HESI Med/Surg Flashcards
Hesi hint: fever can cause dehydration because?
excessive fluid loss due to diahoresis. INcreased temperature also increases metabolism and the demand for O2
Hesi Hint: When feeding those with pneumonia, you should?
- raise the head of the bed
- position the client on his or her side NOT the back
How should you assist a pneumonia pt to cough productively?
- deep breathing every 2 hours (may use incentive spirometer)
- Use high humidity to loosen secretions (may be oxygenate)
- Suction airway
For a pneumonia pt, provide fluids up to ___L/day (helps liquefy lung secretions)
3L/day
Normal ABGs PO2, PCO2
- PO2 >80
- PCO2<45
HESI hint: Bronchial breath sounds are heard over areas of ___1_ or ___2___. Sound waves are easily transmitted over __3___ tissue.
- density
- consolidation
- consolidated
Hesi Hint: ___________
- enables liquefication of mucus trapped in the bronchioles and alvel, facilitating expectoration
- is essential for client experiencing fever
- is important because 300, to 400 mls is lost daily by lungs through evaporation
hydration
HESI hint: irritability and restlessness are early signs of ________ ; the clients brain is not receiving enough O2
cerebral hypoxia
Assign which patho is emphysema, asthma, and chronic bronchitis?
- sputum with cough production on daily basis for minimum of 3 months per year. Chronic hypoxemia, cor pulmonale. Increased mucus, clia production, bronchial wall thickness
- reduced gas exchange surface area, increased air trapping (AP diameter), decreased capillary network, increased work and O2 consumption
- Narrowing or closure of the airway due to a variety of stimulants
- Chronic Bronchitis
- Emphysema
- Asthma
HESI hint: Exposure to _______ is the primary cause of COPD in the United States
tobacco smoke
In advanced __\__1_, due to alveoli being affected, hypercarbia is a problem, rather than in _\__2___, where the airways are affected
- emphysema
- bronchitis
HESI hint: Productive cough and comfort can be facilitated by __\__1_______, which lessens pressure on the diaphragm by abdominal organs. __\___2______ becomes a priority in these clients because it elevated the diaphragm and inhibits full lung expansion
- Semi-fowler/high-fowler
- Gastric distention
Normal ABG: pH, PCO2, PO2, HCO3
- pH: 7.35-7.45
- PCO2: 35-45
- PO2: 80-100
- HCO3: 21-28
Administer no more than __ L O2 to a COPD client
2 L O2
Why do COPD clients stop breathing when given too much O2?
The stimulus to breathe is hypoxia (hypoxic drive), not the usual hypercapnia, which is the stimulus to breathe for healthy people. Therefore, if too much O2 is given, the client may stop breathing
HESI hint: when asked to prioritize nursing actions, use the ______ rule
ABC rule: Airway first, then breathing, then circulation
HESI hint: watch for NCLEX-RN question s that deal with O2 delivery. In adults O2 must bubble through some type of ____(1)\___ so it can be humidified if given at > ___(2)\___L/min, or delivered directly to the trachea. If given at __\_(3)__L/min or by mask or nasal prongs, the oropharynx and nasal pharyns provide adequate humidification.
- water solution
- >4 L/min
- 1-4 L/min
HESI hint: drug therapy for TB usually lasts? How should it be taken?
last 9 months or loner. Should be taken as prescribed for the entire time, no skipping ro ending early.
Rifampin (for TB) reduces the effectiveness of? Other complications?
oral contraceptives. Also gives body fluids orange tinge and stains soft contact lenses.
Why are several anti-TB drugs given at once?
Resistance develops more slowly
Leading cause of cancer-related deaths in the US
lung cancer
If chest tube drainage system breaks, what should you do?
Place the distal end of the tubing connection in a sterile water container at 2cm level as an emergency water seal. Chest tubes are NOT routinely clamped
If the chest tube is accidentally removed from the client…?
Apply pressure immediately with an occlusive dressing and notify the health care provider
If fluctuation of fluid ceases with chest tube…?
Check for kinked tubing, accumulation of fluid in the tubing, occlusions or change in the client’s position. When external suction is applied, fluctuations SHOULD cease.
abrupt dterioration of the renal system, a reversible syndrome
Acute renal failure (ARF)
For adults, total daily urine output ranges between?
