Med Surge Flashcards
(333 cards)
1
Q
What lab finding do you expect in the initial 24 hours of a burn client?
A
- HCT & HGB elevated due to loss of fluid volume
- Na decreased due to third spacing
- K increased due to cell destruction
- Blood glucose increased due to stress
- WBC increase
- ABG metabolic acidosis
2
Q
What lab findings do you expect within 48-72 hrs of a burn client?
A
- Hgb & Hct decreased due to fluid shift
- Na decreased due to renal loss
- K decreased due to renal loss movement back to into cells
- WBC decreased
3
Q
Pt exhibit ventricular fibrillation what is the priority nursing intervention?
A
Defibrillation followed by CPR
4
Q
Why is an arterial line insertion used?
A
Needed for continuous blood pressure monitoring and access to withdraw ABG sample and CBC.
5
Q
What is a pulmonary artery catheter insertion is used for?
A
Inserted to measure cerebrovascular pressure, pulmonary artery pressure and CO. Used for the management of fluids and inotropic medications
6
Q
What is the diagnostic procedure best to asses for ECG changes associated with MI and dysrhythmias?
A
ECG
7
Q
What is the diagnostic procedure best used for cardiomegaly, cardiomyopathy, evaluation of cardiac contractility and function, PE, and pleural effusion?
A
Echocardiogram
8
Q
What is the diagnostic procedure to diagnose cardiomegaly, pneumothorax, and evaluation of the lungs?
A
CT scan
9
Q
Injection of photosensitizing agent that is absorbed by all the cells in the body, one to three days later when the agent remains in only the cancer cells, tumor is exposed to a specific wavelength of the light via an endoscope.
A
Photodynamic Therapy (PDT)
10
Q
Patient using PDT, client educaiton
A
- Instruct client to avoid sun exposure for 6 weeks
- Instruct the client to consume a liquid diet for several days until pain subside
11
Q
Delivery of synchronized, direct countershock to heart; elective treatment for atrial dysrhythmias supraventricular tachycardia, ventricular tachycardia with pulse
A
Cardioversion
12
Q
Delivery of unsynchronized, direct countershock to the heart. stops all electrical activity in the heart allowing the SA node to take over and re-establish a perfusing rhythm; tx for ventricular fibrilation or pulseless ventricular tachycardia
A
Defibrillation
13
Q
Pre procedure for client prior to cardioversion
A
Anticoagulation therapy to prevent dislodgment of thrombi in blood stream
14
Q
What is the priority nursing intervention for client receiving cardioversion
A
Obtain consent
15
Q
What should the nurse do before cardioversion takes place?
A
Administer sedation as prescribed before cardioversion
16
Q
Nursing procedure for cardioversion
A
- Administer sedation
- Administer prescribed antidysrhythmic -medication
- Monitor the client in a lead that provides upright QRS wavelength
- Perform CPR for cardiac asystole or pulsless rhythm
- Monitor client for PE pr systemic emboli following cardioverison
17
Q
Client education after cardioversion
A
Teach client and family how to assess pulse
Advise client to report palpitations or irregular heart beat
18
Q
Client diagnosed with osteoporosis, client teaching on estrogen (Premarin).
A
Caution to clients with DVT, and encourage self breast exams
19
Q
Client teaching on Raloxifene hydrochloride (Evista)
A
Monitor liver function tests
20
Q
Client teaching on Calcium carbonate supplement
A
Give with food.
Monitor kidney stones
21
Q
Client teaching on Alenodrate sodium (Fosamax), Ibandronate sodium (Boniva), Risedronate (Actonel)
A
Take with 6-8 oz of water early in am before eating
Remain upright for 30 min
22
Q
Client teaching Vit D supplements
A
Watch for S&S of toxicity: nausea, constipation, kidney stone
23
Q
Client education on Calcitonin
A
Can be taken IM/SC or nasally
24
Q
Pt teaching with osteoporosis
A
- Exposure to vit D (sunlight, fortified milk)
- Encourage weight bearing exercise to improve strength
- Reinforce use of safety measures and assistant device
- Adequate amounts of protein, Mg, K and trace minerals
25
What are the clinical manifestations of a client with L-sided heart failure?
Dyspnea, othopnea, fatigue, S3 gallop, hypertrophy, pulmonary congestion,( dypnea, cough, bibsalar crackles), frothy sputum(blood tinged), altered mental status, oliguria
26
Client teaching about topical coritcoidsteroids to a client with contact dermatitis?
Topical corticosteroids triamcinolone acetonide apply but avoid face, folds, and take periodic medication vacations.
27
Pt teaching on coal tar
- May stain skin and hair
- May stimulate growth of skin cancer
- Apply at night with gloves
28
What is medication for a client with contact dermatitis is contraindicated for pregnant client?
Tazarotene (Tazorac) caused birth defects
| Methotrexate (Mexate)
29
What to monitor for client taking Methotrexate (Mexate)?
Monitor for fever, sore throat, bleeding, bruising, and fatigue.
30
Pt exhibits, vomiting, diarrhea, and is having a tap water enema is at risk for.
Hyponatremia
31
What are the clinical manifestations for a client with hyponatremia?
Hypothermia, tachycardia, rapid thready pulse, hypotension, head ache, confusion, lethargy, muscle weakness and fatigue
32
Pt with increased gastric motility. hyperactive bowel sounds, and abdominal cramping is at risk for.
Hyponatremia
33
Client with mOsm of less than 270 mOsm/L
Hyponatremia
34
Client with CHF and is hyponatremic what would you administer?
Loop diuretics
| Ace inhibitors
35
A pt that has acute hyponatremia, what would the nurse administer?
- Administer hypertonic oral and IV fluids
| - Administer 3% NaCl slowly and monitor Na
36
What would you recommend a pt with hyponatremia in their diet?
Cheese, milk, and condiments
37
How do you restore normal ECF fluid volume?
- Administer isotonic IV (0.9% NaCl)
| - Administer lactated Ringers
38
What should you tell patient to report to provider who is hyponatremic?
Encourage client to report weight gain of 1-2 lbs in 24 hrs
39
What to monitor for pt who is hyponatremic
Monitor I&O and weight daily
40
What are the expected findings for a pt with an eye disorder?
