Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Medical Surgical Nursing Lecture > Final Exam > Flashcards

Final Exam Flashcards

1
Q

What is anemia?

A

a deficiency in the

  1. number of RBCs
  2. quantity of Hgb
  3. vol of packed RBCs (Hct)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are 3 causes of anemia?

A
  1. blood loss
  2. impaired production of RBCs
  3. Increased destruction of RBCs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the critical number of severe anemia?

A

Hgb less than 6 g/dl

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the nursing intervention when Hgb is less than 6 g/dl?

A

blood transfusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are some clinical manifestations for anemia?

A
  1. pallor
  2. jaundice
  3. increase in CO
  4. fatigue
  5. sensitivity to cold
  6. irritability
  7. pain
  8. hypoxia with sickle-cell crisis
    9.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What type pf anemia is caused by the presence of large RBCs?

A

Megaloblastic anemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

If Sam has Megaloblastic anemia what are 2 factors he may be deficient?

A
  1. Vitamin B12 (Cobalamin)

2. Folic Acid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is necessary for Vitamin B12 (Cobalamin) to be absorbed by the body?

A

Intrinsic factor (IF).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the main cause of Cobalamin Deficiency/

A

pernicious anemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is pernicious anemia?

A

caused by the lack of IF. The gastric mucosa is not secreting IF because of either gastric mucosa atrophy or autoimmune destruction of parietal cells.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are other causes of pernicious anemia?

A
  1. Gastrectomy
  2. Nutritional deficiencies
  3. Chronic alcoholism
  4. Hereditary enzymatic defects
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Without IF what is the result of B12?

A

it cannot be absorbed by the body. pernicious anemia leads to B12 deficiency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Folic Acid Deficiency

A

a cause of megaloblastic anemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is Folic acid required for?

A

DNA synthesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Define pancytopenia

A

decrease in all blood cell types (RBCs, WBCs, and platelets)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What type of anemia is a result of pancytopenia?

A

aplastic anemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What part of the body does aplastic anemia affect most?

A

bone marrow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

If Sam has aplastic anemia, what are 2 methods to treat his condition?

A
  1. blood transfusions

2. Bone marrow Transplant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Describe hemolytic anemia

A

a condition caused by the destruction or hemolysis of RBCs at a rate that exceeds production

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the results of hemolytic anemia?

A

jaundice
enlarged spleen and liver
renal tubules obstruction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Describe Sickle Cell Disease (SCD)

A

Presence of an abnormal form of Hgb in the erythrocyte

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What happens to red blood itself when a person has SCD?

A

it become sickle shaped, stiffens, and elongates

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What are those with SCD prone to develop?

A

Infections

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What are the nursing interventions for someone with SCD?

A
  1. Pain management
  2. give O2
  3. Increase hydration (IV and PO)
  4. antibiotics
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What is a pt. teaching for someone with SCD?

A

avoid high altitudes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What medication is given with SCD? Another form of tx?

A

hydroxyurea

blood transfusions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What is the goal of hydroxyurea?

A

antisickling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

How do you administer hydroxyurea?

A
  1. wear gloves, so don’t touch with bare hands

2. give PO

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What are some nursing interventions for hemolytic anemia?

A
  1. blood transfusions
  2. bone marrow transplant
  3. splenectomy
  4. maintain renal fxn
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is my nursing action prior to administering a blood transfusion?

A
  1. Confirm the prescription by the doctor
  2. Dr. discusses with the pt,
  3. Assess lungs
  4. Assess for allergies
  5. Call lab for typing
  6. pick up blood and examine the blood
  7. Make sure pt has a good IV (18-20 GAUGE
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

How do we administer a blood transfusion?

A
  1. Verify the blood with 2nd nurse
  2. Administer the blood within 30 mins of picking up blood
  3. Prime tube with NS ONLY
  4. Start transfusion slowly then increase the rate
  5. Stay with pt for the first 15 mins
  6. Check VS
  7. Educate pt, regarding SI/SX of allergies
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Do some pts require Lasix with their transfusion?

