Final Exam (class review) Flashcards
what does SIRS stand for?
systemic inflammatory response syndrome
what are 4 parts of the 1 hr sepsis bundle?
-drawing lactate and blood cultures
- administer broad spectrum ABX
- administering IV fluids
- giving vasopressors (if needed)
what may an increases lactate and increased bands indicate?
what are 2 other levels that may be effected?
sepsis
- abnormal WBC and rising procalcitonin (elevates in response to inflammatory cytokines)
what may redness around a surgical site indicate?
infection
what do pain, serous drainage and mild edema indicate around a surgical site?
normal findings of a surgical wound
what should the nurse ensure to do first before giving antibiotics to a patient with sepsis?
ensure blood cultures were drawn first
what does a urine output of 15 mL/hr indicate?
organ dysfunction (poor perfusion)
what is the MOST effective mechanism of prevention for prevention of infection spread?
hand hygiene
what are some risk factors for sepsis?
- immunocompromised
- central lines
-malnutrition - invasive procedures
- older than 80 yr
- history of DM; cancer
what is a major modifiable risk factor for cardiovascular disease?
smoking
List 4 nonmodifiable risk factors for cardiovascular disease?
age, gender, ethnic origin and family hx
what does the P wave represent on an EKG?
atrial depolarization
which part of an EKG represents ventricular depolarization and atrial repolarization?
QRS wave
what does the T wave represent?
ventricular repolarization
what is a normal cholesterol level?
<200 mg/dL
Describe the correct sequence of electrical conduction throughout the heart.
- SA node
- AV node
- bundle of HIS
- purkinje fibers
what is a venous duplex ultrasound used to diagnose?
DVT
what are the parameters for monitoring PTT with IV heparin?
- daily
- 6 hr after initiation
- 6 hr after any dose change
what is protamine sulfate the antidote for?
heparin
what is the antidote for warfarin?
vitamin K
what are some findings with DVT?
- sudden onset of pain
- warmth
- edema
how can DVT be prevented?
- early ambulation
- leg exercises
- adequate hydration
- compression socks
- SCDs
- venous plexus foot pump
- anticoagulants
what does an elevated troponin indicate?
cardiac cell damage
what are 3 treatment interventions for symptomatic bradycardia?
IV atropine, IV fluids, and oxygen
why should beta blockers not be given with bradycardia?
they cause bradycardia
what is a benefit of direct oral anticoagulants?
list some examples of these meds
no need for frequent lab monitoring
- dabigatran, rivaroxaban, apixaban, and edoxaban
what action should be taken for a client who has recently received benzocaine prior to a bronch and has developed persistent cyanosis?
notify the rapid response team (methemoglobinemia)
What medication can the nurse prepare for administration of if a patient has developed methemoglobinemia after receiving benzocaine?
IV methylene blue
how does a tension pneumothorax lead to decrease cardiac output?
- air collects putting pressure on blood vessels, limiting blood return causing decreased filling of the heart
what is gold standard for chest tube placement?
chest x- ray
what should be assessed first in a person with chest trauma?
chest expansion
what is a finding that should require immediate follow-up following a lung biopsy?
absent breath sounds (may indicate pneumothorax)
what is expected for the water seal chamber of a chest tube drainage system?
tidaling (rise and fall of water - 2-4 in)
which chamber is expected to have intermittent bubbling?
water seal chamber
what type of chest wall movement is expected with flail chest?
paradoxical movement
what causes flail chest?
fractures of multiple ribs causing instability
- during expiration thorax bulges out
why may hyperparathyroidism cause fractures?
elevation in PTH increases release of calcium and phosphate from bone into the blood, making the bone less dense
what does heat intolerance indicate in a patient who has graves disease?
an exacerbation
what happens to TSH with hypothyroidism?
elevation
what would happen to calcium levels with parathyroid hormone deficiency?
decreased serum calcium
what does PTH do to bone resorption?
increases it to increase serum calcium
what are expected findings of thyroid storm?
heat intolerance, tachycardia, sweating, insomnia
what condition is thyrotoxicosis common in?
graves disease
what may cause thyroid storm?
trauma, infection, palpation of goiter, overdose of levothyroxine
why should the nurse inspect behind a client’s neck after a thyroidectomy?
blood is dependant and hemorrhage is a potential complication
what signs may be seen with hypocalcemia?
trousseaus and chvosteks
what severe complication of hypothyroidism may cause bradycardia, hypotension, and respiratory failure?
myxedema coma
what is the priority to monitor post thyroidectomy?
airway patency
what are some ways that airway may be impaired following a thyroidectomy?
