botulism
[gloves + handwashing]
Plaque= DROPLET
*For Pneumonic Plague- full face respirator; Patient wears mask when being transported.
Droplet- gown glove, mask, goggle
Viral hemorrhagic fever (Ebola) (DROPLET+CONTACT)
Contact- gown and glove
Droplet- gown glove, mask, goggle
Smallpox= Airborne and contact
Contact- gown and glove
Airborne- N95 / respirator
Contact- gown and glove
Droplet- gown glove, mask, goggle
wears mask when being transferred.
Airborne- N95 / respirator
HYPOTHERMIA AND FROSTBRITE PREVENTION
A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? SATA
a. Wear synthetic clothing instead of cotton to keep your skin dry
b. Know your physical limits. Come in out of the cold when limits are reached
c. Wear sunglasses to protect skin and eyes from harmful rays.
FROSTBRITE PREVENTION:
▪ Management
o Controlled but rapid rewarming 37 to 40 C (104 F) circulating bath for 30-40 min intervals
Treatment is repeated until circulation is effectively restored
o Do not massage or handle
If feet are involved do not walk
▪ Avoid using dry heat
a. Wear synthetic clothing instead of cotton to keep your skin dry
b. Know your physical limits. Come in out of the cold when limits are reached
c. Wear sunglasses to protect skin and eyes from harmful rays.
What do you do if patient has BLOOD SUGAR OF 62?
15/15 rule- HYPOGLYCEMIA MNGMNT.
- 15 g of fast-acting, concentrated carbohydrate
- * Three or four glucose tablets/ 8 oz of low-fat milk * 4 oz of juice or regular soda (not diet soda) =1/2 cup * 6 saltine crackers/ 3 graham crackers
-
* Retest blood glucose in 15 minutes; retreat if < 70 mg/dL; (repeat 2 times if <70)
- If glucose remains low after 2 to 3 times; call HCP or EMS
- Treat with 25–50 mL 50% dextrose IV or glucagon 1 mg subQ or IM
➢ Provide a snack with protein and carbohydrate unless the patient plans to eat a meal within 30 to 60 minutes
● If the patient cannot swallow or is unconscious: - Subcutaneous or intramuscular glucagon 1 mg
- May repeat in 10 min if pt remains unconscious * If regain consciousness, provide a snack with protein and carbohydrate unless the patient plans to eat a meal within 30 to 60 minutes