A

yes to stop hypervolemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

If my pt has anemia what are nursing implementations or plan of care?

A
  1. Monitor Hgb and HCT
  2. Close to nurse’s station
  3. Assess for numbness or tingling
  4. Have the pt rest during the day
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

If Hgb is 9.8 what is my nursing teaching?

A
  1. change diet by eating beef and chicken liver
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Who are most risk for developing anemia?

A
  1. iron deficiency
  2. bleeding
  3. chronic disease/ inflammation
  4. renal insufficiency
  5. hematologic cancer
  6. Inadequate dietary intake or malabsorption
  7. bone marrow suppresion
  8. age
    (for some pts. some anemias are idiopathic)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What is the major cause of anemia in adults?

A

blood loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

If Sara has Iron deficiency what is your pt. teaching?

A

change diet by eating

  1. dark green leafy veggies
  2. liver
  3. eggs
  4. dried fruits
  5. legumes
  6. cereal
  7. potatoes
  8. whole-grain and enriched breads
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What are some pt. teaching for a pt who is taking an iron supplement?

A
  1. do not chew the tablet

2. stool will become dark/black and tarry

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What are some nursing diagnosis for a pt with anemia?

A
  1. altered tissue perfusion
    2 fatigue
  2. imbalanced nutrition
  3. ineffective health management
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

What is thromboxane?

A

mediator for platelets

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

What is the MOA for thromboxane?

A

promotes blood clotting by vasoconstriction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

What type of half-life does thromboxane have?.

A

short half-life

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What is cardiac catheterization?

A

it provides info about CAD, coronary spasm, and congenital and valvular heart disease, and ventricular fxn.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

What is the highest priority for a pt post. OP after a cardiac catheterization?

A
  • *1. Assess the site for bleeding and thrombosis**
    2. Assess VS
    3. Cardiac monitoring
    4. Monitor urine output and administer IV fluids for hydration
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

What is CAD?

A

A type of blood vessel disorder that is included in the general category of atherosclerosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

What are the nonmodifiable RFs for CAD?

A
  1. Age
  2. gender
  3. ethnicity
  4. fam history
  5. genetics
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

What are the modifiable RFS for CAD?

A
  1. Elevated serum lipids
  2. elevated BP
  3. tobacco use
  4. sedentary lifestyle
  5. obesity
  6. diabetes
  7. metabolic syndrome
  8. stress
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

What are the risk factors of CAD related to smoking?

A
  1. Increases risk by 2-6x
  2. the number of cigarettes smoked/day
  3. smoking also increases LDL levels promoting atherosclerosis
  4. vasoconstriction due to the increase of catecholamine release
  5. CO has a higher binding to RBCs
  6. second-hand smoke
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

If a pt. is taking hydrochlorothiazide, what is my teaching?

A

change positions slowly because it is a diuretic which causes orthostatic hypotension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

For pts at risk for CAD what are some pt teachings?

A
  1. increase physical activity
  2. weight loss
  3. change diet ( decrease Na+)
  4. medications
  5. consistent doctor visits
  6. Decrease alcohol consumption
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

What is HTN?

A

Persistent SBP OF 140 mm HG or higher and DBP of 90 mm HG or higher

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Which pop has higher risk of developing HTN?

A

African Americans, but Mexican Americans are least likely to receive tx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

What is the name of the diet most recommended for pts. with HTN?

A

DASH eating plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

What is the DASH eating plan?

A

emphasizes fruits, vegetables, fat-free or low-fat milk and milk products. Contains less red meat and Na+, fewer sweets, added sugars, and sugar-containing beverages

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

What is the benefit of the DASH eating plan?

A

significantly lowers BP and lowers LDL levels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

What are some pt. teachings for a pt. with HTN?