- nerve damage
- hypocalcemia induced tetany
- and edema
what should the nurse do if they here stridor after a client has had a thyroidectomy?
contact provider and prepare for intubation
what should the nurse encourage a patient with hyperthyroidism to do to prevent thyroid crisis?
encourage them to rest
- keep environment quit/reduce stimuli
- dim lights
- limit visitors
- provide cool blankets
what are some client education points the nurse should tell the diabetic patient regarding sick day management?
- take insulin as prescribed
- check glucose more often than normal (2-4 hr)
- need to eat food (prevent hypoglycemia)
what is a good intervention to implement for a client who is alert and oriented with a blood glucose of 60?
administer 15 g of oral carbohydrates
when should IM glucagon be utilized?
if pt is unconscious/unable to swallow and does NOT have an IV
what are 3 s/s of type 1 DM?
increased thirst, hunger, and urination
what are some s/s of type 2 DM?
frequently no s/s, but may have thirst, fatigue and blurred vision
what is a symptom of hyperglycemia in a patient with type 1 DM?
confusion
-polyuria, hunger, tachypnea
what are 2 potential side effects a client may experience with IV insulin that is being given for treatment of DKA?
hypokalemia
hypoglycemia
how can insulin administration potentially cause hypokalemia?
insulin forces potassium from the blood stream and into the cells
what is the onset of regular insulin (short acting)?
30 mins - 1 hr
when should a patient who has been given regular insulin eat?
about 30 mins after administration
what should we teach type 2 DM pts about exercise?
exercise can cause hypoglycemia
what angle should subQ insulin be given?
90 degrees (in anterior thigh, upper arm, buttocks and abdomen)
what foot care instructions should be given to diabetic patients?
- inspect feet daily (in between toes)
- wash feet daily w/lukewarm water
- dry feet thoroughly
- don’t walk barefoot
what are s/s of ureteral renal stones
n/v and severe pain
- pallor and clammy skin
what is a potential cause for pyelonephritis?
reflux of urine from the bladder into the kidney
what is the most common cause of pyelonephritis (what pathogen)?
e. coli
what are expected findings with pyelonephritis?
flank pain, fever, chills, anorexia, and n/v
why may dehydration lead to renal calculi?
causes hypercalcemia which can leaf to stone formation
what should we teach a client with polycystic kidney disease?
check BP and weigh self daily
what increases risk for cystitis within women?
urethral proximity to anus
what dietary restriction should a client with uric acid calculi avoid?
purine foods (organ meats, poultry, fish, gravies, red wines and sardines)
what is an expected finding of the urine following a cystoscopy?
pink-tinged urine is expected
why should pt increase oral fluid intake following a cystoscopy?
to increase urine output and limit dysuria
when should a patient start being NPO before a cystoscopy?
NPO at midnight the night before
what position should be in for a cystoscopy?
lithotomy position
what does an indwelling catheter increase the risk for?
UTI
what are some things a nurse should do directly after a kidney biopsy?
- promote bed rest
- check for flank pain
- monitor for hematuria
- assess biopsy site
what is the purpose of Buck’s traction?
relieve muscle spasms
what is a trademark of fat embolism?
petechiae on chest
- also: hypoxemia, dyspnea, tachypnea, agitation, and headache
what is it called when a broken bone ends jam together?
impacted
what is a comminuted fracture?
when impact fragments bone into several pieces
what is a transverse fracture?
break goes straight across bone shaft
what is an oblique fracture?
occurs at an angle across the bone
how can flexion contracture be prevented following an AKA (above the knee amputation)?
