Passpoint 2 Flashcards
Why is 20mL of urine output a concern for a nurse with a client who just suffered from MI
Oliguria is a sign of cardiogenic shock, due to reduced blood flow to the kidneys.
Low BP
Rapid weak pulse
Confusion due to reduced blood flow to brain
Cardiogenic shock is serious with 90% death rate
Which is most important for a client with pertussis
A. Gloves & Gown
B. Negative Pressure Room
C. Masks for everyone
D. Use goggles for direct contact with child
C.
Pertussis (whooping cough) is spread via droplets
Masks requiered for first 5 days after start of medical treatment
TB, Measles, Varicella need negative pressure
Respiratory Alkalosis S/S
Vs
Respiratory Acidosis
Alkalosis = lightheaded / paresthesia
Acidosis = Nausea, Vomit, Diarrhea
Left-sided heart failure S / S
Vs
Right-sided heart failure
Left = pulmonary edema, bibasilar crackles (Bubbling orcracklingsound originating from the base of the lungs. Occur inflation or deflation)
Right = jugglar vein distention, right quadrant pain (hepatomegaly), and dependent edema (Gravity Caused feet & hands) - Usually Chronic
Cystitis is …
an infection of the bladder that almost always follows (is secondary to) bacterial infection in the urine. It is the most common type of urinary tract infection (UTI), particularly in women.
After surgery
- Establish air patency
Check: Bleeding, VS, and promote urine output
VS: HR 130, BP 98 / 56, Respiration 24
These are signs of
Shock
rare condition caused by a combination of four heart defects that are present at birth.
defects cause oxygen-poor blood to flow out of the heart and into the rest of the body.
Risk factors include a viral illness such as rubella during pregnancy, maternal alcoholism, or a family history of the condition.
Tetralogy of Fallot
Polyneuritis
disorder affecting several or many peripheral nerves, especially when thought to be of inflammatory origin.
Guillian-Barre syndrome
(Immune system attacks the nerves)
which assessment is most important
Lungs
ICP
pain
Metabolic State
Lungs
Polyneuritis causes weakness and paralysis, which may ascend to the trunk amd lungs
Which will help a client with thick secretions
A. Elevation of bed 30 degrees
B. Turning q2hrs
C. Increase of fluids
D. Cool room temperature
Increase fluids
Helps to thin the thickened mucous
Match
Wheezing in Single lung field
Decreased / absent lung sounds in base of lungs & decreased Ox Sat
Wheezing Bilateral lung fields, coughing, shortness of breath
Acute bronchitis
Atelectasis
Aspiration pneumonia
Aspiration pneumonia
Wheezing in Single lung field
Atelectasis
Decreased / absent lung sounds in base of lungs & decreased Ox Sat
Acute bronchitis
Wheezing Bilateral lung fields, coughing, shortness of breath
IV corticosteroids are prescribed for asthma, bronchitis, ______
Anaphylaxis
Client has an obstruction due to foreign body aspiration
What is required to remove it
Bronchoscopy
Bronchoscope, a thin, flexible tube with a light and camera on the end, to look for signs of blockages or disease in the throat, airways, and lungs
_____ aka ataxic or Biot’s breathing, is a dangerous, irregular, unpredictable deep breaths followed by periods of apnea.
Alert HCP
Cluster breathing
Which is most important for nurse to include in discharge for asthma patient with a Rescue Inhaler
Monitor HR
Report Nausea/ Vomiting
Watch for hyperactivity
Record change in taste
Monitor Hr
Tachycardia is the most serious SE of rescue inhalers
All other SE are valid
A lesion in the upper medulla or lower pons is usually the cause of (this type) of dangerous breathing
cluster
pattern characterized by rapid, shallow, rhythmic breathing cycles in clusters, followed by periods of apnea
Biot’s respiration
Sucking stab wound in chest gets covered with gauze and tape on 3 side.
Why is this done?
Prevent pneumothorax (Collapsed Lung)
Cardiac tamponade (Fluid in pericardial sac) is a medical emergency
It prevents ____ from filling with blood
Manifestaciones
Pulsus Paradoxus ( condition where a patient’s blood pressure drops by more than 10 millimeters of mercury (mmHg) during inspiration.)
hypotension, chest pain, jugular distention, diminished heart sounds
Left ventricle
Tension pneumothorax occurs when an injury to the chest allows air to enter but not leave the pleural space.
What can be the result of this
Shifting of heart to uncompromised side
Result
MI
Why would a patient with Emphysema have respiratory Acidosis
A. Narrowed bronchioles and decreased oxygen
B. Increased work of breathing
C. Increased production of mucus, lack of oxygen
D. Alveoli lost elasticity, retains carbon dioxide
Alveoli lost elasticity, retains carbon dioxide
Narrowed bronchioles and increased mucus production is characteristics of chronic bronchitis which causes Hypoxemia
Crackles are typically heard (inspiration/ expiration) can be high or low pitched and classified as fine or course.