A
  1. Instruct client to report SI/SX of electrolyte imbalances
  2. Encourage the pt. to schedule regular dr. appt
  3. Teach the client or SO how to monitor BP at home
  4. Ensure the pt. has the resources to pay for meds
  5. Consult a dietitian
  6. smoking cessation
  7. stress reduction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

What are some meds for HTN?

A
  1. beta blockers
  2. ACE inhibitors
  3. Ca2+ channel blockers
  4. Diuretics
  5. ARBS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

What electrolyte imbalance does ACE inhibitors cause?

A

hyperkalemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

What electrolytes should HTN consume?

A

Mg2+ and CA2+

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

What is a stroke?

A

a disruption in the cerebral bloods flow secondary to ischemia, hemorrhage, brain attack, or embolism?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

What are the 2 types of strokes?

A
  1. ischemia- most common

2. hemorrhage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Which disorders increase a pt. risk for a stroke?

A
  1. HTN
  2. DM
  3. Smoking
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

What is the mnemonic for a stroke?

A 
Balance
Eyes 
Facial drop 
Arm 
Speech 
Time
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

How do you assess for a stroke in a stable pt?

A
  1. description of current illness with attention to initial Sx
  2. history of similar Sx
  3. current meds
  4. history of RFs and other illness such as HTN
  5. Fam history of stroke aneurysm, or CVD
  6. LOC
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Describe a hemorrhagic stroke

A

result from a bleeding into the brain tissue itself or into the subarachnoid space or ventricles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

What is the most common cause of hemorrhagic stroke?

A

HTN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Describe an ischemic stroke

A

results from inadequate blood flow to the brain from partial or complete occlusion of an artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

What is TPA?

A

tissue plasminogen activator

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

What is the fxn of TPA?

A

dissolves blood clots

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

If a pt has an ischemic stroke what medication is typically given? Criteria?

A

TPA

  1. only only for ischemic strokes
  2. stroke must be timed
  3. administered 3-4.5 hours from onset of SI/SX of ischemic stroke
  4. administered based on weight
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

If pt has a stroke by themselves are they a candidate for TPA?

A

NO!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

What is the greatest concern for a stroke pt?

A

aspiration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

Before a stroke pt is given food what is nursing action?

A

assess gag reflex so keep pt NPO until this is done

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

What is the UAP role in caring for a stroke pt?

A
  1. obtain VS
  2. Measure and record I&O
  3. Reposition pt
  4. ROM
  5. Place equipment needed for seizure precautions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

What is the major cause of CAD?

A

Atherosclerosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

What is a seizure?

A

uncontrolled electrical discharge of neurons in brain, interrupting normal fxn

78
Q

T/F. Seizures resulting form metabolic disturbances are considered epilepsy if seizures cease when underlying condition is treated

A

False. Those are not considered epilepsy

79
Q

Define epilepsy

A

condition in which a person has spontaneously recurring seizures caused by underlying chronic condition

80
Q

What are the 2 major classes of seizures? Define each

A

generalized- involves the whole brain and loss of consciousness
partial- only involves one hemisphere of the brain, conscious

81
Q

What are the 6 types of generalized seizures?

A
  1. absence
  2. tonic-clonic
  3. myoclonic
  4. atonic
  5. tonic
  6. clonic
82
Q

Describe an absence seizure

A

commonly occurs in children, resembles “daydreaming” or spacing out. If it is complex the blank star is accompanied by some type of movement (blinking, chewing, or hand gestures)

83
Q

Describe tonic seizures

A

a sudden onset of increased tone in the extensor movement or a loss of muscle tone and begins suddenly with the person falling to the ground backwards.

  • person remains conscious
  • require helmets
84
Q

Describe clonic seizures

A

loss of consciousness and loss of muscle tone followed by rhythmic jerking

85
Q

Describe myoclonic seizures

A

twitch of short muscles

86
Q

Describe tonic-clonic seizure

A

characterized by losing consciousness and falling to the ground if the pt is upright, followed by stiffening of the body for 10-20 seconds and subsequent jerking of the extremities for another 30-40 seconds

87
Q

What are 2 types of partial seizures?