- lie prone every 3hr for 20 - 30 mins
- avoid prolonged sitting
- avoid elevating residual limb for prolonged periods
what interventions should be performed with Buck’s traction?
- ensure weights are free hanging
- monitor peripheral pulses
- examine skin under traction splint
- assess skin temp
what are signs that may indicate compartment syndrome following a surgical repair of an open fracture?
absent pulse
- pain, pallor, paresthesia, paralysis
what medication can be given for phantom limb pain?
IV calcitonin (infusions the week after amputation)
what are the symptoms of carpel tunnel syndrome?
thumb, index, middle and half of ring finger
what does RICE stand for? when is it used?
- rest
- ice
- compression
- elevation
- injuries
who does GERD occur most in?
middle age and older
what are GERD interventions?
- 4-6 small meals/day
- remain upright 1 -2 hr after meals
- avoid spicy, alcohol, caffeine, citrus, carbonation
what 3 med types are used for GERD?
PPIs, H2 blocker, antacids
what are the goals for medication treatment of GERD?
- inhibit gastric acid secretion
- accelerate gastric emptying
- protect mucosa
what are 2 s/s of rolling hernia?
breathlessness and feeling of suffocation after eating
what type of hiatal hernia causes GERD?
sliding
- heartburn, chest pain, dysphagia, and belching
what are 2 risk factors for the development of esophageal tumors?
smoking and obesity
- also: malnutrition, intreated GERD, and excessive alcohol
what is the purpose of NG tube placement after a nissen fundoplication?
to prevent fundoplication wrap from becoming too tight around the esophagus
what causes barretts epithelium?
body substitutes normal squamous cell epithelium of the esophagus with columnar epithelium as a compensation for GERD
what causes many peptic ulcers?
h. pylori
what drug would the nurse expect for a client who has a postoperative ileus?
alvimopan (increases GI motility)
how may a pt with a small bowel obstruction present?
- profuse vomiting
- fluid and electrolyte imbalances
what are some characteristics of a large bowel obstruction?
- slow development
- shape of stool altered
- minimal n/v
what are 3 risks for colorectal cancer?
> 50, hx of crohns, smoker
what are the 3 most common signs of colorectal cancer?
rectal bleeding, anemia, and change in stool consistency/shape
-also: fatigue, ABD fullness, uninentional weight loss
what may cause a false positive for a FOBT?
NSAIDS, vitamin C and red meat
what should be avoided for 48 hr before an FOBT?
aspirin, Vitamin C, and red meat
how long should anti-inflammatory meds be discontinued before an FOBT?
7 days
what is the best means of ensuring removal of colorectal cancer?
surgical removal of tumor with margins free of disease
how should a healthy stoma appear?
reddish pink and moist
when should a colostomy begin to function properly?
2 -3 days
how is stool expected to be with a colostomy in the ascending colon?
liquidy
an ostomy in which part of the colon is expected to be pasty?
transverse colon
what may cause appendicitis initially?
hard pieces of stool
what does ulcerative colitis cause in the colon?
edema and inflammation
which GI condition are fistulas common in?
crohns disease
- fistula = abnormal connection btwn 2 organs
what are 3 s/s of peritonitis?
where is pain likely to be felt w/appendicitis?
RLQ
why are enemas and laxatives contraindicated with appendicitis?
increases risk of rupture that could lead to peritonitis or sepsis
what types of foods should be avoided with diverticular disease?
seeds, nuts, corn, popcorn, figs and tomatoes
what is a priority concern for a pt with gastroenteritis?
fluid replacement (Gatorade and pedialyte)
what may diminishing bowel sounds, tachycardia, rigid, board-like abdomen, fever and tachycardia indicate?
peritonitis
can a person with celiac eat rice?
yes (gluten free) but cannot eat barley, rye, or wheat
why may ulcerative colitis lead to low H&H?
bloody stools
what are 3 s/s of crohn’s disease?
anemia, diarrhea, and weight loss
what is a good food choice for a client with crohns?
chicken and rice
when should famotidine be taken?
bedtime