Frequent headaches, eye strain, Blurred vision, poor judgement of depth, diplopia
41
The tendency to close or favor one eye and poor hand eye coordination may be objective findings for what type of patient?
A patient with an eye disorder
42
What is the nursing intervention for a client with an eye disorder?
Increase amount of light in the room
43
What do you provide for a client with an eye disorder?
Magnifying lens and large print books and newspapers
44
Client education for a patient with eye disorder?
Wear protective sunglasses to protect the eyes
45
Client education for a patient with eye disorder?
Wash hands before and after eye medication
46
What foods do you want patient with eye disorder to incorporate in their diet?
Foods rich in antioxidants , such as green leafy vegetables
47
Client teaching to older clients to prevent eye disorders
Clients 40 years or older should have annual eye checks ups and measurements of IOP
48
To prevent injury for a client with eye disorder
Arrange the home to remove hazard, such as throw rugs
49
A pressure monitoring system comprised of catheter with infusion system, a transducer, and a monitor is used to display hemodynamic information.
Arterial Line
50
What are the components of a hemodynamic monitoring system?
- Pressure transducer
- Pressure tubing
- Monitor
- Pressure bag and flush device
51
Arterial lines are not used for
intravenous fluid infusion
52
Where are arterial lines placed?
Radial (most common), brachial, femoral artery
53
What should be assessed to verify the integrity of arterial waveform?
Blood Pressure readings
54
How do you monitor the circulation of limbs with arterial line?
Capillary refills, temperature, and color of the limbs
55
Permit of withdrawal of blood samples can be done through what?
Arterial line
56
Client presents with tachycardia, bounding pulse, hypertension, tachypnea, increased CVP is in what state?
Client is hypervolemic
57
Clinical manifestations of hypervolemia
Dyspnea, orthopnea, crackles, diminished breath sounds, edematus, and distended neck veins
58
Critical lab finding for pt with Hypervolemia
- Hct decreased
- Osmolarity decreased
- Na WNL
59
A client who is respiratory alkalosis and chest xray reveals possible pulmonary congestion
Pt is at risk for hypervolemia
60
Causes of hypervolemia
- Chronic stimulus to the kidney to conserver sodium and water
- CHF, cirrhosis, increased glucocorticoids
61
Nursing implementations for a client who is hypervolemic?
Check ABGs, SaO2, and chest x ray
62
What position should a pt with hypervolemia be placed in
semi Fowler's position
63
What do you want to monitor for a patient with hypervolemia?
Daily weight
| I&O
64
What would you administer for a client with hypervolemia?
-Administer diuretics (osmotic, loop) as prescribed.
65
A client with hypervolemia should limit
fluid and sodium
66
What lung sounds would you expect for a client with hypervolemia?
crackles
67
What do you monitor and document for a pt with hypervolemia?
Presence of edema (pretibial, sacral, periorbital)
68
Client education for a patient with hypervolemia
-Encourage client to weigh themselves daily,and notify PC if 1 to 2 lb gain in 24 hrs
69
What diet should a patient with hypervolemia have?
-consume a low sodium diet, read food labels to check for sodium contents
70
What are the client outcomes for a patient with hypervolemia?
- Client will maintain adequate oxygen level
- Client will be free for anxiety
- Client will be compliant with fluid restriction intake
- Client will consume a low sodium diet
71
What are the causes for hypovolemia?
-Abnormal GI losses (vomiting, nasogastric sunctioning, diarrhea,) diaphoresis, diuretic therapy, DI, renal disease, adrenal insufficiency
72
Pt is hyperthermic, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased CVP is in what state?
Hypovolemic
73
Pt is dizzy, syncope, confused, and weak, and fatigued, what is the priority nursing intervention?
Administer supplemental oxygen
74
Pt exhibits increased osm greater than 300 mOsm/L, increased protein, BUN, electrolytes, and glucose. This patient is in what state?
Hypovolemic shock
75
What fluid replacements would you administer for a patient with hypovelmia?
- Colloids (whole blood, packed RBCs, plasma, synthetic plasma expanders)
- Crystalloids (Ringer's lactate, normal saline)
76
What vasconstrictors would you administer to a pt with hypovolemia?
dopamine (Intropin)
| norepinephrine (Levophed)
77
A patient with respiratory acidosis nursing priority intervention.
Oxygen therapy
78
A patient with respiratory alkalosis nursing priority intervention.
Oxygen therapy
79
A patient with metabolic acidosis and has DKA nursing priority intervention.
Administer insulin
80
A patient with metabolic acidosis and has GI disruption what is nursing priority intervention?
Administer antidiarrheal and provide rehydration
81
A patient with metabolic alkalosis and has GI loses what is nursing priority intervention?
Administer antiemetics and electrolyte replacements
82
Respiratory acidosis nursing care:
- Oxygen therapy
- Maintain patent airway
- Positioning (enhance gas exchange)
- Breathing techniques
- Ventilatory support
- Bronchodilators
- Mucolytics
83
Respiratory alkalosis nursing care:
- Oxygen therapy
- anxiety reduction
- rebreathing techniques
84
Pt exhibits tachycardia, tachypnea, shallow, rapid breathing, pale and is cyanotic is experiencing what acid base imbalance?
Respiratory Acidosis
85
Pt exhibits tachypnea, anxiety, tetany, tingling, and numbness has rapid deep respirations is experiencing what acid base imbalance?
Respiratory Alkalosis
86
What clinical manifestations does a client with metabolic acidosis exhibit?
Bradycardia, weak peripheral pulses, hypotension, tachypnea, muscle weakness, flaccid paralysis, fatigue, confusion, Kussmaul respirations.
87
A client with depressed skeletal muscles resulting in ineffective breathing is in what acid base imbalance state?
Metabolic alkalosis
88
pH 7.30 PaCO2 50 HCO3 24
Respiratory acidosis
89
pH 7.47 PaCO2 37 HCO3 21
Metabolic alkalosis
90
A patient with acid base imbalance is at risk for convulsion, coma, respiratory arrest. What is the priority nursing intervention?
Implement seizure precautions and perform management interventions in necessary .