A
  1. simple partial

2. complex seizures

88
Q

Describe a simple partial seizure

A

pt remains conscious and alert but experience unusual feelings or sensations that can take various forms

89
Q

Describe a complex partial seizure

A

loss of consciousness or an alternation in their awareness producing a dreamlike experience

90
Q

If a pt has a tonic-clonic seizure in a chair what is your nursing intervention?

A

safely place the patient on the floor

91
Q

If a pt has history of seizure and has a seizure, what will you ask the pt?

A

ask about meds they are taking

92
Q

If a pt is on anti-seizure med what is your pt teaching?

A
  1. do not stop abruptly

2. take as prescribed

93
Q

What is status epilepticus?

A

a state of continuous seizure activity or a condition in which seizures recur in rapid succession without return to consciousness between seizures. Last longer than 5 minutes

94
Q

What should be in the room for a pt with status epilepticus?

A
  1. Oxygen mask or cannula
  2. IV access
  3. Pulse Ox
  4. suctioning
95
Q

What 2 types of meds can a pt with seizures be prescribed?

A
  1. Tegretol (carbamzepine)

2. Dilantin (phenotyin)

96
Q

What is the therapeutic class of Tegretol?

A

anticonvulsant

97
Q

If Sara says she has seen the eye doctor a few times in the last 6 months, which med should you ask her if she is taking?

98
Q

What is serious side effect of Tegretol?

99
Q

If the doctor prescribes a glaucoma pt on Tegretol, what is your nursing action?

A

notify the physician and recommend a different med

100
Q

What type of therapeutic class is Dilantin?

A

anticonvulsant

101
Q

MOA of Dilantin?

A

prevent seizures

102
Q

What are some pt teachings for taking Dilantin?

A
  1. check Dilantin levels regularly because pt can develop Dilantin toxicity
  2. Brush teeth regularly and keep up with hygiene because it can gingival overgrowth
  3. the color of the med may be orange, BUT it DOES NOT cause the urine to be orange
103
Q

How do you assess for each type of partial seizure?

A

Simple: aura, focal sensory, cognitive or motor function
Complex: altered consciousness with inappropriate behaviors

104
Q

What is the common diagnostic test for seizures?

105
Q

What do you do when a pt has a seizure?

A
  1. lay the pt flat
  2. turn them to the side-lying position
  3. place padding on side rails
  4. suction
  5. provide oxygen (mask works best)
  6. document the time of seizure
106
Q

What do you do when the pt has stopped seizing?

A
  1. maintain the pt side-lying
  2. assess VS
  3. Assess for injuries
  4. Perform neurological checks
  5. Allow the client to rest by placing a “Do not Disturb” sign
  6. Determine the trigger and ask if they had an aura
107
Q

How do you verify a pt is having a seizure?

A

check the O2 sat

108
Q

What is a thoracentesis?

A

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

109
Q

What are the invasive respiratory tests?

A
  1. ABGs
  2. bronchoscopy
  3. thoracentesis
  4. lung biopsy
110
Q

What are the noninvasive respiratory tests?

A
  1. pulse ox
  2. sputum cultures
  3. nasal cannula, masks
  4. pulmonary function test
111
Q

When reading a PPD, do the reddened, flat area measured?

A

no, they are not measured

112
Q

If a diameter of a PPD is greater or equal to 5 is negative or positive?

113
Q

What is respiratory failure?

A

when or both gas-exchanging fxns are inadequate (insufficient O2 transferred to the blood or inadequate CO2 is removed from the lungs

114
Q

What is the pt teaching for someone receiving a thoracentesis?

A

pt should position themselves to sitting on the edge of the bed over the side table

115
Q

Can a pt eat or drink after a thoracentesis?

A

no, they will be kept NPO before a swallow test is given

116
Q

What is the nursing plan of care for someone with respiratory failure?

