page 11-20 Flashcards

1
Q

Blood Administration

What must be received before a transfusion started?

A

Signed written consent

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2
Q

Blood Administration

What blood type is considered universal & can be used for all other donors?

A

Type O Negative

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3
Q

Blood Administration

What blood type is considered the universal recipient & can receive all blood?

A

Type AB Positive

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4
Q

Blood Administration

What is the most common infection spread through blood transfusions?

A

Hepatitis B

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5
Q

Blood Administration

In order to determine donor compatibility, what must be done?

A

Type & cross match

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6
Q

Blood Administration

What must be done to determine a client’s baseline before starting the transfusion?

A

Take vital signs

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7
Q

Blood Administration

What size IV gauge must the client have?

A

18G with a filter needle

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8
Q

Blood Administration

How many nurses confirm the unit of blood?

A

2

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9
Q

Blood Administration

How long after blood is removed from blood bank’s refrigerator do you have to start it?

A

30 minutes

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10
Q

Blood Administration

How long must you stay with the client after transfusion is started?

A

15 minutes

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11
Q

Blood Administration

How many mLs are in one unit of packed RBCs?

A

About 250 mL

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12
Q

Blood Administration

What are the signs of an adverse reaction?

A
  • restlessness
  • nausea
  • hives
  • SOB
  • fever
  • chills
  • back pain
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13
Q

Blood Administration

What do you do if an adverse reaction occurs?

A
  • STOP Blood & run the normal saline that hangs with blood
  • do vitals
  • notify physician & blood bank
  • make sure urine & blood cultures are done
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14
Q

Blood Administration

Why must you run blood at a slow rate?

A

because running blood fast can cause fluid overload

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15
Q

Blood Administration

What drug is also used to treat anemia because it increases red blood cell production?

A

Epoetin alfa

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16
Q

Blood Administration

Clients taking Epoetin alfa should be monitored for what?

A

Hypertension & seizures

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17
Q

Blood Pressure

What is Blood Pressure?

A

The force of blood flowing through the arteries.

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18
Q

Blood Pressure

What is the recommended blood pressure?

A

120/80

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19
Q

Blood Pressure

What are the top & bottom values?

A

Systolic & diastolic pressure

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20
Q

Blood Pressure

Define the terms: systolic &diastolic pressure

A

Systolic
-pressure while heart beats

Diastolic
-pressure while heart rests

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21
Q

Blood Pressure

Which value determines if a person has HTN?

A

Diastolic - if the pressure of the heart is elevated at rest, then HTN is present.

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22
Q

Blood Pressure

What are the risk factors for hypertension?

A
  • African American
  • obesity
  • anxiety
  • diabetes
  • smoking
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23
Q

Blood Pressure

What are the physical signs of hypotension?

A
  • Blurry vision
  • headache
  • chest pain
  • but remember that HTN is called a silent killer because most people don’t have symptoms
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24
Q

Blood pressure

How can the size of the blood pressure cuff affect blood pressure reading?

A

If it is too small, the BP will be higher than it really is.

If it is too big, the BP will be lower than it actually is.

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25
Q

Blood pressure

What are some other factors that alter blood pressure?

A

Position, caffeine, anxiety, activity

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26
Q

Blood pressure

What is pulse pressure?

A

The difference between systolic and diastolic numbers

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27
Q

Blood pressure

what is the mean arterial pressure?

A

Diastolic pressure (+) 1/3 of pulse pressure; this value should be greater than 60.

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28
Q

Blood pressure

Before you give a blood pressure medication, always check ______ and ______ .

A

Blood pressure and pulse rate

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29
Q

Blood pressure

Hold the medication if systolic BP is less than _____ Or heart rate is less than _____.

A

100, 60

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30
Q

Blood pressure

What classes of medications are used for HTN?

A

Diuretics,
beta blockers,
calcium channel blockers,
vasodilators

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31
Q

Blood pressure

Medications that end in “pril” are _____?

