NR462 Exam 1: REV Flashcards
Morphine Side Effects
MORPHINES
- Myosis
- Orthotatic Hypotension
- Respiratory depression
- Pneumonia (aspiration)
- Hypotension
- Infrequent waste release
- Nausea
- Emesis (vomiting)
- Sedation
The nurse is having difficulty reading a physician’s order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take?
Call the physician to have the order clarified
1 tablespoon = (mLs)
15
for patients greater than 3 years of age, how does the nurse pull the patient’s ear when administering the medication?
Upward and outward
A nursing student takes a patient’s antibiotic to his room. The patient asks the nursing student what it is and why he should take it. What information does the nursing student include when replying to the patient?
The student provides the name of the medication and a description of its desired effect.
The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse’s next best course of action?
Ask the prescriber to change the order
A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse should…:
Stops the administration of the medication and follows agency policy.
Redness, warmth, and tenderness at the IV site are signs of
plebitis
After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to:
Explain to the physician that the order needs to be given to a registered nurse.
Students cannot take orders
A nurse accidently gives a patient a medication at the wrong time. The nurse’s first priority is to:
Assess the patient for adverse effects.
What is most appropriate for the nurse to do when interviewing an older patient?
Ensure all assistive devices are in place
Assessment criteria of an older adult
- Free of pain
- Provide Xtra Time
- interview the patient and caregiver separately to ensure a reliable assessment related to any possible mistreatment.
Which assessment findings would alert the nurse to possible elder mistreatment x4
- Agitation
- Depression
- Weight Loss
- Hypernatremia
A 67-year-old woman who has a long-standing diagnosis of incontinence is in the habit of arriving 20 minutes early for church in order to ensure that she gets a seat near the end of a row and close to the exit so that she has ready access to the restroom. Which tasks of the chronically ill is the woman demonstrating
- Controlling Systems
- Preventing/Managing a Crisis
A 70-year-old man has just been diagnosed with chronic obstructive pulmonary disease (COPD). At what point should the nurse begin to include the patient’s wife in the teaching around the management of the disease?
As soon as possible
A nurse who is providing care for an 81-year-old female patient recognizes the need to maximize the patient’s mobility during her recovery from surgery. What accurately describes the best rationale for the nurse’s actions?
Continued activity prevents deconditioning.
(This consideration supersedes any possible effect on pharmacokinetics, prevention of cognitive deficits, or the patient’s sense of purpose)
Diseases Associated with the effects of Aging
- Obesity
- Diabetes,
- Hypertension
- Cancer
Lifestyle components related to the aging process x5
- Exercise
- Good nutrition
- Social support
- Stress management
- Coping resources
What should be included when planning care for an older adult?
Additional time related to declining energy reserves
Aging primarily affects the _________of drugs.
Metabolism
is pain subjective or objective
subjective
Patients most at risk for respiratory depression include x4
- older
- lung disease
- history of sleep apnea
- central nervous system depressants
For postoperative patients the greatest risk for respiratory depression
In the first 24 hours after surgery
Respiratory depression related to opioid administration vulnerability
higher in hospitalized patients who are opioid naïve
The registered nurse (RN) is caring for patients on a surgical unit. Which tasks may the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
Administer oral pain medications to a patient after abdominal surgery.
This is manifested by a withdrawal syndrome that occurs when blood levels of the drug are abruptly decreased
Physical Dependence
This is a condition characterized by aberrant behaviors arising from a drive to obtain and take substances for reasons other than the prescribed therapeutic value.
Tolerance
A 68-year-old man has chronic pain because of lung cancer that has metastasized to the bone in his back and hip. The nurse is teaching the patient and his family about tolerance and physical dependence to opioid medications. What statement, if made by the patient, indicates a need for further teaching?
“If I need higher doses of the drug to relieve pain, I have developed an addiction.”
The nurse is developing a treatment regimen for an active 78-year-old woman who has osteoarthritis with chronic joint pain. Which modality would be the safest for this patient?
Regular exercise program and acetaminophen as needed
After administering acetaminophen and oxycodone (Percocet) for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient’s room?
Ensure that the upper two side rails are raised.
(help prevent the patient from falling from bed, while not restraining the patient)
Which assessment is of highest priority for the nurse to complete before administration of morphine?
Respiratory Rate
(think ABCs)
Which nursing intervention is most appropriate when preparing to administer an opioid analgesic agent?