A
  1. Maintain a patent airway and monitory respiratory status
  2. Mechanical ventilation with positive pressure
  3. Oxygenate before suctioning
  4. Assess and document sputum
  5. Assess lung sounds
  6. Monitor for pneumothorax
  7. Obtain ABGs
  8. Maintain continuous ECG monitoring
  9. VS
  10. Mobilization of secretions
    - effective couging
    - hydration
    - ambulation
    - chest physiotherapy
  11. bronchodilators
  12. Nutrition support
117
Q

What type of people are at risk for developing TB?

A
  1. immunosuppressed
  2. low SES and the homeless
  3. Poorly ventilated environment s
  4. Adv. age
  5. Traveling outside the US
  6. Immigration
  7. Health care occupation
118
Q

So if Ken gets his PPD read and the diameter is greater than 5mm, does he have active TB?

A

no, individuals who have latent TB can have a positive rxn

119
Q

If Ken goes in for a Quantiferon Gold test and it is positive, he is admitted to the hospital what type of isolation precaution is he placed?

120
Q

What are the requirements for an airborne contact precaution?

A
  1. negative air pressure
  2. close doors and windows unless, exiting
  3. no one allowed under the age of 14
  4. nurse or dr. must wear N95
121
Q

If Ken is being transferred to radiology and he has TB, what should he wear?

A

a regular face mask

122
Q

What is pneumonia?

A

acute infection of thee lung parenchyma

123
Q

What are 3 ways pneumonia can develop?

A
  1. aspiration
  2. inhalation
  3. hematogenous
124
Q

What are diagnostic test for pneumonia?

A
  1. chest x-ray

2. sputum culture

125
Q

What are pt. teachings for pneumonia?

A
  1. Adequate sleep, fluids and regular exercise
  2. Educate patient on the importance of continuing their treatment for pneumonia
  3. Encourage rest periods
  4. Encourage patient to maintain hand hygiene
  5. Encourage patient to
  6. avoid crowded areas
  7. Encourage immunizations
  8. Promote smoking cessation
126
Q

What are some nursing interventions for pneumonia?

A
  1. Position pt in high-fowlers
  2. encourage coughing or suction to remove secretions
  3. administer breathing treatments and meds
  4. give O2
  5. monitor for skin breakdown around nose
  6. use incentive spirometer
  7. Increase fluid intake (2-3L/day)
  8. Rest periods for those with dyspnea
127
Q

What is the CO2, pH, and HCO3- values for metabolic alkalosis?

A

pH greater than 7.45
and HCO3- greater than 26
CO2 level is normal

128
Q

What are some causes metabolic alkalosis?

A
  1. vomiting
  2. gastic suction
  3. ingestion of baking powder
129
Q

What is metabolic alkalosis?

A

the lung’s compensatory mechanism, the respiratory rate decreases in order to increase plasma CO2.

130
Q

SI/SX of metabolic acidosis

A
  1. lethargy
  2. confusion
  3. dizziness
  4. headache
  5. coma
  6. hypotension
  7. dysrhythmias
  8. cold, clammy skin
  9. N/V
  10. Diarrhea
  11. abdominal pain
  12. muscle weakness
  13. deep, rapid respirations
131
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
132
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
133
Q

How often should trache care be performed?

A

qshift (minimum) or PRN

134
Q

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

A

stop and give O2

135
Q

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

A

on the way out

136
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
137
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

138
Q

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

139
Q

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

A

trache tube of equal or lesser size for emergency reinsertion

140
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

141
Q

What can an RN nurse delegate to Carlos at Silverlake for the pt in 608 who has seizures?

A
  1. Administer oral antiseizure meds as scheduled
  2. In the ambulatory and home setting, monitor patient adherence to meds and lifestyle changes and report problems to the RN
142
Q

How do you assess a stroke pt?

A
  1. Ask questions about history
    - previous seizures
    - birth defects or injuries
    - alcoholism
    - metabolic disorders
  2. Meds taking
  3. electrolyte imbalances
  4. weakness
  5. paralysis
143
Q

What is the meaning of the P wave on EKG?