91
Clinical manifestations for a client with hyponatremia
headache, tachycardia, confusion, muscle weakness, fatigue, decreased deep tendon reflexes, seizures
92
What should the nurse administer for a patient with hypernateremia?
```
hypotonic IV fluids (0.45 NaCl)
isotonic IV (0.9% NaCl)
```
93
Client education for a client with hypernatremia?
Encourage water intake and discourage sodium intake
94
Monitor the client's level of consciousness and ensure safety.
Seizure Precautions
95
What nursing intervention can decrease thirst?
Provide oral hygiene
96
What to report to PCP for a client with hypernatremia?
Inadequate renal output less than 30 ml/hr
97
For a client with acute hypernatremia complications include seizures, convulsions if not treated immediately. What is the priority nursing intervention?
Maintain open airway and monitor clients vital signs
98
What does the volume (low pressure) alarm indicate in a ventilator?
Low exhale volume due to disconnection, cuff leak, and or tube displacement.
99
What does pressure (High pressure) alarms indicate in a ventilator?
Excess secretion, client biting the tubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasms, and pneumothorax
100
What does apnea alarms indicated in a ventilator?
Ventilator does not detect spontaneous respiration in preset time.
101
What pressure should the cuff pressure be kept to reduce the risk of tracheal necrosis?
20 mm Hg
102
A client speaking, air hissing, or decreasing Sa O2 may indicate what?
Air leak around the cuff. Inadequate cuff pressure can result in inadequate oxygenation and or accidental extubation.
103
Clients receiving mechanical ventilation may require sedation or paralytic agents to prevent competition between extrinsic and intrinsic breathing. What are types of sedatives to use?
propofol( Diprivan), diazepam (Valium), lorazepam (Ativan), midazolam (versed_ and haloperidol (Haldol)
104
How often do you reposition the oral endotracheal tube?
Q24H
105
How do you assess for adequate nutrition for mechanically ventilated patients?
- Bowel movement q8h
- Monitor bowel habits
- Administer enteral or parental feedings as RX
106
A client with RR greater than 30, BP changes more than 20% baseline, and SaO2 less than 90%, elevated ST segments, shows signs of what?
Weaning intolerance
107
Following extubation what should you monitor the client for?
Respiratory distress, airway obstruction such as ineffective cough. dyspnea, and stridor
108
Older clients have decreased respiratory muscle strength and chest wall compliance which make them susceptible to what.
Aspiration, atelectasis, and pulmonary infection
109
A client who is on a mechanical ventilator has a risk of increased thoracic pressure which results in what?
Increased Positive Pressure
110
Monitor for tachycardia, hypotension, urine output less than or equal to 30 ml/hr, cool clammy extremities, decreased peripheral pulses and decreased LOC illustrates:
Hemodynamic compromise
111
How do you decrease risk of aspiration?
Elevated HOB 30-45 degrees
112
What are medications used to prevent ulcers in mechanically ventilated patients?
sucrafalate
| Histamine 2 blockers
113
What is the flow rates of T-pieces?
10L/min
114
What device can be used for clients who have tracheostomies, laryngectomies, or ET?
T-piece
115
What is the disadvantages of T-pieces?
High humidifications require frequent monitoring
116
What is the priority nursing interventions for a T-piece?
- Ensure that exhalation port is open and uncovered
- Make sure that the T piece does not pull on the tracheostomy or ET tube
- Ensure that the mist is evident during inspiration and expiration.
117
What are the signs and symptoms of hypoxemia?
SOB, anxiety, tachypnea, tachycardia, restlessness, pallor, cyanosis of the skin, or mucous membranes, adventitious breathe sounds, confusion
118
Client exhibits tachypnea, tachycardia, restlessness, pale skin, elevated BP, adventious lung sounds which is representative of early or late findings of hypoxemia?
Early findings
119
What are late findings of hypoxemia in a client?
Confusion and stupor, cyanotic skin and mucous membranes, bradypnea, bradycardia, hypotension, and cardiac dysrhythmias
120
What position should the client be to facilitate breathing and promotion of chest expansion?
semi-fowler's position or fowler's position
121
What are the S&S of hypercarbia?
Restlessness, hypertension, and headache
122
Which symptoms of respiratory depression should be notified to the PCP?
Decreased RR and Decreased LOC
123
What are the clinical manifestations for a pt experiencing oxygen toxicity?
Nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation
124
What is the nursing priority with a pt exhibiting oxygen toxicity.
Use the lowest level of oxygen necessary to maintain and adequate SaO2.
125
What are the signs and symptoms of hypoxemia?
SOB, anxiety, tachypnea, tachycardia, restlessness, pallor, cyanosis of the skin, or mucous membranes, adventitious breathe sounds, confusion
126
Client exhibits tachypnea, tachycardia, restlessness, pale skin, elevated BP, adventious lung sounds which is representative of early or late findings of hypoxemia?
Early findings
127
Nursing actions for a client using oxygen therapy
- Signs to alert others of a fire hazard
- Know where the closest fire extinguisher is located
- Educate clients/family about smoking due to O2 use
- Have the client wear cotton gown, bc synthetic or wool fabrics can generate static electricity
- Ensure that all electric devices (razors, hearing aids, radios) are working
- Ensures electric machinery (monitors, suction machines) well grounded
- Do not use volatile, flammable materials (etOH) near clients receiving O2)
128
What are the advantages of Positive-pressure ventilators?
- Forced/enhanced lung expansion
- Improved gas exchange (oxygenation)
- Decreased work of breathing
129
How do you establish method of communication with a patient who is on a mechanical ventilation?
- Asking yes/no questions
- Providing writing materials
- Using dry erase boards
- Picture communication board, or lip reading
130
Which symptoms of respiratory depression should be notified to the PCP?
Decreased RR and Decreased LOC
131
What are the clinical manifestations for a pt experiencing oxygen toxicity?
Nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation
132
What do you monitor and document in ventilators settings hourly?
- Rate, FiO2, and tidal volume
- Mode of ventilation
- Use of adjuncts (PEEP, CPAP)
- Plateau or peak inspiratory pressure
- Alarm settings
133
What do you monitor for a client with oxygen induced hypoventilation?
