Midterm Week 5 Flashcards
Hydrochlorothizide Nursing Instruction
Obtain baseline data, including orthostatic blood pressure, weight, electrolytes, and location and extent of edema
Monitor potassium levels
Weigh clients at the same time each day
If potassium level drops below 3.5 mEq/L monitor the ECG and notify the provider because the might require K+ supplement
Advise client to get up slowly due to postural hypotension
Hydrochlorothizide client education
Take medication first thing in morning
Take second dose before 1400 to prevent nocturia
If GI upset occurs take meds with or after meals
Report significant weight loss, lightheadedness, or general weakness - could indicated hypokalemia or hypovolemia
Hyperkalemia with hypertension
Hyperkalemia can develop with hypertension
Lisinopril priority
First dose orthostatic hypotension: stop taking diuretic 2-3 days prior to start of medication
Clients might experience a cough
Inform provider if develop a rash
Angioedema- swelling of the tongue
Atenolol adverse effects
Bradycardia (if below 50 hold medication)
Can mask hypoglycemia
Decreased cardiac output
- use cautiously for those with heart failure
Orthostatic hypotension
Congestive heart failure on digoxin- first priority/actions
Hypokalemia can increase risk for dysrhythmias
Anorexia (usually the first manifestation of toxicity. N/V and abdominal pain
Blurred vision and halos around objects
Spironolactone consideration: Diuretics for heart failure
With spironolactone
Clients at risk for hyperkalemia and hyponatremia
Therefore restrict potassium in diet
Heart failure with history of asthma
Noncardioselective drugs: Propanolol, carvedilol are contraindicated in clients with asthma —> due to adverse effects of bronchoconstriction.
Left sided heart failure clinical manifestations
Pulmonary congestion (cough, crackles)
Dyspnea
Frothy sputum
S3 heart sound
Decreased o2
Alerted LOC
Nocturia
Hypokalemia Clinical manifestations
Muscle cramping, Muscle weakness
Shallow breathing
Respiratory distress
Weak irregular pulse
Hypoactive bowel sounds —> constipation
NV
Abdominal distention
Sublingual nitroglycerin patient teaching
Do not crush or chew tablets, let dissolve under the tongue. Rest for 5 min.
A sip of water can help the medication dissolve
Use at first indication of chest pain. Do not wait till pain is severe.
Used for acute attacks
Should be stored in a dark, cool place.
Transdermal Nitroglycerin (will be select all that apply question)
Is slow onset, long duration
Long term prophylaxis against anginal attack
Do not stop taking long-acting nitro abruptly
patches should not be cut
Place the patch on hairless skin (chest, back, or abdomen) and rotate sites
Remove old patch and wash skin with soap and water, and dry before applying new patch
Remove patch at night to reduce the risk of developing tolerance and be medication free between 10-12 hrs a day
Low fat, low sodium, and low cholesterol diet and further teaching
Clients should limit the intake of cheese due to high levels of fat and sodium
Consent
Nurse is not responsible for obtaining consent but is responsible for witnessing.
Ensure the provider gave the necessary information
Ensure the client understood the information and is competent to give informed consent
Document questions the client has and inform the provider
Post op day 2- Progressing from clear liquid to full liquid diet.
Clear liquid
Examples:
Fruit juices
Gelatin (jello)
Broth
Full liquid
- can be clear plus dairy (must verify if patients are able to tolerate lactose)
Examples:
Milk
Allergic reaction to blood transfusion- symptoms
Mild: itching, urticaria, flushing
Anaphylactic: bronchospasms, laryngeal edema, hypotension, and shock
Asthma and albuterol- Understanding the teaching
Metered dose inhaler teaching
Hold inhaler 1-2 inches 2-4 centimeters away from clients mouth
Ask client to take deep breath and exhale completely
Inhale slowly and deeply while pressing the inhaler
Breath in from 3-5 seconds then hold breath for 10 seconds
Medication reaches lower airways then the back of the throat
Used in prevention of asthma exercise induced episodes
Provides bronchospasm relief by bronchodilation
Inhale bronchodilators before inhaling glucocorticoid
Watch for tremors and tachycardia
Asthma attack and what to expect
Agitation
—> due to neurological changes from poor oxygen exchange
Other:
Dyspnea, chest tightness, anxiety or stress
Task for COPD - Occupational therapist
Consult rehabilitative care if client has prolonged weakness and needs assistance with increasing activity level
works with the client to develop fine motor skills and coordination, such as improving hand strength and hand movements. The occupational therapist focuses on self-management of ADLs, such as skills needed for eating, hygiene, and dressing.
Also can teach clients to perform other independent living skills, such as cooking and shopping.