Count the number of doses on hand before administration.
Following a bilateral mastectomy, a 50-year-old patient refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. What approach should you take?
Matter-of-fact
“I see that you’ve combed your hair and put on makeup.”
A patient diagnosed with major depressive disorder has a nursing diagnosis of chronic low self-esteem related to negative view of self. Which of the following would be the most appropriate cognitive intervention by the nurse?
Focus on identifying strengths and accomplishments
What is common for those with self concept deficits?
difficulty making decisions
A depressed patient is crying and verbalizes feelings of low self-esteem and self-worth such as “I’m such a failure…I can’t do anything right.” The best nursing response would be to:
Remain with the patient until he or she stops crying.
An adult woman is recovering from a mastectomy for breast cancer and is frequently tearful when left alone. The nurse’s approach should be based on an understanding of which of the following:
dealing with the loss of a body part
When caring for an 87-year-old patient, the nurse needs to understand that which of the following most directly influences the patient’s current self-concept:
Adjustment to role change, loss of loved ones, and physical energy
A 20-year-old patient diagnosed with an eating disorder has a nursing diagnosis of situational low self-esteem. Which of the following nursing interventions would be best to address self-esteem?
Offer independent decision-making opportunities
The nurse asks the patient, “How do you feel about yourself?”
The nurse is assessing the patient’s:
Self Esteem
The nurse can increase a patient’s self-awareness through which ACTIONS?
- Help define problems
- Allow to explore thoughts/feelings
- Reframing thoughts/feelings in a positive way
An appropriate nursing diagnosis for an individual who experiences confusion in the mental picture of his physical appearance is:
Disturbed Body Image
In planning nursing care for an 85-year-old male, the most important basic need that must be met is:
preservation of self esteem
The home health nurse is visiting a 90-year-old man who lives with his 89-year-old wife. He is legally blind and is 3 weeks’ post right hip replacement. He ambulates with difficulty with a walker. He comments that he is saddened now that his wife has to do more for him and he is doing less for her. Which of the following is the priority nursing diagnosis?
Risk for situational low self-esteem
A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first?
Serum potassium
Dietary sodium restriction is important with heart failure because
Na+ holds water in the extracellular fluid, making the ECV excess worse
Why does heart failure commonly causes extracellular fluid volume (ECV) excess ?
because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na+ and water
You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid?
Fluid that has sodium (salt) in it
The registered nurse cannot delegate
- working with IV tubing
- Changing IV infusion
Assessment findings consistent with intravenous (IV) fluid infiltration include
- Edema and pain
- Pallor and coolness
What is a defining characteristics is consistent with fluid volume deficit?
Dry mucous membranes, thready pulse, tachycardia
Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl?
Auscultate dependent portions of lungs
Excessive or too-rapid infusion of 0.9% NaCl (normal saline) causes
- extracellular fluid volume (ECV)
- excess with pulmonary vessel congestion
- pulmonary edema
When is assessment of muscle strength important?
potassium imbalances
While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action?
Stop the transfusion
he health care provider’s order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid?
Oliguria (abnormally small amounts of urine)
Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient’s breathing?
Provide frequent oral care to keep her mucous membranes moist
What is a compensatory mechanism for metabolic acidosis
hyperventilation (allow to continue)
How do you calculate volume for ice chips
1/2
requires the integration of mental and muscular activity
psychomotor
The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur?
- When the patient’s pain medications are working
- Just before lunch, when the patient is most awake and alert
A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse’s best plan in teaching this patient?
Provide only the information that the patient needs to go home
in denial phase, just immediate info needed.
A nurse is going to teach a patient how to perform breast self-examination. Which behavioral objective does the nurse set to best measure the patient’s ability to perform the examination?
The patient will perform breast self-examination correctly on herself before the end of the teaching session.
The nurse is teaching a parenting class to a group of pregnant adolescents. The nurse pretends to be the baby’s father, and the adolescent mother is asked to show how she would respond to the father if he gave her a can of beer. Which teaching approach did the nurse use?
Role Play
An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse:
Allows the patient time to express himself or herself and ask questions.
A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn?
Expressing the importance of learning the skill correctly
A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use?
Demonstration, to help w/ psychomotor skills
A term for using familiar images when teaching to help explain complex information
Analogies
A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first?
Remembers what you tell them first
ABC’s
“How to use an inhaler during an asthma attack”
escribes what the learner will do after the teaching session.
A learning objective
A nurse is teaching a 27-year-old gentleman how to adjust his insulin dosages based on his blood sugar results. What type of learning is this?
Cognitive
What signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid?
Difficulty arousing the patient
is 100 times more potent than morphine and not recommended for acute postoperative pain
Fentanyl
A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication?
Stimulant laxative
A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours prn. Which part of the order does the nurse question?
The time interval (should not be ordered PRN)
A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of:
physical dependence
patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse’s first action is to:
Assess the characteristics of the pain.
When using ice massage for pain relief, which of the following are correct?
- Apply ice using firm pressure over skin.
- Apply ice until numbness occurs and remove the ice for 5 to 10 minutes
involves stimulation of the skin with a mild electrical current passed through external electrodes
TENS
While caring for a patient with cancer pain, the nurse knows that the World Health Organization (WHO) analgesic ladder recommends:
Transitioning use of adjuvants with nonsteroidal antiinfl ammatory drugs (NSAIDs) to opioids
A postoperative patient is currently asleep. Therefore the nurse knows that:
The sedative administered may have helped him sleep, but assessment of pain is still needed.
Normal Value for Sodium
135 - 147 mEq/L
Normal Value for Potassium
3.5 - 5 mEq/L
Normal Value for Chloride
95 - 107 mEq/L
Glucose Value 2 hours after eating
Up to 140
A normal fasting (no food for eight hours) blood sugar level is
between 70 and 99 mg/dL
Hemaglobin Female
12.0 - 15.0
Hemaglobin Male
13.5 - 16.5
Hematocrit (%)
38-47.7
WBC
5,000 - 10,000
Platelets
150,000 - 300,000
(150 - 350)
the most accurate method for determining fluid balance
the patients weight
blood urea nitrogen (BUN)
8 - 21
8 bun twists x 3
6 Rights of Medication Administration
Patients Make Drugs Red To Death
- Right Patient
- Right Medication
- Right Documentation
- Right Route
- Right Time
- Right Documentation
What should the flow meter setting be for a nasal cannula?
1-6 liters/minute
What should teh F102% be for a nasal cannula
24 - 44%
What should the flow meter setting be for a non-rebreather mask?
15 liters/minute
What percent should the F102 be for a non rebreather mask
60-90%
What is the correct patient position for a person short of breath
semi-fowlers or high fowlers position w/ elbows resting on knees
What assessment should the nurse provide prior to oxygen administration? x5
- oxygen saturation
- sputum production
- auscultate lugs
- respiratory rate
Humidication should be used with any oxygen source if the oxygen is greater than how many liters/min
4
What are the 3 safety checks before administering a medication
- Check labael against order
- Verify label against MAR
- Check ID band against MAR
When do you deliver a PRN medication
as needed
when do you deliver a medication labeled “STAT”
immediately
When do you deliver a medication marked “now”
within the hour
When do you deliver a medication marked “on call”
as requested by OR
When do you deliver a medication marked A.C.
before a meal (think AM)
When do you deliver a medication marked P.C.
after a meal
How do you deliver an oral sublingual medication?
under the tongue
How do you deliver an oral buccal medication
in contact with mucous membranes of the cheek
Nurse assessments prior to delivering an inhaled medication
- Respiration and breath sounds
- Ask patient about subjective symptoms
- Explain procedure to the patient
What is the length of time between inhalation of the same medications
20-30 seconds
The length of time to wait before administering different inhaled medications
2-5 minutes
What protection does a nurse need adminstering a topical medication
gloves
What information with the nurse write on a topical medication patch
Date, time, initials
How will the nurse position a patient for administering a laxative suppository?
Left side lying sims position with right leg flexed
challenges for caregivers of family members suffering from chronic illnesses x6
- prejudice
- lack of respite
- conflict of decisions
- not meeting their own needs
- financial
- lack of education
This type of illness lasts longer than 6 months. The onset is gradual, and irreversible.
Chronic illness
What are 4 examples of Chronic Illness
- Diabetes
- COPD
- Parkinsons
- MS
This type of illness is sudden. It can last 3-6 months. It can also be reversed
Acute Illness
Name 4 examples of an acute illness?