A

Ace inhibitors

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32
Q

Blood pressure

Ace inhibitors correct heart failure by _____ afterload.

A

Decreasing

They also promote vasodilation by inhibiting the production of angiotensin.

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33
Q

Blood pressure

____Is an adverse reaction seen with the use of ACE inhibitors.

A

Angioedema

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34
Q

Blood pressure

Signs of angioedema are?

A

Swelling of the lips and mouth

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35
Q

Blood pressure

Client may also have a persistent, nagging ______.

A

Cough

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36
Q

Blood pressure

Which is more dangerous in angioedema: a cop or swelling of the lips and mouth?

A

Swelling of the lips and swelling mouth may indicate laryngeal angioedema.

A compromise airway is the priority.

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37
Q

Blood pressure

Medications that end in “olol” are______?

A

Beta blockers

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38
Q

Blood pressure

Client who take anti—hypertensive medications should be taught what method to avoid falling?

A

Sit in a chair or at the bedside for 30 minutes after taking medication to adjust to a lower circulating blood pressure.

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39
Q

Blood pressure

What the herbal medication is used to lower BP?

A

Garlic

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40
Q

Blood pressure

Clients taking antihypertensives should avoid hot showers, baths, and weather . True or false?

A

True. These things can cause dizziness.

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41
Q

Blood pressure

What is the best diet for a hypertensive client?

A

Low Sodium, low-fat DASH diet Dietary approaches to stop HTN

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42
Q

Breast-feeding

Breast-feeding moms will often feel what while feeding the baby?

A

Abdominal cramps

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43
Q

Breast-feeding

This is due to the release of?

A

Prolactin and oxytocin

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44
Q

Breast-feeding

What is the best way to burp a baby?

A

While he or she is sitting up

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45
Q

Breast-feeding

What are the benefits of breast-feeding?

A

Passive immunity
Quicker weight loss in mother after birth
Increase in bonding
Economically low cost

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46
Q

Buerger’s Disease (Thromboangitis Obliterans)

This disease is the obstruction and inflammation of blood vessels mainly where?

A

Hands and feet

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47
Q

Buerger’s disease (Thromboangitis Obliterans)

Clients presents with what symptoms?

A

Pale, blue, cold hands and feet; they may tingle or be painful.

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48
Q

Buerger’s disease (Thromboangitis Obliterans)

Who is most At risk for this disease?

A

Males who smoke or chew tobacco

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49
Q

Buerger’s disease (Thromboangitis Obliterans)

What are the treatment goals?

A

There is no cure, only symptom control

Teach trying to Stop smoking, dress appropriately for the weather and try to reduce life stressors.

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50
Q

Bulimia Nervosa

What is the eating cycle involved?

A

Eating binges followed by purging.

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51
Q

Bulimia Nervosa

Will you be able to see physical changes or weight loss?

A

Client usually remains at a normal weight.

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52
Q

Bulimia Nervosa

Besides purging, what other methods are used to loose weight?

A
Vomiting
Enemas
Drugs (speed)
Diuretics 
Diet’s
Pills
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53
Q

Bulimia Nervosa

What are the medical complications associated with bulimia nervosa?

A

tooth decay

electrolyte imbalances

ulcers

cardiac arrhythmias

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54
Q

Bulimia Nervosa

Safety is a concern in clients with bulimia nervosa because of______.

A

Suicidal thoughts

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55
Q

Bulimia Nervosa

List the treatment goals.

A
  1. Encouraging talking, safety and assessing suicidal potential
  2. Establishing a diet plan
  3. Supervision during meal time
  4. Antidepressants may be prescribed
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56
Q

Burns

What are the two age groups most at risk for suffering a burn injury?

A

Children and elderly

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57
Q

Burns

What are the types of burns?

A

Chemical, electrical, thermal, radiation

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58
Q

Burns

If the face/neck has been burned, what is the nursing priority?

A

Airway obstruction

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59
Q

Classification of burns

First degree (Superficial partial thickness)

A

Skin pink/red, painful (sunburn)

60
Q

Classification of burns

Second- degree (deep partial thickness)

A

Skin red/white, blisters, swelling

61
Q

Classification of burns

Third- degree (full thickness)

A

Skin black/brown, edema, all layers of skin burned, grafting needed

62
Q

Classification of burns

What is the formula used to determine fluid replacement for the first 24 hours?

A

Parkland formula

63
Q

Classification of burns

What is the Parkland formula?

A

4 ml of LR x wt. (kg) x % of body burn

64
Q

Classification of burns

How much of this fluid do you give in the first 8 hours?

A

1/2 of the total volume

65
Q

Classification of burns

How much fluid do you give for the second eight hours?

A

1/4 of total volume

66
Q

Classification of a Burns

How much fluid do you give for the third eight hours?

A

1/4 of total volume

67
Q

Classification of burns

Should you burst a blister?

A

No

68
Q

Classification of burns

What is the best route for pain meds?

A

IV

69
Q

Classification of burns

What diet is appropriate for burn patients?

A

High calorie, high-protein

70
Q

Classification of burns

What is a common electrolyte problem in clients with burn?

A

Hypokalemia or hyper kalemia; both can be seen in clients with burns.

71
Q

Classification of burns

Due to prolong stressed, clients are at risk for what type of ulcers?

A

Curling’s ulcers

72
Q

Classification of burns

What medication should be given before dressing changes?

A

Pain medication

73
Q

Cancer

True or false? Cancer is an abnormal growth of cells.

A

True-growth of cells is uncontrolled.

74
Q

Cancer

When the cancer cells travels from the original location to a new place, what is it called?

A

Metastasis

75
Q

Cancer

What acronym is used to describe the warning signs of cancer?

A

CAUTION

76
Q

Cancer

What do the letters CAUTION stand for?

A
Change in bowel or bladder
Any store that does not heal
Unusual bleeding/discharge
Thickening in breast
Indigestion
Obvious change in wart
Nagging cough or hoarseness
77
Q

Cancer

What are the two ways to describe a tumor?

A

By grading or staging

78
Q

Cancer

What is the difference between Grading or staging?

A

Grading describes tumor By the cells.

Staging describes the progression of a tumor by the clinical symptoms

79
Q

Cancer

What are the three types of radiation treatment?

A
  1. External and unsealed
  2. Internal sealed
  3. Internal
80
Q

Cancer

What precautions must be taken for a client receiving radiation treatment?

A

Private room/bathroom
Limit visitors
Rotate nursing staff who provide care
Place sign at door and bedside

81
Q

Cancer

What is the most dangerous type of radiation?

A

Sealed internal radiation because a solid radio active implant is placed inside tumor

82
Q

Cancer

What additional precautions must be taken for clients receiving sealed internal radiation?

A

All body fluids are radioactive; use hazardous clean up gloves/gown.

83
Q

Cancer

If a client’s sealed internal implant falls out. e.g. cervical implant, what should you do?

A

Pick it up with a long handle forceps and put it in a lead container.

84
Q

Cancer

Chemotherapy works by destroying the cell_______.

A

Wall

85
Q

Cancer

What are the side effects of chemo therapy?

A
Nausea
Anorexia
Alopecia
Sterility
Decrease bone marrow and platelets
86
Q

Cancer

Why is Reglan (metoclopramide) given?

A

To reduce nausea

87
Q

Cancer

Is alopecia from chemotherapy permanent?

A

No it is temporary.

88
Q

Cancer

is alopecia from chemotherapy permanent?

A

No, it is temporary.

89
Q

Cancer

Is the sterility From chemotherapy permanent?

A

Yes

90
Q

Cancer

Client with the cancer will also need____.

A

Neutropenic precautions

91
Q

Cancer

What are the neutropenic precautions?

A
Strict handwashing
No visitors who are sick
No children
No raw food, no Live plants
No free standing water
92
Q

Cancer

What is Filgrastim?

A

Drug used to treat neutropenia; monitor WBCs

93
Q

Cancer

When is the best time to do a breast self exam?

A

Once a month however these are no longer recommended.

94
Q

Cancer

When is the best time to do a self-testicular exam?

A

The same day each month.

95
Q

Cancer

If a client has had a mastectomy, can you take a blood pressure on the affected side?

A

No IV or BP

96
Q

Cancer

List some other post-mastectomy client education tips.

A

Elevate affected extremity
No initial exercise after surgery
Encourage discussion for positive self-image

97
Q

Cataracts

What are the signs of Cataracts?

A

Milky/white lens

Painless, blurred vision

98
Q

Cataracts

How are they treated ?

A

No treatment until vision is severely impaired

99
Q

Cataracts

During surgery, what is done?

A

The cataracts Are removed and a new lens may be implanted.

100
Q

Cataracts

After surgery, will vision be corrected?

A

Only if a new lens is placed.

If no lens is placed, the client will need glasses/contacts.

101
Q

Cataracts

After surgery, what is the main concern?

A

To check for hemorrhage of the eye.

Please client in semi Fowler’s position.

102
Q

Cataracts

What do you tell clients to avoid?

A

Coughing, sneezing, bending over at the waist, straining, rubbing, or crying.
No lifting greater than 5 pounds.

103
Q

Cataracs

How should the post-op client sleep?

A

Sleep on Unaffected side or if surgery was on both eyes, sleep on back.
Use eye shield at night to protect eye.

104
Q

Celiac disease

Foods containing______must not be eaten.

A

Gluten(This is a protein)

105
Q

Celiac disease

In celiac’s disease, malabsorption of____a curse.

A

Fats

106
Q

Celiac disease

What foods contain gluten?

A

BROW

Barley
Rye
Oats
Wheat

107
Q

Celiac disease

The client’s abdomen is often______.

A

Distended

108
Q

Celiac disease

What does the client’s stool look like?

A

Smelly, pale, bulky; expect lots of gas with some diarrhea.

109
Q

Celiac disease

The best food substitutes are___and_____.

A

Corn, rice

110
Q

Celiac disease

Can a client on a gluten-free diet have cookies, spaghetti, or waffles?

A

No all these products have grain in them.

111
Q

Celiac disease

What is another name for celiac disease?

A

Celiac sprue

112
Q

Cerebrovascular Accident (CVA)

Define the term CVA.

A

Reduction of cerebral blood flow and oxygen causing brain cell damage.

113
Q

Cerebrovascular Accident (CVA)

The three most common causes of CVA are?

A

Embolism
Hemorrhage
Thrombus

114
Q

Cerebrovascular Accident (CVA)

What are the signs of a CVA?

A
Client complaints of:
headache, 
nausea, 
nuchal rigidity, 
HTN, 
slow bounding pulse, 
Cheyne- Stokes respirations, 
speech changes, 
facial droop
115
Q

Cerebrovascular Accident (CVA)

What is the difference between CVA and transient ischemic attack (TIA)?

A

TIA Is it temporary period of neurological deficit. It has similar signs as a CVA, but the symptoms will all resolve.

116
Q

Cerebrovascular Accident (CVA)

What is agnosia?

A

Inability to use an object correctly.

117
Q

Cerebrovascular Accident (CVA)

Expressive aphasia occurs when_____.

A

Client cannot communicate properly (Aphasia can be expressive or receptive)

118
Q

Cerebrovascular Accident (CVA)

If the left hemisphere is affected, you will see weakness on the ____side.

A

Right side

119
Q

Cerebrovascular Accident (CVA)

If the right hemisphere is affected, you will see weakness on the___side.

A

Left

120
Q

Cerebrovascular Accident (CVA)

Remember the place the client’s belongings on the_____side.

A

Unaffected

121
Q

Cerebrovascular Accident (CVA)

The tests used to determine CVA are?

A

CT, EEG, Cerebral arteriography

122
Q

Cerebrovascular Accident (CVA)

Patient with hemorrhagic stroke are at increased risk for which complication?

A

Seizures due to possible bleeding in the cerebral cortex.

123
Q

Cerebrovascular Accident (CVA)

What are the nursing assessments?

A
Monitor vital signs, 
Neuro checks, 
Watch for seizures, 
monitor for increase in intracranial pressure, 
check ability to swallow
124
Q

Cerebrovascular Accident (CVA)

What complications of the eyes can a client with a CVA have?

A

Corneal abrasions (lacrimal glands will not produce secretions)

125
Q

Cerebrovascular Accident (CVA)

What is the activity level for this client?

A

Strict bed rest

126
Q

Cerebrovascular Accident (CVA)

How should the room environment be?

A

Quiet, peaceful, with objects within reach on unaffected side.

127
Q

Cerebrovascular Accident (CVA)

How do you position the CVA client?

A

Turn every two hours on unaffected side
20 minutes on affected side
Make sure to elevate affected extremities

128
Q

Cerebrovascular Accident (CVA)

Why would a thrombolytic be given?

A

To dissolve a clot

129
Q

Cerebrovascular Accident (CVA)

Do not give thrombolytics if the cause is ______.

A

Hemorrhage

130
Q

Cerebrovascular Accident (CVA)

What other medications may be prescribe to treat a CVA?

A

Anti-hypertensive, anti-coagulant
(not for hemorrhage stroke!)
anticonvulsants

131
Q

Cerebrovascular Accident (CVA)

Do anticoagulants like Coumadin and aspirin dissolve clots?

A

No, they only thin the blood; they do not dissolve clots.

132
Q

Chronic obstructive pulmonary disorder COPD

What are the three disorders that make up COPD?

A

Asthma
Bronchitis
Emphysema

133
Q

Chronic obstructive pulmonary disorder COPD

What are the signs/symptoms of COPD?

A

SOB with activity
Wheezing
Productive cough
Cyanosis

134
Q

Chronic obstructive pulmonary disorder COPD

What would the ABG of a client with COPD show?

A

Hypoxemia

135
Q

Chronic obstructive pulmonary disorder COPD

What does the chest of a client with COPD look like?

A

Barrel chest

136
Q

Chronic obstructive pulmonary disorder COPD

What would the fingers of a client with COPD look like?

A

Clubbed

137
Q

Chronic obstructive pulmonary disorder COPD

Due to SOB with activity clients may experience______because of difficulty eating.

A

Weight loss

138
Q

Chronic obstructive pulmonary disorder COPD

Why must you access the amount of O2 your COPD client receives?

A

COPD’ers Keep a high level of CO2 in their blood; breathing is controlled by this fact.

139
Q

Chronic obstructive pulmonary disorder COPD

A client with a COPD should not receive 02 by NC greater than____.

A

2 LPM

140
Q

Chronic obstructive pulmonary disorder COPD

To control SOB, the____technique should be taught.

A

Pursed lip breathing

141
Q

Chronic renal failure

Chronic renal failure is progressive and irreversible. True or false?

A

True

142
Q

Chronic renal failure

What are possible causes of CRF?

A

Hypertension
Frequent infections
DM 2
Renal/urinary obstruction

143
Q

Chronic renal failure

what signs/symptoms would clients show?

A

Decrease urine output
Hypertension
Decreased urine specific gravity
Fluid overload

144
Q

Chronic renal failure

What is uremic frost?

A

Urea crystals that come through the skin with perspiration

145
Q

Chronic renal failure

What are the nursing interventions for chronic renal failure?

A

Modification of diet
Give diuretics
Antihypertensives, monitor BUN and creatinine
Daily weight

146
Q

Chronic renal failure

Where would you see uremic frost?

A

Face, Underarms, groin

Teach client to wash skin with plain water

147
Q

Chronic renal failure

Client may need____to assist with waste removal.

A

Dialysis