TB medications and nursing plan for those medications (RIP drugs)
R- Rifampin: observe for hepatotoxicity, liver function test should be completed prior to
I- Isoniazid: Should be taken on an empty stomach. Monitor for hepatotoxicity and neurotoxicity
P- Pyrazinamide: observe for hepatotoxicity and liver enzymes should be completed
Ethambutol: obtain baseline visual acuity test
Pulmonary tuberculosis expected findings
Purulent sputum
Cough lasting longer than 3 weeks
Fatigue
Hemoptysis- late sign (blood in sputum from forceful cough
Dyspnea (late sign)
Weight loss and anorexia
Night sweats
TB multi drug therapy
Streptomycin sulfate
- high level of toxicity, this med should only be used in clients who have multi drug-resistant TB
- can cause ototoxicity, so monitor hearing function and tolerance
- Report changes in urine output and renal function
notify the provider if hearing declines
drink at least 2L of water
Course is up to 2 years
A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for chest x-ray?
Have the client wear a mask
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure which of the following nursing actions should the nurse complete first?
Auscultate lung fields
A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0-10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?
a. Admin another nitroglycerin tablet
b. Initiate a peripheral IV
c. Call the Rapid Response Team
d. Obtain an ECG
A. Admister another nitroglycerin tablet
Admin guideline for sublingual nitroglycerin indicate that it is appropriate to admin another tablet 5 min after the first one if the client is still reporting pain
A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?
A. Apply a heating pad on a low setting to help relieve leg pain
B. Adjust the thermostat so that the environment is warm
C. Wear antiembolic stockings during the day
D. Rest with the legs above heart level
B. Adjust the thermostat so that the environment is warm
Client discharge teaching for PAD
Encourage client to exercise to build collateral circulation (walk till point of pain then rest)
Provide warm climate for client
-wear insulated socks
Never apply direct heat
Avoid stress, caffiene, and nicotine because it can cause vasoconstriction
Avoid crossing legs, restricted clothing
Elevate legs but not higher than the level of the heart
A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?
A. Thin, pliable toe nails
B. Leg pain at rest
C. Hairy legs
D. Flushed, warm legs
B. Leg pain at rest
Clinical manifestations of peripheral arterial disease (PAD)
Intermittent claudication (muscle pain due to lack of O2, triggered by activity and relieved by rest)
Parenthesia —> Numbness or burning pain in feet when in bed
Pain that is relieved by rest and in dependent position (hanging down)
Bruit
Shiny extremities and taut with hair loss and thickened toenails
Atrophy and posible gangrene of toes
Redness of extremity
Muscle atrophy
Advanced stage—> pain is continued even with leg at rest
A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort?
A. Obtain a pair of slipper socks for the client
B. Rub the client’s feet briskly for several minutes
C. Increase the client’s oral fluid intake
D. Place a moist heating pad under the client’s feet
A. Obtain a pair of slipper socks for the client
A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?
A. Intermittent claudication
B. Dependent Rubor
C. Rest Pain
D. Foot ulcers
A. Intermittent claudication
A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?
Keep the client’s affected leg elevated while in bed
The nurse should keep the client’s leg elevated when he is in bed to decrease edema. No massaging for DVT
Deep vein thrombosis (DVT) plan of care
Anti coagulation therapy
Dorsiflexion/plantar flexion exercise
Elevation and warm moist compress
Thigh high compression or anti embolism stocking
Iron deficiency anemia- what are you gonna have them take
Vitamin C can increase oral iron absorption.
Take iron supplements between meals to increase absorption, if tolerated.
Stools can appear green to black in color while taking iron.
Health promotion for those who are iron deficient
iron-rich foods that are not red or organic mats into their diets (iron-fortified cereal and breads, fish, poultry, and dried peas and beans)
Regularly consume foods high in folate (spinach, lentils, bananas) and folic acid fortified grains and juices.
Pernicious anemia
There’s a deficiency of intrinsic factor produced by gastric mucosa
(this is necessary for the absorption of vitamin B12 —> B12 deficient)
Client education:
Patients are then administered vitamin B12 injections weekly to begin with, followed by month for rest of their life
Schilling test: measures Vitamin B12 absorption with and without intrinsic factor.
- can determine whether its malabsorption or pernicious anemia
Syncopal episodes in a patient
Thrombocytopenia ?? What should we know
Either inherited or
Acquired
- immune thrombocytopenia purpura (ITP)
- Thrombotic thrombocytopenia purpura (TTP)
- Heparin-induced thrombocytopenia (HIT)
DVT and shortness of breath
shorntess of breath and chest pain can indicate that the embolus has moved to the lungs (pulmonary embolism)
New diagnosis for venous insufficiency- instructions
Venous insufficiency occurs secondary to incompetent valves in deeper veins of lower extremities, allows pooling of blood and dilation of vein—> causing swelling in the legs
Nursing care
Elevate legs for at least 20 min, four to five times a day.
Elevate the legs above the heart when in bed
Client education
Avoid crossing legs and wearing constrictive clothing
Wear elastic compression stockings. Apply them after the legs have been elevated and when swelling is at a minimum.
Infiltration symptoms
Cool to touch
Pallor
Local swelling at site
Fluid leaking from site
If iv site is painful to the touch what would you do
Stop the infusion and discontinue catheter
A client has varicose veins with ulcerations and lower extremity edema with a report of feeling heaviness. Which nursing diagnosis should the nurse identify as being priority?
A. Impaired tissue perfusion
B. Alteration in body image
C. Alteration in activity tolerance
D. Impaired skin integrity
A. Impaired tissue perfusion
The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues
A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?
A. Apply Ice packs to your legs
B. Use elastic Stockings
C. Remain on bed rest
D. Place your legs in a dependent position while in bed
B. Use elastic stockings.
Treatment for venous insufficiency focuses on preventing stasis, decreasing edema, and promoting venous return. Elastic stockings reduce venous stasis and assist in venous return of blood to heart
Nurse caring for client who has hypernatremia and requires IV fluid therapy due to NPO status. Which of the following solutions should the nurse prepare to infuse for this client?
Hypotonic solution
- 0.45% sodium chloride
Iron deficiency anemia
Nursing care
Encourage increased dietary intake of iron
Monitor oxygen saturation to determine a need for O2
Teach the client about energy conservation and risk of dizziness upon standing
Teach client about time frame for resolution
- A post op patient following gastric bypass surgery 2 weeks client report minimal pain and adherence to diet and fluid intake they remain on puréed the client stops smoking for surgery :
Laboratory findings for Immune thrombocytopenic purpura (ITP)
Hemoglobin decreased (normal: males 14-18 g/dL; females 12-16 g/dL)
Platelet levels decreased (normal: 150,000 to 400,000 mm3)
A nurse is preparing educational material for a client who has a thrombocytopenic disorder. Which of the following information should the nurse include?
Notify the dentist of condition prior to invasive procedure
Client with COPD what is the priority action
Position client into high-Fowler to maximize ventilation
Oxygen levels should be maintained between 88% and 92%
Encourage coughing, or suction to remove secretions
Use of incentive spirometer
Increased work of breathing increases caloric demands
Mild reaction for blood transfusion- course of action
Give antihistamine
Example: diphenhydramine (Benadryl)
Transfusion of RBCs
Preparing blood and the patient is A+ and blood is O- , what would you do
Continue to administer the medication
(O- blood is universal donor)
What action to take first when administering Red blood cells
Assess lab values and verify order and consent
Type and cross match
Initiate large bore iv access
Assess vital signs and history of transfusion
Prime blood admin set with 0.9% NaCL
Verify client and compatibility with 2 nurses
A nurse is assessing a client who has end stage COPD which of the following images should the nurse identify as a late manifestation of this terminal illness
Straight hand with large ends of fingers.
Digital clubbing
3% sodium chloride when to administer
Used for hyponatremia since 3% is hypertonic saline solution
Serum calcium levels- what is the plan of care
Normal range 9.0 to 10.5 mg/dL
Hypocalcemia- administer vitamin D supplements, and courage foods high in calcium: salmon, sardines, oysters, dark leafy greens.
- monitor for positive trousseau’s sign
Hypercalcemia- can weaken bones so you wanna watch out for fractures
While reviewing a clients laboratory results , a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take?
Implement seizure precautions
—>The client is at risk for seizures due to low excitation threshold as a result of a decreased calcium level. The nurse should initiate seizure precautions to prevent injury.
Hypo magnesium levels – client history to determine cause
Risk factors
- increased magnesium output: GI loss, diuretics, often associated with Hypocalcemia
- shift to inactive form
- inadequate magnesium intake or absorption: Laxative, alcohol use disorder
Magnesium levels - normal
1.3-2.1 mEq/L
Respiratory alkalosis nursing action
Hyperventilation can result n respiratory alkalosis
Nursing care: oxygen therapy, anxiety reduction interventions, and rebreathing techniques
— client can require sedation to decrease respiratory rate
Actions for WBC count 10.2 hemoglobin
Acute exacerbation of COPD
Ventilation with client who has COPD
Mechanical ventilation is indicated for exacerbation of COPD
Until lung function is restored
— positive pressure ventilators deliver air to the lungs throughout inspiration to keep the alveoli open and to prevent alveolar collapse during expiration.
Can be delivered by ET tube and tracheostomy tube
Pulmonary function test for spirometer
PFT- determine lung function and breathing difficulties
Can be performed before surgical procedures to identify respiratory risks
**instruct client not to smoke 6-8 hours prior to testing
withold inhalers 4-6 hours prior to testing
Spirometers are used to monitor and promote lung expansion while pulmonary function test determine effectiveness of therapy
BMI of 18.5 clients goal
Aplastic anemia
Bone marrow supression (can be a side effect of chemo therapy)—> Failure of bone marrow to produce RBCs as well as platelets and WBCs
Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?
a. A patient with chronic heart failure
b. A patient who has viral pneumonia
c. A patient who has right leg cellulitis
d. A patient with multiple abdominal drains
A. A patient with chronic heart failure
** Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.**
Interventions for sickle cell crisis
