FINAL REVIEW Flashcards
malignancy with?
hypercalcemia
tetany. wrist spams
hypocalcemia
hypocalcemia
&
hypomagnesemia have?
trousseau’s sign
chovestks sign
as calcium increases….what decreases
phosphate
total daily intake
2500
400 ml is loss by which
skin & lungs
treat hypernatremia with?
D5W
Na
135-145
Ca
8-10
Cl
85-115
HCO3-
22-26
K
3.5-5.5
PO4+
2.5-4.5
Mg+
1.3-2.0
fans of electrolytes
- promote neuromuscular excitability
- maintain fluid volume
- distributes water between fluid compartments
- regulates acid base balance
ex of diffusion
exchange of CO2 & O2
ex of filtration
(hydrostatic pressure)
arterial capillary bed to interstitial fluid
hypotonic solution
0.45%
isotonic solution
0.9%
hypertonic solution
3.0%
force of BP pushing out of blood stream
hydrostatic pressure
how not to give K+
IM
IV push
hypovolemia is treated with which type of fluid?
isotonic fluid
dehydration is treated with which type of fluid?
hypotonic solution
pt at greatest risk of hypovolemic shock
hemorrhage (multiple trauma)
sx of hypovolemia–
oliguria
2.2 lbs =
1 L of fluid added
alcoholism
hypomagnesemia
hypophosphatemia
salt substitutes is not okay for pts taking?
potassium sparing diuretics
Hyponatremia
floppy
if Na falls below 115
increased ICP
what to do if pt is hypernatremia
offer fluids
heart wave on hypokalemia
prominent U wave & flat T wave
heart wave of hyperkalemia
peak T wave
hypocalcemia: floppy or twitchy?
twitchy
hypocalcemia sign
trousseau’s sign
hypercalcemia: floppy or twitchy
floppy
hypotonic solution treats
hypernatremia & severely dehydrated patient
hypokalemia sx:
muscle weakness
fatigue
not a sx of hypovolemia
HTN
treating hyponatremia with solution. what to assess
breath sounds
most accurate way to determine fluid & electrolyte imbalances
daily weights
metabolic alkalosis compensation sxs….
increased urine output
hypokalemia, what do you monitor?
assess cardiac function
tingling around the mouth
hypocalcemia
infiltration manifestations
cool to touch
swollen
what should you do 1st in phlebitis
stop infusion
COPD develops into
respiratory acidosis
antacids and bicarb can cause
metabolic alkalosis
hypocalcemia
trousseau’s sign
carpedal spasms
what causes tingling and numbness?
hypokalemia
what will you see with metabolic acidosis
deep, rapid respirations
perform venipuncture quickly and release tourniquet quickly for who?
elderly
a patient in respiratory alkalosis, and is telling you they hurt, what should you do?
admin PRN pain medication
pH
7.35-7.45
PaCO2
35-45
HCO3-
22-26
what can oral antacids cause?
metabolic alkalosis
with someone who is hypokalemia, what would you watch?
breathing (affects muscle contraction)
role of kidneys on metabolic acidosis
the kidneys excrete hydrogen ions and conserve bicarbonate ions
a patient has just returned from surgery, what is nurses first priority?
maintain a patient airway
a patient has been admitted with hyponatremia. what would the nurse frequently assess?