1500 to 2000 ml
________ are profoundly affected by kidney problems
electrolytes
primary extracellular ions in the body
sodium and chloride
primary intracellular ions in the body
potassium and phosphate
Kayexalate is prescribed if ______ is too high
K+
- Dyspnea
- tachycardia
- JVD
- peripheral edema
- pulmonary edema
- weight gain
*all signs of ?
signs of excess fluid
*signs of?
- dizziness, weakness, cardiac irregularities, muscle cramps, diarrhea, nausea
signs of hyperkalemia
primary cause of uremia?
accumulation of waste products from protein metabolism
________must be restricted in CRF clients. However, if ____ intake is inadequate, a negative nitrogen balance occurs, causing muscle wasting. GFR is used as an indicator for the level of ____ consumption
Protein
Why can decreased urinary output also be a sign of cardiac problems?
If cardiac output decreases, the amount of blood going through the kidneys decreases, urniary output is the decreased.
Number one cause of stroke in hypertensive clients is?
Noncompliance with medication regiment. HTN is often symptomless, and antiHTN medicine is expensive and has side effects.
A client is admitted with severe chest pain and states that he feels a terrible tearing sensation in his chest. He is diagnosed with a dissecting aortic aneyrysm. What assessments should the nurse obtain in the first few hours?
- vital signs every hour
- neurologic vital signs
- respiratory status
- urinary output
- peripheral pulses
normal BUN levels
10-20
normal creatinine
0.6-1.2
Ratio of BUN to creatinine is __ to ___. When this ration increases or decreases, suspect?
- 20:1
- suspect renal problems
Administration do’s and don’ts of heparin
- do not cause tissue trauma, which can lead to bleeding
- do not massage are or aspirate
- rotate sites
heparin antagonist
protamine sulfate
PTT and APTT for heparin
1.5-2.5 times normal control
Warfarin (Coumadin) antagonist
vitamin K
Warfarin PT
1.5-2.5 times normal control
INR therapeutic level for Warfarin?
2-3 seconds (reflects how long it takes a blood sample to clot)
Difference in synchronous and asynchronous pacemakers:
- Synchronous, or demand: Pacemaker fires only when the client’s heart rate falls below a rate set on the generator. •
- Asynchronous, or fixed: Pacemaker fires at a constant rate.
Restricting sodium reduces salt and water retention, thereby reducing ?
vascular volume and preload
Infective endocarditis damage to heart valves occurs with the growth of vegetative lesions on valve leaflets. These lesions pose a risk for embolization, erosion or perforation of the valve leaflets, or abscesses within adjacent myocardial tissue. Valvular stenosis or regurgitation (insufficiency), most commonly of the mitral valve, can occur, depending on the type of damage inflicted by the lesions, and can lead to symptoms of ?
left- or right-sided heart failure
There are two types of infective endocarditis:
- acute: often affects individuals with previously normal hearts and healthy valves and carries a high mortality rate
- subacute: typically affects individuals with preexisting conditions, such as rheumatic heart disease, mitral valve prolapse, or immunosuppression.
The presence of a friction rub is an indication of ____ (inflammation of the lining of the heart). ST-segment elevation and T-wave inversion are also signs
pericarditis
client will exhibit excessive fatigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, or pulmonary edema. There will be a rumbling apical diastolic murmur, and atrial fibrillation is common.
mitral valve stenosis: blood is regurgitated back into the left atrium from the left ventricle.
Teaching plan for a client taking nitro
Take at first sign of anginal pain. Take no more than three, 5 minutes apart. Call for emergency attention if no relief in 10 minutes.
Develop a teaching plan for a client taking antihypertensive medications.
Explain how and when to take medication, reason for medication, necessity of compliance, need for follow-up visits while on medication, need for certain lab tests, and vital sign parameters while initiating therapy.
Describe intermittent claudication.
Pain related to peripheral vascular disease; the pain occurs with exercise and disappears with rest.
What lab values should be monitored daily in a client with thrombophlebitis who is undergoing anticoagulant therapy?
PTT, PT, Hgb, Hct, platelets
When do PVCs (premature ventricular contractions) present a grave danger?
When they begin to occur more often than once in 10 beats, occur in twos or threes, land near the T wave, or take on multiple configurations
Differentiate between the symptoms of left-sided cardiac failure and right-sided cardiac failure.
Left-sided failure results in pulmonary congestion due to backup of circulation in the left ventricle. Right-sided failure results in peripheral congestion due to backup of circulation in the right ventricle.
List three symptoms of digitalis toxicity.
Dysrhythmias, headache, nausea, and vomiting
What immediate actions should the nurse implement when a client is having a myocardial infarction?