Monitor client's RR and pattern, LOC, and SaO2
134
What type of mask should the nurse use for delivery of precise oxygen levels?
Venturi masks
135
Nursing actions for a client using oxygen therapy
Signs to alert others of a fire hazard
Know where the closest fire extinguisher is located
Educate clients/family about smoking due to O2 use
Have the client wear cotton gown, bc synthetic or wool fabrics can generate static electricity
Ensure that all electric devices (razors, hearing aids, radios) are working
Ensures electric machinery (monitors, suction machines) well grounded
Do not use volatile, flammable materials (etOH) near clients receiving O2)
136
How do you establish method of communication with a patient who is on a mechanical ventilation?
Asking yes/no questions
Providing writing materials
Using dry erase boards
Picture communication board, or lip reading
137
What is the priority nursing intervention in a patient on a mechanical ventilator?
Maintain a patent airway
138
What diet restrictions should a client with Crohn's disease have?
- Educate client to eat foods high in protein and calories, and low in fiber
- Instruct client to avoid caffeine and alcohol, and take multivitamin that contains iron
139
A client with a mild case of diverticulitis should be prescribed what by the health care provider?
- Antibiotics
- Analgesics
- Antispasmodics
- Rest
140
What delivers an FiO2 of 24%-55% at flow rates of 2-10 L/ min via different sized adaptors?
Venturi Mask
141
A client taking Sulfasalazine (Azulfidine) should be advised to
- Take with food
- Avoid sun exposure
- Increase fluid intake
- Urine and skin may appear yellow or brown
142
What delivers an FiO2 of 80%-95% at flow rate of 10-15 L/min to keep the reservoir bag 2/3 full during inspiration and expiration?
Nonrebreather mask
143
What adverse side effects should a client inform the PCP when taking Mesalamine (Asacol, Pentasa, Rowasa)?
Headache or GI problems, such as abdominal discomfort or diarrhea
144
Clients taking Prednisone (Deta son) for Ulcerative colitis should report what to PCP?
Unexpected weight gain or other signs of fluid retention
145
What diet restrictions should a client with Crohn's disease have?
Educate client to eat foods high in protein and calories, and low in fiber
Instruct client to avoid caffeine and alcohol, and take multivitamin that contains iron
146
A client with a mild case of diverticulitis should be prescribed what by the health care provider?
Antibiotics
Analgesics
Antispasmodics
Rest
147
What type of diet is appropriate for a client with diverticulitis?
Limited to clear liquids initially but may progress to a high fiber, low fat diet.
148
A client taking Sulfasalazine (Azulfidine) should be advised to
Take with food
Avoid sun exposure
Increase fluid intake
Urine and skin may appear yellow or brown
149
A client taking Olsalzine (Dipentum) is intolerant to sulfaszlazine and should report what to the PCP?
Sore throat, rash, bruising, and or fever
150
Clients taking Prednisone (Deta son) for Ulcerative colitis should report what to PCP?
Unexexpected weithg gain or other signs of fluid retention
151
Client teaching for use of Budesonide (Entocort)?
Avoid crowds and other exposures to infectious disease
152
A client with IBS taking Cyclosporine (Sandimmune) and methotrexate (Rheumatrex) should monitor for?
Bleeding, bruising, or infection
153
Client education on levothyroxine (Synthroid)
- Tx begins slowly and dosage is increased 2-3 weeks
- Serum TSH labs will be drawn at sched times to ensure appropriate dosage
- Monitor for and report signs and symptoms of hyperthyroidism ( irritability, tremors, tachycardia, and palpitations, heat intolerance)
- Inform client that tx is lifelong requiring medical assessment of thyroid function
154
Client with myxedema coma will exhibit:
- Significantly depressed respirations
- Decreased CO
- Worsening cerebral hypoxia
- Stupor
- Hypothermia
- Bradycardia
- Hypotension
- Hypoglycemia
- Hyponatremia
155
What do you observer the client for when taking Diphenoxylate hydrochloride and atropine (Lomotil)
Respiratory depression
156
Decreased T3, Elevated TSH with primary, Decreased T4, Elevated cholesterol, CBC showing anemia are lab findings for?
Hypothyroidism
157
What is the treatment of choice for a client with hypothyroidism?
Thyroid hormone replacement therapy levothyroxine (Synthroid)
158
levothyroxine (Synthroid) effects of warfarin
It increases effects of warfarin (Coumadin) and can increase the need for insulin and digoxin (Lanoxin)
159
Nursing Actions for preprocedure to a client receiving hemodialysis:
- Assess patency of access site (presence of bruit, palpable thrill, distal pulses, and circulation
- Avoid taking BP, administering injections, or venipunctures on arm with access site
- Assess VS, lab values (BUN, creatine, electrolyte, Hct) weight
160
Client with myxedema coma will exhibit:
```
Significantly depressed respirations
Decreased CO
Worsening cerebral hypoxia
Stupor
Hypothermia
Bradycardia
Hypotension
Hypoglycemia
Hyponatremia
```
161
What is the priority nursing intervention to a client with myxedema coma?
Maintenance of airway patency with ventilatory support if necessary
162
What is the client outcome for a client taking a Synthroid?
The client's TSH will return to the expected reference range.
163
What complication is the client at risk for using hemodialysis?
Clotting and infection of access site
164
What is the priority nursing intervention for a client receiving hemodialysis?
Use surgical aseptic technique during cannulation
165
Client education after dialysis procedure?
- Avoid lifting heavy objects with access site arm
- Avoid carrying objects that compress the extremity
- Avoid sleeping on top to the extremity with access device
- Perform hand exercises that promote fistula maturation
166
What types of medications are witheld until after dialysis?
Medications that lower BP
167
Client experiencing hypotension during dialysis, what is the priority nursing intervention?
Carefully replace fluid volume with transfusion of IV fluids or colloids as Rx. and then slow dialysis exchange rate then lower head of bed
FOR SEVER Hypotension: D/C dialysis
168
A client with anemia who is receiving dialysis, nursing intervention:
- Administer Rx med therapy (erythropoetin)
- Monitor Hgb, and RBC levels
- Monitor of hypotension and tachycardia
169
After dialysis what would you expect a decrease in?
Decreases in BP, weight, and lab values
170
What complications should the nurse assess for after dialysis?
Hypotension, clotting of vascular access, headache, muscle cramps, bleeding
171
What is the preventative measure the nurse will use for a client with an bloodborne disease?
Use standard precautions
172
A peritoneal dialysis (PD) is used for
A client requiring dialysis and are unable to tolerate anticoagulation, or have difficulty with vascular access
173
Client experiencing hypotension during dialysis, what is the priority nursing intervention?
Carefully replace fluid volume with transfusion of IV fluids or colloids as Rx. and then slow dialysis exchange rate then lower head of bed
FOR SEVER Hypotension: D/C dialysis
174
How long is continuously ambulatory peritoneal dialysis (CAPD) done?
7 days a week for 4 to 8 hrs
175
What is the client teaching on a pt's diet who is anemic and receiving hemodialysis?
Educate client to eat foods high in folate (beans, green veggies)
176
A client who has frequent blood transfusions and frequent blood access due to hemodialysis are at risk for?
Transmission of blood borne disease such as HIV and hep B and hep C
177
A peritoneal dialysis is used for
A client requiring dialysis and are unable to tolerate anticoagulation, or have difficulty with vascular access
178
Signs of infection and complications for a client receiving PD?
Infection: fever, blood, cloudy, or frothy dialysate return; drainage at access site
Complications: respiratory distress, abdominal pain, insufficient blood flow, discolored outflow
179
What is the priority nursing interventions for a client receiving PD?
Monitor client's VS frequently during initial dialysis in a hospital setting
180
What lab value will you be monitoring for a client during PD?
serum glucose level
181
What will the nurse record while a client is receiving a PD?
Record the amount of inflow compared to outflow of dialysate
182
Signs of infection and complications for a client receiving PD?
Infection: fever, blood, cloudy, or frothy dialysate return; drainage at access site
Complications: respiratory distress, abdominal pain, insufficient blood flow, discolored outflow
183
How do you prevent reflux of a client receiving PD?
Keep the outflow bag lower than the client's abdomen
184
Post procedure for a client receiving PD, nursing actions:
Monitor weight, serum electrolytes, creatine, BUN, and blood glucose
185
What to teach client for home care of access site (PD)?
Instruct the client and family how to perform peritoneal dialysis with home visits and support groups
186
A client that is receiving PD may allow microorganisms into the peritoneum and cause what?
Peritonitis
187
What is the nursing actions for a client at risk for peritonitis?
Maintain surgical asepsis during procedure
| Monitor for infection: fever, purulent drainage, redness or swelling, and cloudy or discolored drained dialysate
188
What should you educate the client about to prevent peritonitis?
Educate the client to use sterile asepsis during procedure
189
What do you want to assess for in the access site to prevent infection?
Assess site for wetness from a leaking catheter
Purulent drainage, redness or swelling
190
For protein loss in a client receiving PD what lab value do you want to monitor?
serum albumin
191
What do you want to teach the client with protein loss during peritoneal dialysis?
Instruct client to follow recommended renal diet with an increase in dietary protein
192
If the tubing is obstructed or twisted causing a decrease in flow what should the nurse do?
- Reposition the client if inflow or outflow is inadequate
- Milk tubing to break fibrin clots
- Check tubing for kinks or closed clamps
- Tell the client to avoid constipation by using stool softeners and consuming a diet high fiber
193
What lab value will you monitor for if patient is at risk for hyperglycemia?
Glucose
194
What would the nurse administer when hyperglycemia is suspected?
Administer insulin for glycemic control
195
A client with hyperglycemia should be instructed to:
Instruct pt to check serum glucose
196
A client with increased AST aspartate amniotransferase (5-40 u/L) and ALT alanine aminotransferase (8-20 u/L)
Elevated AST and ALT occurs with hepatitis or cirrhosis
197
What is the function of dialysis?
Rids the body of excess fluids and electrolytes
Achieves acid base balance
Eliminates waste products
Restores internal homeostasis by osmosis , diffusion, and ultrafiltration
198
What is disequilibrium syndrome?
DS is caused by too rapid a decrease in BUN and circulating fluid volume. It may cause cerebral edema and increased ICP
199
What is the nursing intervention for a client experiencing disequilibrium syndrome (nausea, vomiting, change in LOC, seizures, and agitation)?
Use a slow dialysis exchange rate
| Administer anticonvulsants/ barbiturates if needed
200
A client with increased ALP alkaline phosphatase (42-128 u/L)
Elevated ALP indicates liver damage
201
A client with elevated Amylase (56-90 IU/L), Lipase (0-110 u/L)
Elevated amylase and lipase indicate pancreatitis
202
A client presents with GI bleeding and unexplained diarrhea and is positive for c.diff is indicative of an opportunistic infection. What is the client education for this pt?
Instruct client about proper collection of stool sampling using a card or a collection cup. The client may be instructed to restrictions before collecting ( red meat, anticoagulants)
203
Client with decreased albumin ( 3.5-5.0 g/dL)
Decreased albumin indicate hepatic disease
204
Client with elevated AFP Alpha fetoprotein ( <40 mcg/L) and Ammonia ( 15-110 mg/dL)
Elevated AFP and ammonia found in liver cancer
205
What diagnostic procedure is used for visualization of the oropharynx, esophagus, stomach and duodenum?
Esophagogastroduodenoscopy
206
What medications restrictions should the patient follow before having an endoscopy procedure?
NSAIDs, warfarin, aspirin
207
Client presents with anemia secondary to bleeding, abdominal discomfort, and abdominal distention. What is the nursing action for this patient to have an endoscopy done?
Evaluate the client's understanding of the procedure
208
What do you want to ensure the client be prior to most endoscopic examinations?
Client needs to be NPO for 6-8 hrs prior to endoscopic examinations
209
A client having a colonscopy should be in what position?
Left side with knees to chest
210
What type of anesthesia should the pt receive before a colonoscopy?
Moderate sedation: midazolam (Versed) usually given with an opiate analgesic
211
A client that may need laxatives such as bisacodyl (Dulcolax), clear liquid diet, NPO after midnight, will be having what procedure done?
Colonscopy
212
What would monitor for after a colonoscopy procedure?
Monitor for rectal bleeding
Encourage plenty of fluids
Monitor VS esp, respiratory status
Instruct client that there may be increased flatulence
213
What position will the pt be lying during an EGD?
left side lying
214
What type of sedation will the client with an EGD be administered?
Moderate sedation
| topical anesthetic
215
Preparation for this procedure includes NPO 6-8 hrs; removal of dentures
EGD
216
When performing an EGD advise client to notify PCP when what occurs?
Notify PCP of bleeding, abdominal or chest pain, and any evidence of bleeding
217
A client receiving a conscious sedation such as a topical anesthetic and initally semi prone with repositioning throughout the which procedure?
ERCP
218
When performing EGD when can you give fluids?
When gag reflex returns
219
How is a client receiving a sigmoidoscopy is positioned?
on left side
220
What complications is a pt at risk for during moderate sedation?
Oversedation
221
Difficulty arousing the client, poor respiratory effort, evidence of hypoxemia, tachycardia, and elevated or low BP indicate?
Oversedation
222
What is the nurse's priority intervention with a client who is oversedated?
Prepare to administer antidotes to the sedatives
Maintain an open airway
administer oxygen
and monitor VS
223
Symptoms of hemorrhage
bleeding, cool, clammy skin, hypotension, tachycardia, dizziness, and tachypnea
224
What labs should the nurse monitor after a hemorrhage?
Hgb and Hct
225
What should the client report to the PCP after a hemorrhage occurs?
Report fever, pain, and bleeding
226
After any procedure using moderate sedation that affects the gag reflex places the clients at risk for?
aspiration
227
What is the nursing action for a client at risk for aspiration?
The client should be NPO until the gag reflex returns
228
A client with potential diagnosis of gastric ulcers, peristaltic disorders, tumors, varices and intestinal enlargements may have what type of study done?
Gastrointestinal studies with barium
229
Pre procedure Gastrointestinal study
Inform client about medications, food and fluid restrictions (NPO after midnight) and avoid smoking or chewing gum (increases peristalsis)
230
When do you schedule barium enema studies?
Barium enema studies must be scheduled prior to upper gastrointestinal studies
231
Client education before GI studies?
Tell the client to restrict food and fluids for bowel preparations
232
What do you monitor after the GI study procedure?
Monitor elimination of contrast material and administer a laxative if Rx
Force fluids to promote elimination of contrast material
233
Why are clients receiving chemotherapy immunocompromised?
Immunosupression is due to bone marrow suppression by cytotoxic medications
234
What lab value do you want to monitor for a client who is immunocompromised?
WBC
235
If a client's WBC drops below 1,000 mm3 what precaution should be initiated?
Neutropenic Precautions
- Place client in a private room
- Place a mask on pt if he needs to be transported
- Protect the client form possible sources of infection (plants, visitor restriction), water equipment changed daily
236
What is a primary prevention that client, staff, and visitors can do to prevent spread of infection?
Perform frequent hand hygiene
237
What colony stimulating factors stimulates WBC production?
filgrastim (Neupogen, Neulasta)
238
Client education for a pt that is immunocompromised
- Avoid crowds whil undergoing chemotherapy
- Avoid eating fresh fruits and veggies
- Avoid yard work, gardening or changing a pet's litter box
- Avoid fluids sitting at room temp for greater than 1 hr
- Wash toothbrush daily in dishwasher or rinse with bleach
- Report fever >37.8 C
239
A client undergoing chemotherapy is experiencing vomiting, what should the nurse do first?
Give the client antiemetic medications at times that are appropriate, prior to tx, during tx, and after tx
240
What would you administer to increase appetite for a client undergoing chemotherapy?
megestrol (Megace)
241
How can you promote adequate nutritional intake to client undergoing chemotherapy?
Provide liquid supplements as needed, add protein powders to food or tube feedings
242
What technique may be useful adjuncts to antiemetics?
Visual imagery and relaxation techniques
243
How do you enhance the client's appetite?
Perform mouth care prior to serving meals
244
What type of diet is suggested for a client who is going through chemotherapy and has nausea and vomiting?
Encourage consumption of high protein, high calorie, nutrient dense foods and avoidance of low or empty calorie foods
245
What would you suggest to a client with a metallic taste in the mouth?
Encourage use of plastic eating utensils, sucking on hard candy, and avoidance of red meats
246
What is the nursing intervention for a client with alopecia?
Discuss the impact of alopecia on self image. Discuss options such as hat, turbans, and wigs to deal with hair loss
247
After hair loss client education:
Client should protect the scalp form the sun and can cause diaper rash ointment/ cream itching
248
Mucositis
also known as stomatitis is an inflammation of tissues in the mouth, such as the gums, tongue, roof and floor of the mouth, and inside the lips and cheeks.
249
What is the nursing action for a client with mucositis?
- Examine the client's mouth several times a day
- Document the location and sz of lesions
- Avoid using glycerine-based mouthwashes or mouth swabs
- Administer a topical anesthetic prior to meals
- Discourage selection of salty, acidic, or spicy foods on the menu
- Offer mouth care before and after each meal
250
Client education for a client with mucositis
- Encourage client to rinse mouth with a soln: half 0.9%NaCl and half peroxide at least 2 times a day
- Brush teeth using soft bristles
- Encourage consumption of soft foods (mashed potatoes, scrambled eggs, cooked cereal) or ice cream, bananas, milk shakes
251
Anemia
Decreased number of circulating RBC
252
Thrombocytopenia
Decreased number of circulating platelets
253
Symptoms of Anemia
Fatigue, pallor, dizziness, and SOB
254
Symptoms of Thrombocytopenia
Petechiae, ecchymosis, bleeding of the gums, nosebleed, occult or frank blood in stools, urine, vomit
255
Nursing intervention for anemia induced fatigue
Schedule activities with rest periods in between and using energy saving measures (sitting during showering)
256
What erythropoeitic medications should be administered to a client who is anemic?
```
erythropoeitn alfa (Epogen)
ferrous sulfal (Feosol)
```
257
How do you evaluate the effectiveness of the erythropoetitic medications?