A

ATRIAL Depoloarization, SA node impusle to the AV node. The heart is contracting

144
Q

SI/SX of hypovolemia

A
  1. tachycardia
  2. hypotension
  3. weakness
  4. acute weight loss
  5. thready pulse
  6. tachypnea
  7. dizziness
  8. syncope
  9. confusion
  10. fatigue
  11. dry mucosa
  12. oliguria
  13. N/V
  14. poor skin turgor= tenting
145
Q

What are the nursing implementations for informed consent preOP?

A
  1. ensure that the provider gave the client the correct information
  2. ensure that the client understood the info and is competent to give informed consent
  3. Notify the provider if the client has more questions
  4. Have the client sign the consent form
  5. Document questions the client has
  6. Provide a trained medical interpreter if necessary
146
Q

What are some items on the preOP checklist for the RN?

A
  1. History
  2. allergies
  3. labs
  4. code status
  5. meds
  6. HT and WT
  7. NPO (when was the last time you ate or drank anything)
  8. smoking or ETHOL consumption
  9. Foley catheter places
  10. blood bracelet
  11. correct ID band
  12. Body piercings removed
  13. informed consent is signed
147
Q

What is a “timeout” in a procedure?

A

it is initiated by the circulating nurse. everyone steps away from the patient to verify it the right pt, correct procedure and if amputating verify the right extremity is amputated

148
Q

What is the purpose of a timeout?

A

the purpose is to ensure the procedure is carried out on the correct person, side, and procedure preventing legal issues

149
Q

How do you prevent pelvic relaxation disorder?

150
Q

When using crutches how should a pt stand up?

A

hold both crutches on the unaffected side and use the other side to push up

151
Q

How many inches to the side and to the front should a pt place the crutches?

A

about 6 inches, crutch stance

152
Q

For a pt who can tolerate bearing weight on both legs should use what kind of gait with crutches?

A

4- point, walk in opposition, but place the crutch first

153
Q

What is the 3-pt gait with crutches?

A

it used for pts who can not bear weight on one leg. move crutches forward and then move the unaffected leg forward

154
Q

What is the 2-point gait with crutches?

A

for pts who can manage partial weight on both legs, but still need assistance

155
Q

Define thrombophlebitits

A

it is a blood clot that causes inflammation and pain in the veins

156
Q

Who are at risk to develop thrombophlebitis?

A
  1. Hip surgery
  2. total knee-replacement
  3. open prostate surgery
  4. HF
  5. Immobility
  6. preggerz
  7. oral contraceptives
  8. active cancer
157
Q

What are some pt teachings for a pt. with thrombophlebitis?

A
  1. encourage pt to rest
  2. administer intermittent or warm or moist compressors
  3. Do not massage
  4. Provide compression or antiembolism stockings
  5. ROM
158
Q

What is an ostomy?

A

a surgically created opening on the abdomen that allows the discharge of body waste

159
Q

How do you provide ostomy care?

A
  1. assess the site for skin irritation
  2. apply skin barriers and creams to the skin and wait until it is dry before applying a new appliance
  3. Evaluate the stoma output
  4. empty the ostomy bag when it 1/4 to 1/2 full of drainage
160
Q

What are some difference in the elderly you will observe in a urinary assessment?

A
  1. serum creatinine increases
  2. BUN increases
  3. decrease of creatinine clearance
  4. alt. in drug excretion
  5. nocturia
  6. less concentrated urine
  7. hesistancy
  8. frequency
  9. urgency
  10. dribbling
  11. straining to urinate
161
Q

If Laura is having a severe allergic rxn to coffee, what is my priority nursing acting?

162
Q

What route of medication is the fastest?

163
Q

What route of medication is the second fastest? MOA?

A

SL, it is absorbed by the blood vessels in the mouth

164
Q

After picking up blood from the blood bank, how long do I have to administer the blood to my pt?

165
Q

What are some nursing interventions for the postOP DVT prevention?