Place the client on immediate strict bed rest to lower O2 demands on heart; administer O2 by nasal cannula at 2 to 5 L/ min; take measures to alleviate pain and anxiety (administer PRN pain medications and antianxiety medications).
What precautions should clients with valve disease take prior to invasive procedures or dental work?
Take prophylactic antibiotics.
_____can cause or exacerbate ulcers. Teach _____reduction methods, and encourage those with a family history of ulcers to obtain medical surveillance for ulcer formation.
stress
- Pallor: conjunctival, mucous membranes, nail beds
- Dark, tarry stools
- Bright-red or coffee-ground emesis
- Abdominal mass or bruit
- Decreased BP, rapid pulse, cool extremities (shock), increased respirations
clinical manifestations of GI bleeding
a distended intestinal wall accompanied by decreased muscle tone may lead to ?
Intestinal perforation
A client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is diagnosed as having diverticulitis. What are the nutritional needs of this client throughout recovery?
- Acute phase: NPO, graduating to liquids
- Recovery phase: no fiber or foods that irritate the bowel
- Maintenance phase: high-fiber diet with bulk-forming laxatives to prevent pooling of foods in the pouches where they can become inflamed; avoidance of small, poorly digested foods such as popcorn, nuts, seeds, etc.
Blood gas analysis will show an alkalotic state if the bowel obstruction is __1__ in the small intestine where gastric acid is secreted. If the obstruction is in the ___2__ bowel where base solutions are secreted, the blood will be acidic.
- High
- Lower
American Cancer Society recommendations for early detection of colon cancer:
- A digital rectal examination every year after 40.
- A stool blood test every year after 50.
- A colonoscopy or sigmoidoscopy examination every 3 to 5 years after the age of 50, based on the advice of a physician
An early sign of colon cancer is ?
Rectal Bleeding: Encourage patients 50 years of age or older and those with increased risk factors to be screened yearly with fecal occult blood testing. Routine colonoscopy at 50 is also recommended.
distinctive breath odor of chronic liver disease. It is characterized by a fruity or musty odor that results from the damaged liver’s inability to metabolize and detoxify mercaptan, which is produced by the bacterial degradation of methionine, a sulfurous amino acid.
fetor hepaticus
Esophageal varices may rupture and cause hemorrhage. Immediate management includes ?
insertion of an esophagogastric balloon tamponade (a Blakemore-Sengstaken or Minnesota tube). Other therapies include vasopressors, vitamin K, coagulation factors, and blood transfusions.
Acute pancreatic pain is located retroperitoneally. Any enlargement of the pancreas causes the peritoneum to stretch tightly. Therefore ? reduces the pain.
sitting up or leaning forward
Nonsurgical management of a client with cholecystitis includes:
- Low-fat diet
- Medications for pain and clotting if required
- Decompression of the stomach via NG tube
List four nursing interventions for the client with a hiatal hernia.
Sit up while eating and for 1 hour after eating. Eat frequent, small meals. Eliminate foods that are problematic.
List three categories of medications used in the treatment of peptic ulcer disease.
Antacids, H2 receptor blockers, mucosal healing agents, proton pump inhibitors
List four nursing interventions for postoperative care of a client with a colostomy.
Irrigate daily at same time; use warm water for irrigations; wash around stoma with mild soap and water after each ostomy bag change; ensure that pouch opening extends at least ⅛ inch around the stoma.
In a client with cirrhosis, it is imperative to prevent further bleeding and observe for bleeding tendencies. List six relevant nursing interventions.
Avoid injections; use small-bore needles for IV insertion; maintain pressure for 5 minutes on all venipuncture sites; use electric razor; use soft-bristle toothbrush for mouth care; check stools and emesis for occult blood.
What is the main side effect of lactulose, which is used to reduce ammonia levels in clients with cirrhosis?
Diarrhea
How should the nurse administer pancreatic enzymes?
Give with meals or snacks. Powder forms should be mixed with fruit juices.
Thyroid storm is a life-threatening event that occurs with uncontrolled hyperthyroidism due to Graves disease.
Symptoms and primary nursing intervention?
- Symptoms include fever, tachycardia, agitation, anxiety, and hypertension.
- Primary nursing interventions include maintaining an airway and adequate aeration.
Drugs used to treat thyroid storm?
Propylthiouracil (PTU) and methimazole (Tapazole) are antithyroid drugs used to treat thyroid storm. Propranolol (Inderal) may be given to decrease excessive sympathetic stimulation.