breath sounds
caused by alveolar hypoventilation– acute or chronic
respiratory acidosis
ex of chronic respiratory acidosis
COPD
ex of acute respiratory acidosis
overdose
manifestations of respiratory acidosis
low pH
high PaCO2
HCO3 normal if acute
HCO3 high if chronic
treatment of respiratory acidosis
improve alveolar ventilation
caused by alveolar hyperventilation–acute or chrnoic
respiratory alkalosis
manifestations of respiratory alkalosis
high pH
low PaCO2
HCO3 normal if acute
HCO3 high if chronic
treatment of respiratory alkalosis
treat cause of hyperventilation
caused by gaining acid or by loss of ability to excrete acid or by loss of base
metabolic acidosis
cause of metabolic acidosis
diabetes diarrhea lower intestinal fistula ureterostomies diuretic use early renal insufficiency excessive administration of chloride administration of parenteral nutrition without bicarb
levels for metabolic acidosis
low Ph
low HCO3
manifestations for metabolic acidosis
headache confusion drowsiness increased RR and depth N/V decreased BP cold clammy skin dysrhythmias shock
treatment of metabolic acidosis
sodium bicarb
caused by potassium ion depletion or by excess sodium bicarbonate intake
metabolic alkalosis
which patient has metabolic alkalosis
antacid overdose
NG tube patients
levels for metabolic alkalosis
high pH
high HCO3
manifestations for metabolic alkalosis
tingling of fingers and toes, dizziness, hypertonic muscles, respiratory depression, atrial tachycardia
treatment of metabolic alkalosis
replace potassium carefully
what to do for phlebitis
stop infusion
cold compress
what to do for infiltration
stop infusion
warm compress
hypertonic cells
shrink
isotonic cells
normal
hypotonic cells
swollen/fat
use of hypertonic fluids
prevent fluid from 3rd spacing
isotonic fluids are used to?
expand ECF volume
hypotonic solutions are used to?
replace cellular fluids or to provide free water for excretion of body wastes
uncontrolled type 1 diabetes mellitus
metabolic acidosis
respiratory acidosis levels that you will see….
pH 7.50
PaCO2 50
heroin OD
respiratory acidosis
a patient has just returned from surgery, what is the nurses first priority?
maintain patient airway
a patient just had abdominal surgery and is refusing to wear anti embolism stockings. what is the patient at risk for?
PE
the PACU nurse is caring for a patient that is still unconscious. the patient is bluish and dusty. The patient is not breathing. What is the nurses initial reaction?
check for laryngeal obstruction then tilt head back and push jaw forward
Patient identification prior to the ER: select all that apply
name of physician performing procedure
have a patient stage first and last name
compare patient ID with chart
A patient admitted for surgery wants to know why he’s not allowed to eat for 8hrs prior to his surgery. The nurses best response is:
Pts. should be NPO for 8 hours to decrease the risk for aspiration
a 38 year old pt that is in recovery from surgery is apprehensive, restless, and thirsty. the pt asks if he can have a drink of water. Upon assessment you notice the pt’s skin is cool, moist, and pale. What should you be concerned for?
hemorrhage and shock
what is a PACU nurses first responsibility?
resp. status
what is a unit nurses first responsibility?
vital signs
if a patient says she doesn’t know what the surgery entails, what should the nurse do?
don’t have patient sign consent and inform the doctor.
the OR personnel responsible for maintaining safety of the client and the surgical environment.
Circulating nurse:
a patient is in the PACU with BP of 117/60, P of 72, and with warm dry skin; his pre-op BP was 121/72 what should the nurse do?
administer O2 therapy
Problems with obese clients:
impaired tissue perfusion
The scrub nurse is responsible for
preparing the sterile instruments for the surgical procedure.
the PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. Which short-term outcome would be most important for this client? The client:
maintains adequate oxygenation status
Pt. has normal BP and increased respirations
tell them to breathe in deeply
The nurse understands that the purpose of the “time-out” is to:
maintain the safety of the client
a client has a hysterectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
auscultate bowel sounds
as a circulating nurse, what task are you solely responsible for?
keeping records
the nurse recognizes which of the following as clinical manifestations of shock?
rapid, weak, thready pulse
Your patient is in the recovery room following chest surgery. The patient complains of severe nausea. What would you do next?
turn the patient completely to one side
You are discharging your patient home from day surgery after a general anesthetic, what instruction would you give the patient prior to the patient leaving the hospital?
the patient is not to drive a vehicle
Your patient is a 78-year-old male who has had outpatient surgery. You are getting him for his first walk postoperatively. To decrease the potential for orthostatic hypotension, what should you plan to have the patient do?
stand upright for 2-3 minutes prior to ambulating
occurs when the postoperative patient fails to move, cough, and breathe deeply. with good nursing care, this is an avoidable complication
atelectasis
a WBC count of 14,000 indicates:
infection
You admit a patient to the postanaesthesia care unit with a blood pressure of 130/90 and a pulse of 68 beats per minute. After 30 minutes, the patient BP is 120/65, and pulse is 100. You document the patients skin as cold, moist, and pale. what is the patient showing signs of?
hypovolemic shock
You are the nurse caring for a patient after abdominal surgery in the post anesthesia care unit. The patient’s BP is increased and the patient is restless. The patient’s oxygen saturation is 97%. You know that the change in your patient is most likely caused by?
the patients in pain
a 38 year old patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is restless and asking for “a drink of water.” The nurse checks his skin and it is cold, moist, and pale. What is the nurse concerned the patient may be at risk for?
hemorrhage and shock
The nursing instructor is discussing postoperative care with the junior nursing students. A student nurse asks, “Why does the patient go to the PACU prior to the medical-surgical unit?” What is the nursing instructor’s best response?
“The PACU allows the patients to recover from the effects of anesthesia, and the patient says in PACU until he or she is oriented, HAS STABLE VITAL SIGNS, and is without complications.”
You are the intraoperative nurse transferring a patient from the OR to the PACU after replacement of the right see. The patient is a 73 year old female. You know that special attention must be paid to what?
keeping the patient warm—HYPOTHERMIA
What are the determining factors for a patient to be discharged from the PACU?
stable BP
adequate oxygen saturation
adequate respiratory function.
the nursing student is preparing an elderly patient for surgery. the patient is scheduled for a general anesthetic. which side effect should the nurse monitor the patient for?
hypothermia
You are the circulating nurse caring for a 78 year old patient who is scheduled for a total hip replacement. which of the factors should you consider during the preparation of the patient in the operating room
pressure points should be assessed and well padded
earliest sign of malignant hyperthermia?
tachycardia
a patient is admitted to the emergency department complaining of severe abdominal pain. the patient is vomiting, “coffee-ground” like vomitus. The patient is diagnosed with a bowel obstruction and is informed that he needs surgery. when can the patient anticipate the surgery will be scheduled?
without delay because the bowel obstruction is emergent
TCDB & incentive spirometry every 2 hours used to?
promote optimal lung expansion
sign of hypovolemic shock=
rapid, weak, thready pulse
who is more @ risk for hypovolemia?
x48 year old with multiple trauma
patient needs more teaching about infection when states?
red streaks are normal and will disappear
local anesthesia performed when??
had food & fluid
how to check for bladder distention?
palpate
You are the nurse working in the preoperative holding area. Your patient has just received a preanesthetic medication. What should you instruct the patient to do?
use the call light to summon the nurse for assistance
You are obtaining the patient’s signature on the surgical consent form. What are the criteria for a valid informed consent?
consent must be freely given
consent must be obtained by a physician
signature must be witnessed by a professional staff member
nurse takes care of several pts who received anesthesia. which pt is at highest concern?
pt. w/ emphysema
Age related integumentary changes
thinning of skin
uneven pigmentation
dry skin
pt. at greatest risk for pressure ulcers
thoracic vertebrae
where do you check for jaundice?
hard pallets
damage to lg. vessels which result in lack of blood flow to the extremity thus resulting in lack of nutrients
Stasis Dermatitis
ingrown hair
sweating, shaving, or heat
folliculitis
“BOIL”
induration but localized
Furuncles
caused by varicella-zoster virus
Herpes Zoster (shingles)
painful vesicular rash along a dermatome
Herpes Zoster (shingles)
tx Herpes Zoster (shingles) with ?
antiviral
cover with wet dressing
wash hands
found on the lower anterior legs, forearms, thighs & over bony prominences
primary lesions
Diabetic Dermopathy (shin spots)