A
  1. ambulation
  2. anticoagulants
  3. stockings
  4. SED pumps
  5. elevation
  6. thrombolytics (tpa)
166
Q

If Ryan is post from an abdominal surgery, what findings indicate DVT?

A

client can be asymptomatic
1. calf or groin pain
2 tenderness
3. sudden onset of edema of the extremity
4. changes in circumference of right and left calf and thigh over time
5. localized edema over the affected area
6. SOB and chest pain indicate that the embolus has moved to the lungs

167
Q

If Carl has a tibial fracture that requires a cast, what will be your nursing assessment?

A
  1. perform a neurovascular assessment (min q2h for first 48 hrs)
  2. check dr’s orders
  3. keep the cast dry
  4. one finder between skin and cast
  5. elevate cast above heart level for the first 24 to 48 hours
168
Q

What is TPN?

A

A hypertonic IV bolus solution that is given to correct or prevent nutritional deficiencies and minimize the adverse effects of malnourishment

169
Q

If Penelope is receiving a TPN and it ruins out what what is my nursing action?

A

i will keep dextrose 10% near the bedside to administer while the pharmacy prepares the TPN solution

170
Q

What are the lab findings of stage III pressure ulcer?

A

low albumin levels

171
Q

What type of technique refers to the use of precise practices to eliminate all micro-organisms from an object or area and prevent contamination?

A

surgical asepsis

172
Q

What type of technique refers to the use of precise practices to reduce the number, growth, and spread of micro-organisms?

A

medical asepsis

173
Q

What is another term for a clean technique?

A

medical asepsis

174
Q

What is another term for a sterile technique?

A

surgical asepsis

175
Q

What is the recommended management for a tibial fracture?

A

closed reduction followed by immobilization in a long leg cast

176
Q

What is a hiatal hernia?

A

herniation of a portion of the stomach into the esophagus

177
Q

What are some contributing factors for hiatal hernia?

A
  1. weakening of muscles in diaphragm
  2. increased intra abdominal pressure
  3. obesity
  4. pregnancy
  5. heavy lifting
  6. trauma
  7. poor nutrition
  8. forced recumbent position
  9. congenital weakness
178
Q

What do you teach tour pt regarding ostomy management?

A

educate the pt on dietary changes

  1. avoid foods that can cause odor
    - fish
    - asparagus
    - dark green leafy greens
  2. avoid foods that cause gas
    - dark green leafy veggies
    - dairy products
  3. avoid high fiber diet for the first 2 months
  4. filters or breath mints can be placed in the pouch to prevent smells
  5. allow the pt. to express their feelings about the ostomy
179
Q

What are some safety precautions for a seizure pt?

A
  1. maintain an airway
  2. provide O2
  3. establish IV access
  4. perform ECG monitoring
  5. monitor ABG results
  6. O2 sat
180
Q

What is PT?

A

prothrombin time, how long it take blood to clot

181
Q

What is the normal range of PT?

A

11-12.5 seconds

182
Q

What is PTT?

A

partial thromboplastin time, the body’s ability to clot

183
Q

What is the normal range of PTT?

A

30-40 seconds

184
Q

What is INR?

A

international normalized ratio, measures the mean of PT o provide a universally recognized value

185
Q

What is the normal range of INR?

186
Q

What are some pt teachings for iron deficient pt about ferrous sulfate?

A
  1. Black tarry stools is normal when on therapy
  2. Oral undiluted dose may stain teeth
  3. East 30 minutes before meal because jejunum most acidic → if GI irritation take with food
  4. Vitamin C (ascorbic acid) enhances iron absorbtion
187
Q

What can you delegate to an LVN?

A

lvn can not teach, assess, or evaluate

188
Q

What type of effect does Coumadin have on PT and INR?

A

coumadin increases both levels

189
Q

What type of effect does heparin have on APTT?

A

Increases both levels

190
Q

So if my pt has INR and PT, what is my nursing action if they are receiving Warfarin?

A

hold the med

Medical Surgical Nursing Lecture (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions