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.