Hgb to determine response to medications
258
What medications should you administer to a client who is thrombopoietic?
oprelvekin (Interleukin 11, Neumega)
259
What should you instruct the client who has anemia or thrombocytopenia?
- Use an electric razor instead of a razor blade when shaving
- Use soft bristled toothbrush
- Blow nose only when necessary
- Wear shoes when ambulating
- Avoid the use of NSAIDs
260
Upon receiving a client, the nurse should immediately perform full body assessment giving priority to:
Airway, breathing, and circulation
261
What to do if wound dehiscence or evisceration occurs?
- Call for help
- Stay with the client
- Cover the wound with sterile towel or dressing that is moist with sterile saline
- Monitor the client for shock
- Notify health care immediately
262
A client with incision and drain sites should be monitored for:
redness, excessive tenderness, and purulent drainage
263
What to instruct client after a CABG?
- Avoid strenuous exercise
- Immediately report bleeding from insertion site, chest pain SOB, changes in color or temp of the extremity
- Restrict lifting (<10 lbs) for the prescribed period of time
264
What to lifestyle changes to instruct client to follow after CABG?
- Manage weight
- Consume a low fat/ low cholesterol diet
- Exercise regularly
- Stop smoking
- Decrease etoh intake
265
What are signs of complications in a client under hemodialysis?
Hypotension, clotting of vascular access, headache, muscle cramps, bleeding
266
What to instruct a client who will be having a hysterectomy before procedure?
Maintain NPP
| Ensure that informed consent was obtained
267
After a hysterectomy client should be monitored for vaginal bleeding. What is excess bleeding?
Excess bleeding is more than one saturated pad in 4 hr
268
After hysterectomy, monitor the client's VS
VS: fever and hypotension
269
After hysterectomy, monitor the clients breath sounds
Risk of atelactisis
| Turn, cough and deep breath, encourage the use of IS and ambulation
270
After hysterectomy, monitor bowel sounds
Client at risk for paralytic ileus
271
After hysterectomy, monitor the clients urine output
Call PCP if less than 30 ml/hr
272
After hysterectomy, provide IV fluid and electrolyte replacement
Until bowel sounds reture
273
After hysterectomy, monitor client's incision site
At risk for infection, look at integrity, and risk of dehiscence
274
After hysterectomy, monitor client for signs of thrombophlebtitis
warmth, tenderness, and edema will be presesnt
275
Take thromboembolism precautions
ie: sequential compression devices, ambulation
276
Client education after hysterectomy
-Instruct the client about a well balanced diet that is high in protein and vit C and high in iron
277
Psychological reaction to a hysterectomy; nursing action
- Encourage the client to discuss positive aspects of life
- Understand that occasional sadness in the client is normal, but persistent sadness indicates need for counseling assistance
278
What is a positive Kernig's sign?
Resistance and pain with extension of the client's leg from a flexed position
279
What are findings including in compartment syndrome?
- Increased pain unrelieved with elevation
- Intense pain when passively moved
- Paresthesia or numbness
- Color of tissue is pale (pallor)
280
What are clinical manifestations of a fat embolism?
- Decreased mental acuity
- Respiratory distress
- Tachycardia
- Tachypnea
- Fever
- Cutaneous petechia (found in the neck, chest, upper arms, and abdomen)
281
What are S&S of osteomyelitis?
- Bone pain that is worst with movement
- Erythemia and edema
- Fever
- Leukocytosis
282
Nursing Care for PE (pulmonary embolism)
- Administer oxygen
- Initiate and maintain IV access
- Administer anticoagulants
- Provide emotional support and comfort to control client anxiety
- Monitor changes of LOC
283
Client education for treatment and prevention of PE:
- Promote smoking cessation
- Encourage the client to avoid long periods of immobility
- Encourage physical activity such as walking
- Encourage the client to avoid crossing legs
284
What lab findings is indicative of Cushing disease?
Elevated plasma cortisol level in the absence of acute illness or stress
285
Cushing's disease lab findings:
Hypersecretion of ACTH by anterior pituitary
- K and Ca decreased
- Glucose increased
- Na increased
- Lymphocytes decreased
286
Nursing Actions for Phantom Limb Pain
- Recognize the pain is real and manage accordingly
| - Described as deep, burning, cramping, shooting or aching
287
How do you prevent flexion contractures?
- ROM exercises and proper positioning
- Avoid elevating the stump on a pillow after the first 24 hours
- Have the client lie prone several times a day
- Discourage prolonged sitting
288
What type of medications do you treat phantom limb with?
Beta blockers such as propranolol (inderal) and antiepileptics such as gabapentin (Neurontin)
289
Complications of intestinal obstruction include dehydration and electrolyte imbalance. What should you notify to PCP?
Hct, BUN, orthostatic vital signs, urine ouput, and specific gravity
(Assessment of hydration)
290
Monitor client for fluid and electrolyte imbalance in a client with a nasogastric decompression procedure.
Metabolic acidosis: low obstruction
Metabolic alkalosis: high obstruction
291
What are the laboratory findings for a client with Graves?
TSH decreased
FTI and T3 elevated
Thyrotropin releasing hormone (TRH) stimulation test: failure of expected rise in TSH
292
What are the signs of digoxin toxicity?
Fatigue, muscle weakness, confusion, and loss of appetite
293
Client education for pt self administering digoxin:
Count pulse fro 1 min before taking meds. 60-100
Take digoxin at same time ea day
Do not take with antacids
Check digoxin and potassium levels regularly
294
LAB VALUES EXPECTED REF
```
Na 136-145
K 3.5-5.0
Cl 98-106
Ca 9.0-10.5
Mg 1.3-2.1
Ph 3.5-4.5
```
295
How do you position a pt before a thoracentesis?
Position the client sitting upright with his arms and shoulders raised and supported on pillows and or on an overbed table and with his feet and legs well supported
296
Results for a Mantoux test shows and induration (palpable, raised, hardened area) of 10 mm or greater in diameter
Positive skin test for TB
297
An induration of 5 mm is considered what in the Mantoux test?
Positive test for immunocompromised clients
298
After a liver biopsy how should the client position themselves?