- Pneumonia
- Delirium
- Shingles
- Apendicitis
Name 3 types of Disabilities
- Body System
- Developmental
- Acquired (after your born)
Acidosis/Alkalosis
ROME
-
Respirotaroy Opposite
- pH up PCO2 down= Alkalosis
- pH down PCO2 up= Acidosis
-
Metabolic Equal
- pH up HCO3 up = Alkalosis
- pH down HCO3 down = Acidosis
Hypothalamus Functions
TAN HATS
- Thirst & Water balance
- Adenohypophysis
- Neurohypophysis
- Hunger & Satiety
- Autonomic regulation
- Temperature Reg
- Sexual urges & emotions
Causes/ R/T of Hyperkalemia
MACHINE
- Meds
- Acidosis
- Cellular destruction
- Hypoaldosteronism (hemolysis)
- Intake, excessive
- Nephrons, renal failure
- Excretion, impaired
Signs (AEB) Hyperkalemia
MURDER
- Muscle weakness
- Urine, oliguria, anuria
- Respiratory distress
- Decreased cardiac contractility
- EKG Changes, Peaked T Waves
- Reflexes, hyper, or hypo
Signs (AEB) Hypokalemia
6L’s
- Lethargy
- Lethat cardiac arrhthymia
- Leg cramps
- Limp Muscles
- Low, shallow respirations
- Less stool (constipation)
R/T Hypokalemia
GRAPHIC IDEA
- GI losses
- Renal
- Aldosterone
- PEriodic paralysis
- Insulin Excess
- Cushing;s Syndrome
- Insufficient intake
- Diuretics
- Elevated beta adrenergic activity
- Alkalosis
Signs (AEB) of Hypernatremia
FRIED
- Fever
- Restless
- Increase BP
- Edema
- Decreased Urinary Output
Hypertension Treatment
ABCD
- Ace inhibitors/ARBs
- Beta Blockers
- Calcium channel blockers
- Diuretics
What is the process for Medication Administration?
- Ordered by the LIP
- Transcription into EHR (pharm or nurse)
- Dispensing Medication (Pharm)
- Administration of Med (Nurse)
What is the primary goal of teaching activities?
meet learner’s health outcomes
What is the most effective method of learning?
Active-
- what we say, (70%)
- what we say & 90 (90%)
What approach to take educating an older adult? x11
- learner maximum control
- slow pace
- be aware of attention span
- avoid distractions/environmental
- involve family & caretakers
- Sensory deprivation (large print)
- Allow time to process
- write instructions
- concrete/specific
- correct
- praise
Clinical Manifestations for Hypervolemia?
- Pulse is bounding JVD
- High BP
- Tachypneic
- dyspnea
- crackles
- headache, confusion, muscle spasms
- Anorexia, weight gain, ascites
- peripheral edema
Clinical Manifestations of Hypocalcemia
CATS
Convulsions
Arrythmias
Tetany
Spasms/Stridor
Think Sodium think..
neurological
Think Potassium think….
Heart
Vital Signs for Hypernatremia?
- Tachycardia
- Hyperthermia
- Orthostatic hypotension
Clinical Manifestations of Hypermagnesia
Opposite of HYPER
- drowsy
- nausea
- depressed reflexes
- respiratory depression
- sleepy “somnolence”
Clinical Manifestations of Hypomagnesia
OPPOSITE of HYPO
- Increase nerve impulse
- tremors
- seisure
- constipation
- hyperactive
- deep tendon reflex
The average person should have how much urine output per hour?
- 30mL per hour ***
How many mLs in teaspoon
5
Patient 36 wks pregnant, burning w/ urination, back aches, fever, which labs?
- Urinalysis
- CBC
Patient has chest pain moving down left arm, SOB, weak, nausea, what labs would you get?
EKG
CBC
BMP
Cardiac Enzymes
Patient short of breath, fever, cyanosis around moth, coughing up thick green sputum. What labs should you get
- X-ray
Sputum
CBC- WBC (5-10,000)
BMP
How do you replace potassium (hypokalemia)?
- Never IV Push
- Oral
- Monitor I/O
- Potatoes, Avocado, Banana
Reasons for hypovolemia
- ng drainage,
- burns (3rd spacing),
- dehydration,
- shift of plasma into interstitial spaces,
- peritonitis,
- ascites (abdomen)
2.2 kg of fluid equals how much mLs
1000
Acute pain is directly related to…
tissue damage
What type of symptoms are associated with acute pain
sympathetic nervous system responses
this type of pain is highly resistant to treatment
intractable pain (chronic)
pain associated with deep internal pain receptors?
Visceral Pain
Pain in the bones, joints or muscles
somatic pain
Pain identified as hot, stabbing, shooting, or numbing. Associated with damage to peripheral nerve or CNS
Neuropathic
This type of pain can be described as referred and spreading
Radiating pain
Pain perceived from a tissue that has been surgically removed
Phantom pain
Diagnostics Tests for Pneumonia
- chest xray
- blood test
- pulse oximetry
- sputum test
What is the phys assessment prior to meds? x7
- vital signs
- ability to swallow- gag reflex
- GI motility
- Muscle mass
- Venous Access
- Body sys assessment
- right to refuse
What are examples of nursing diagnoses related to med admin
anxiety, deficity of knowledge, impaired mobility, impaired swallowing, fall risk
What are basic rules for administering medication x9
- prep for ONE patient at a time
- compare order with me davailable
- calc drug dose
- Verify order
- Check if it seems excessive
- take meds directly to the patient
- Check 2 patient identifiers
- complete required assessent prior to giving
- DO NOT LEAVE at bedside, stay until that complete
What do you do for enteral medications
- crush and dissolve in water
- flush with water/saline between medications
- make sure wont clog tube
What are precautions for rectal admin
- Past internal sphincter and against the rectal mucosa (side)
- local or systemic effects
- suppositories/enemas
- WEAR GLOVES
What are precautions for vaginal administration
- foams, jellies, creams
- body temperatures
- standard precautions (gloves)
- privacy if client self administer
Is 25 gauge bigger or smaller than a 16 gauge needle
smaller
Normal Phys changes with aging
- body composition
- body cells less able to replace themselves
- reduces lean body mass
- loss of subq fat
- body shrinkage due to loss of cartilage
- body fat atrophy (sagging)
- hard to maintain body temp
- increas risk of dehydration, decrease intracellular fluid
Cardiovascular changes for aging
- decreased contractility
- impaired blood flow
- alter preload/afterload
- vessels tortuous
- heart valves rigidity
- increase atherosclerotic
Respiratroy changes in older adult
- rigid thoracic cage
- decrease vital capcity
- decrease cough efficiency
- decrease in ciliary action- (flow of mucous)
Endocrine changes in adult
- thyroid- decreased metabolism
- pancreas-insufficient release of insulin
- pituitary-decrease release in hormones
Renal Changes in Adult
- decrease bladder capacity
- decreased concentrating / diluting abilities
- decrease creatinine clearance (buildup)
GI changes in adult
- tooth loss
- decrease saliva
- altered digestion
- weakened esophageal sphincter
- decrease in blood flow
- decrease size in organs
- decrease peristalsis
Nervous sys changes in adult
- decrease in neurons & speed of conduction (driving)
- decrease brain weight
- decrease peripheral nerve function
Sensory changes in adult
- presbyopia
- glaring
- difficult distinguishing btwn blue & green
- presbycusis
- ear wax build up
- decrease taste
Reproductive changes in adult
- vaginal mucosa thinning and atrophy
- decrease breast tissue
- decreased libido
skin changes
- heat regulation
- elasticity
- epidermal renewal
- screation of oil/perspiration
- decrease infammatory response
Fluid Volume Excess
- tachycardia
- JVD
- Bounding Pulse
- ansarca (gen edema)
- labs all decrease
Positive Chvosteks and Trousseau’s sign
hypocalcemia
Gen survey assessment
- make sure the patient is safe when they leave the hospital
- living conditions
- safe environment
What is Anasarca?
generalized edema (systemic)
Is “heart failure” a nursing diagnosis or medical diagnosis?
Medical Diagnosis- say “decreased heart function”
Wherever sodium goes..
water follows. Cant hold on to water without sodium
Examples of Body System Disabilities
- Spina Bifida
- Blindness
- Deafness
Examples of Developmental Disabilities
Cerebral Palsey, Down Syndrome
Chvostek’s Sign
Trousseau’s sign
What is RUB MUB
- Respiratory Uses Bicarb,
- Metabolic Uses Breathing
Acutal Problem means
we have evidence (AEB)
A well written nursing diagnosis contains 3 components
Diagnosis,
Related To
As Evidence By
Emotional Aspect, hospice
Affective Domain
What grade level of teaching?
5th grade
measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain.
FLACC scale
FLACC stands for
Face, Legs, Activity, Cry, Consolability