Postoperative thyroidectomy: Be prepared for the possibility of?
laryngeal edema. Put a tracheostomy set at the bedside along with O2 and a suction machine; calcium gluconate should be easily accessible.
• Normal serum calcium
9.0 to 10.5 mEq/ L.
The best indicator of parathyroid problems is
a decrease in the client’s calcium compared to the preoperative value.
Many people take steroids for a variety of conditions. NCLEX-RN questions often focus on the need to teach clients?
the importance of following the prescribed regimen precisely. They should be cautioned against stopping the medications suddenly and should be informed that it is necessary to taper off the dosage when taking steroids.
? is a medical emergency. It is brought on by sudden withdrawal of steroids or a stressful event (trauma, severe infection)
Addison crisis
The body’s response to illness and stress is to produce?
glucose. Therefore, any illness results in hyperglycemia
If in doubt whether a client is hyperglycemic or hypoglycemic, treat for?
hypoglycemia
Describe the physical appearance of clients who have Cushing disease.
Moon face, obesity in trunk, buffalo hump in back, muscle atrophy, and thin skin
In fewer than 10 steps, describe the method of drawing up a mixed dose of insulin (regular with NPH).
Identify the prescribed dose and type of insulin per physician order; store unopened insulin in refrigerator. Opened insulin vials may be kept at room temperature for up to 28 days. Draw up regular insulin first; rotate injection sites; may reuse syringe by recapping and storing in refrigerator.
When making rounds at night, the nurse notes that an insulin-dependent client is complaining of a headache, slight nausea, and minimal trembling. The client’s hand is cool and moist. What is the client most likely experiencing?
Hypoglycemia/ insulin reaction
What activity recommendations should the nurse provide a client with rheumatoid arthritis?
• Do not exercise painful, swollen joints. • Do not exercise any joint to the point of pain. • Perform exercises slowly and smoothly; avoid jerky movements.
NCLEX-RN questions often focus on the fact that avoiding sunlight is key in the management of?
lupus erythematosus; this is what differentiates it from other connective-tissue diseases.
highest risk for development of osteoporosis.
post-menopausal thin, white women
NCLEX-RN questions focus on safety precautions. Improper use of assistive devices can be very risky. When using a nonwheeled walker, the client should ?
lift and move the walker forward and then take a step into it. The client should avoid scooting the walker or shuffling forward into it; these movements take more energy and provide less stability than does a single movement.
The initial symptom of a fat embolism?
confusion due to hypoxemia (check blood gases for Po2). Assess for respiratory distress, restlessness, irritability, fever, and petechiae. If an embolus is suspected, notify physician stat, draw blood gases, administer O2, and assist with endotracheal intubation.
Assess the 5 Ps of neurovascular functioning:
pain, paresthesia, pulse, pallor, and paralysis.
NCLEX-RN questions about joint replacement focus on complications. A big problem after joint replacement is?
infection.
Differentiate between rheumatoid arthritis and osteoarthritis in terms of joint involvement.
Rheumatoid arthritis occurs bilaterally. Osteoarthritis occurs asymmetrically.
Identify the categories of drugs commonly used to treat arthritis.
NSAIDs, of which salicylates are the cornerstone of treatment, and corticosteroids (used when arthritic symptoms are severe)
Identify pain-relief interventions for clients with arthritis.
Warm, moist heat (compresses, baths, showers); diversionary activities (imaging, distraction, self-hypnosis, biofeedback); and medications
What is the priority nursing intervention used with clients taking NSAIDs?
Administer or teach client to take drugs with food or milk.
What are the common side effects of salicylates?
GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation
Describe postoperative residual limb (stump) care (after amputation) for the first 48 hours.
Elevate residual limb (stump) for first 24 hours. Do not elevate residual limb (stump) after 48 hours. Keep residual limb (stump) in extended position, and turn client to prone position three times a day to prevent flexion contracture.
A nurse discovers that a client who is in traction for a long bone fracture has a slight fever, is short of breath, and is restless. What does the client most likely have?
A fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness, fever, and petechiae
NCLEX-RN questions often focus on communicating with older adults who are hearing impaired. You should?
- Speak in a low-pitched voice, slowly and distinctly.
- Stand in front of the person, with the light source behind the client.
- Use visual aids if available.
The presence of ___ ml of residual in an adult usually indicates poor gastric emptying, and the feeding should be withheld.