Instruct client to lie on affected side after the biopsy in order for hemostasis to occur
299
Clinical manifestations of Hep B
Headache, fatigue, arthalgia and myalgia, pruritus, low grade fever, RUQ pain, nausea, vomiting, jaundice, dark urine
300
What is pain?
Pain is whatever the person experiencing it says it is and it exists whenever the person says it does
301
Client education on Oxycodone
- Use medication as directed
- Prevent constipation with diet changes and stool softeners
- Be aware that nausea may subside within a few days
302
Hormonal contraceptives
May be decrease symptoms of PMS and PMDD
| May be initial tx for endometriosis
303
Leuporlide (Lupron)
Can cause birth defects so a reliable form of contraception is advised
May cause decease in libido and increase risk of osteoporosis
304
Hormone replacement therapy (HRT)
```
Should not be taken during pregnancy
Smoking
Hx of Cancer (breast, uterus)
Abnormal vaginal bleeding
Embolism
Stroke
Heart disease
HTN
```
305
Clients with stent placement will receive anticoagulation therapy 6-8 weeks. Client instructions:
Take the medication at the same time each day
Have regular lab tests to determine therapuetic level
Avoid activities that could cause bleeding (use a soft toothbrush, wear shoes when out of bed)
306
Medication Administration : IV
- Apply a clean tourniquet or BP cuff 4-6 in above the proposed insertion site
- Untie the tourniquet, cleanse the area at the site in a circular motion inward to outward
- Remove the cover from catheter, grasp the plastic hub
- Retie the tourniquet
- Anchor the vein below the site of insertion
- Pull the skin taut and hold it
- Insert the the catheter maintaining a 10-30 angle. flashback of blood
- Lower the hub of the catheter close to the skin
- Advance the catheter into the vein
- Stabilize the IV catheter
- Apply pressure 1 1/4 inch above the insertion site
- Remove the needle and activate safety device.
- Dispose of used equipment
- Document
307
Medication to control HTN; Thiazide diuretics such as hydrochlorothiazide (Hydrodiuril) side effects
Monitor for hypokalemia watch for muscle weakness, irregular pulse and dehydration
308
Calcium channel blocker, verapamil hydrochloride (Calan) dilitiazem (Cardizem)
Monitor for hypotension
309
ACE inhibitor S/E
Monitor for hypotension
310
Beta blockers such as metoprolol (Lopressor) and atenolol (Tenormin) adverse S/E
These medications can mask hypoglycemia in clients who have DM
311
Central alpha agonists such as clonidine (Catapres) S/E
S/E include sedation, orthostatic hypotension,and impotence
312
Alpha adrenergic antagonists such as prazosin (Minipress) S/E
S/E include postural hypotension
313
What is the therapeutic effects of Furosemide (Lasix)?
Diuretics are used to decrease preload. Promote fluid excretion
314
Propranolol (Inderal)
Beta adrenergic blocker- Treats sympathetic nervous system nervous system effects (tachycardia, palipations)
315
What to do if there is a shortage of TPN solution?
Keep dextrose 10% in water at the bed side in case solution is unexpectedly ruined or a new bag is not available.
316
Nursing Actions for fluid overload in a client receiving hyperosmotic solution
- Assess the client's lung sounds for crackles
- Monitor clients daily weights and I&O
- Use a controlled infusion pump to administer TPN at a prescribed rate
- Gradually increase the flow rate until prescribed infusion rate is achieved
317
Client on TPN monitor BS
Check cap glucose every 4-6 hrs for the first 24 hrs.
| Need supplemental insulin until pancreas can increase its endogenous production of insulin
318
A client with hypokalemia
Report abnormal findings to the PCP
Replace K
Encourage foods hight in K (avocados, broccoli, dairy products, dried fruits, cantaloup, bananas)
319
IV K supplement
Never IV bolus=cardiac arrest
| Max: 5-10 mEq/hr
320
Client with hypokalemia (what to monitor)
Monitor for adequate urine output
Monitor clients receiving digoxin (Lanoxin) hypokalemia increased digoxin toxicity
Monitor Bowel sounds, and abdominal distention
Monitor kidney f(x) (BUN, creatine, GFR)
Monitor Mg, Ca, Phosphorus
321
ECG for client with hypokalemia
PVC, bradycardia, blocks, v tachy, inverted T waves and ST depression
322
Client with DM who has impaired vision and blindness
Encourage yearly eye exams to ensure the health of the eyes and to protect vision
Encourage management of Blood glucose levels
323
```
Insulin lispro (Humalog)
Rapid acting
```
Onset: less than 15 min
Peak: 0.5-1 hr
Duration:3-4 hr
324
```
Regular Insulin (Humulin R)
Short acting
```
Onset: 0.5-1 hr
Peak: 2-3 hr
Duration:5-7 hr
325
```
NPH insulin (Humulin N)
intermediate acting
```
Onset: 1-2 hr
Peak: 4-12 hr
Duration: 18-24 hr
326
```
insulin glargine (Lantus)
Long acting
```
Onset: 1 hr
Peak: none
Duration: 10.4-24 hr
327
A nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to use a quad cane. Which of the following is the most appropriate gait sequence?
Place the cane in the patient’s left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
328
What are the dietary guidelines for bariatric surgery?
Provide 6 small meals a day when the client can resume intake. Observe for signs of dumping syndrome (cramps, diarrhea, tachycardia, dizziness, and fatigue). The client’s first feeding may only consist of 30 mL of liquid.
329
What type of diet should a patient with heart failure have?
Low sodium diet and fluid restrictions
330
Nontunneled percutaneous central catheter
Indications – Administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition
Insertion location – Subclavian vein, jugular vein; tip in the distal third of the superior vena cava
331
Peripherally inserted central catheter
Indications – Administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition
Insertion location – Basilic or cephalic vein at least one finger’s breadth below or above the antecubital fossa; the catheter should be advanced until the tip is positioned in the lower one-third of the superior vena cava.
332
angina
Precipitated by exertion or stress
Relieved by rest or nitroglycerin
Symptoms last < 15 min
Not associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
333
MI
Can occur without cause, often in the morning after rest
Relieved only by opioids
Symptoms last > 30 min
Associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