100ml
CSF leakage carries the risk for ____ and indicates a deteriorating condition. Because of CSF leakage, the usual signs of increased ICP may not occur.
meningitis
• Physical assessment should concentrate on ____, especially in clients with injury at C-3 to C-5, because the cervical plexus innervates the diaphragm.
respiratory status
a common cause of death after spinal cord injury is?
urinary tract infection. Bacteria grow best in alkaline media, so keeping urine dilute and acidic is prophylactic against infection. Also, keeping the bladder emptied assists in avoiding bacterial growth in urine that has stagnated in the bladder.
Craniotomy preoperative medications:
Corticosteroids to reduce swelling • Agents and osmotic diuretics to reduce secretions (atropine, glycopyrrolate [Robinul]) • Agents to reduce seizures (phenytoin) • Prophylactic antibiotics
In clients with myasthenia gravis, be alert for changes in?
respiratory status; the most severe involvement may result in respiratory failure.
NCLEX-RN questions often focus on the features of Parkinson disease: symptoms?
tremors (a coarse tremor of fingers and thumb on one hand that disappears during sleep and purposeful activity; also called “pill rolling”), rigidity, hypertonicity, and stooped posture. Focus: safety!
An important aspect of treatment for Parkinson disease is drug therapy.
The pathophysiology involves an imbalance between acetylcholine and dopamine, so symptoms can be controlled by administering a dopamine precursor (levodopa)
A woman who had a stroke 2 days earlier has left-sided paralysis. She has begun to regain some movement in her left side. What can the nurse tell the family about the client’s recovery period?
“The quicker movement is recovered, the better the prognosis is for full or improved recovery. She will need patience and understanding from her family as she tries to cope with the stroke. Mood swings can be expected during the recovery period, and bouts of depression and tearfulness are likely.”
Apraxia:
inability to perform purposeful movements in the absence of motor problems
Dysarthria:
difficulty articulating
aphasia
loss of the ability to speak
agraphia
loss of the ability to write
alexia
loss of the ability to read
dysphasia
impairment of speech and verbal comprehension
dysphagia
dysfunctional swallowing
Steroids and H2 inhibitors are administered after a stroke to?
decrease cerebral edema and retard permanent disability. H2 inhibitors are administered to prevent peptic ulcers.
What are the classifications of the commonly prescribed eye drops for glaucoma?
Parasympathomimetic for pupillary constriction; beta-adrenergic receptor– blocking agents to inhibit formation of aqueous humor; carbonic anhydrase inhibitors to reduce aqueous humor production; and prostaglandin agonists to increase aqueous humor outflow
Identify two types of hearing loss.
Conductive (transmission of sound to inner ear is blocked) and sensorineural (damage to eighth cranial nerve)
In your own words, describe the Glasgow Coma Scale.
An objective assessment of the level of consciousness based on a score of 3 to 15, with scores of 7 or less indicative of coma
List four nursing diagnoses for the comatose client in order of priority.
Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, and decreased cardiac output
What nursing interventions prevent corneal drying in a comatose client?
Irrigation of eyes PRN with sterile prescribed solution, application of ophthalmic ointment every 8 hours, close assessment for corneal ulceration or drying
A client with a diagnosis of stroke presents with symptoms of aphasia and right hemiparesis but no memory or hearing deficit. In what hemisphere has the client suffered a lesion?
left
What types of drugs are used in the treatment of myasthenia gravis?
Anticholinesterase drugs, which inhibit the action of cholinesterase at the nerve endings to promote the accumulation of acetylcholine at receptor sites; this should improve neuronal transmission to muscles.
• A 24-year-old is admitted with large areas of ecchymosis on both upper and lower extremities. She is diagnosed with acute myelogenous leukemia. What are the expected laboratory findings for this client, and what is the expected treatment?
Lab: Decreased Hgb, decreased Hct, decreased platelet count,
List three potential causes of anemia.
Diet lacking in iron, folate, or vitamin B12; use of salicylates, thiazides, diuretics; exposure to toxic agents, such as lead or insecticides
Identify two sites that should be assessed for infection in immunosuppressed clients
Oral cavity and genital area
What is the characteristic cell found in Hodgkin disease?
Reed-Sternberg
What is the most commonly reported communicable disease in the united states?
Chlamydia
Describe three nursing interventions to help decrease edema postmastectomy.
Position arm on operative side on pillow. Avoid BP measurements, injections, and venipunctures in operative arm. Encourage hand activity and use.
Which STD is characterized by remissions and exacerbations in both males and females?
Herpes simplex type II