Inspiration
Pneumonia, acute respitory syndrome, pulmonary edema
____ embolism is a relatively rare but serious consideration 24 - 48 hrs after an injury to a Long Bone.
Fat
The fat breaks down into fatty acids which are toxic to the lungs, result maybe pulmonary hypertension
Volkmann contracture….
a deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm. Th
Lower abdominal surgeries:
This position helps gravity pull intra-abdominal organs away from the pelvis, allowing for better access to pelvic organs. It’s used for colorectal, gynecological, and genitourinary procedures.
Central venous catheter placement: This position is used to place a central venous catheter in the internal jugular or subclavian vein.
Hypotension: This position is often the first measure used to treat hypotension.
Vagal discomfort: This position is used to treat vagal discomfort.
Robotic procedures: This position is often used for patients undergoing robotic procedures
Name this posistion
Trendelenburg
First priority for a child with vomiting and diarrhea is to replace fluid and electrolytes.
Dehydration puts them at risk for which serious complication
Heart Arrhythmia caused by hypokalemia <3
Promethazine is a medication used to manage and treat allergic conditions, nausea and vomiting, motion sickness, and ____
Sedation
What is considered a normal urine output per hour.
30 - 50 mL
Which of the following are suggested with loop diuretics
A. Reduce sodium
B. Use salt substitutes to enhance food flavor
C. Adivse HCP if edema occurs
D. Take meds on regular schedule
E. Take meds with evening meal
A, C, D
How many wet diapers daily should a 1 week old have
6 - 8
Destruction of malignant cells during chemotherapy causes large amounts of _____ and tubular obstruction from the crystals.
Allopurinol reduces this build-up
Intervention: Increase fluid intake
Uric acid
Which IV solution is compatible with blood infusions
0.9% NS
Client returns from cardiac step-down unit following cardiac catheterization
Which information should be obtained first
Lab values
Neurological status
Puncture site appearance
Skin warmth and tugor
Puncture site appearance
During discharge of a client with an ileostomay to treat IBD, the nurse should stress the importance of
A. Increase fluid prevent dehydration
B. Wear appliance only at bedtime
C. Consuming low protein, high fiber
D. Take only enteric coated pills
A.
Stool usually forms in large intestines
Ileostomy drains mostly liquid poop
Extra water is needed to prevent dehydration
Avoid high fiber foods - may bother intestines
Avoid enteric coated bc body cant absorb them
Accessing 4 year-old prepheral IV line and notice its not infusing.
What would be the first action
Resposistion the child’s extremity.
Most likely reason of IV not infusing is postitional issues of the child or extremity
Which Score is used 1& 5 minutes after birth to access the health of a newborn
Describe 5 characteristics & scoring
What is a dangerous score
APGAR score
Breathing effort
Heart rate
Muscle tone
Reflexes
Skin color
0 - 2 Zero = Worst
<6
What is a normal urine output ratio
0.5 mL / kg / hr
SIADH which is the most likely outcome
A. Cerebral edema
B. Hypovolemic Shock
C. Hyperkalemia
D. Tetany
Cerebral edema is seen in SIADH
Due to the hypotonic/ hypovolemic the hypotonic fluid will go into the hypertonic brain fluid
First time dialysis patient what should you monitor
Neurological Status
First time may have confusion/ seizures
First time dialysis, monitor for
Neurological Status
Common confusion/ seizures first time
Hh
Jj
Kegel exercises can be performed in any position
2x daily and 10 minutes
Strengthen pelvic muscles
When will changes be noticed
6 weeks
To prevent nausea how long should a client wait after eating dry foods to drink water.
30 minutes
Episiotomy, also known as perineotomy, is…
surgical incision of the perineum and the posterior vaginal wall generally done by an obstetrician. This is usually performed during second stage of labor to quickly enlarge the aperture allowing the baby to pass through
Bandage: joints, ankles, elbow, wrist, knee
This technique
Figure 8
Bandage: use this technique to anchor a Bandage
Circular
Bamdage: Stump, hand, scalp
Recurrent
Bandage: increasing circumference. Ie. A cast
Spiral reverse
Reiki is based on which principal of healing.
Energy from hands being placed lightly or at a distance can be used to heal
Can muslims have caffeine
Yes
Chloroxazone is a centrally acting skeletal muscle relaxant used to treat (acute / chronic) symptoms
Acute
What is the first intervention in the home environment fir minor and major burns
Place affected area in cool water to stop the burn
Discomfort at IV site.
Blanching around site
Swelling, coolness to touch
WBC within normal range
What is occurring
A. Infiltration
B. Phlebitis
C. Infection
D. Infection & Infiltration
A. Infiltration (IV fluid goes into tissues rather than vein)
Discontinue and restart at different site
Phlebitis is evident by redness at cannula tip and long length of vein
Significant hypotension doesnt occur until ___ % of volume loss occurs
30
Right sided heart failure
Assess for
Intermittent Claudication
Dyspnea
Dependent edema
Crackles
Dependent edema: aka pitting edema, buildup in the veins, which leads to swelling in the feet, ankles, and legs.
Rigjt sided heart failure: venous congestion result: peripheral edema, splenomegaly, hepatomegaly, neck vein distention.
Left heart failure: Dyspnea & Crackles associated with pulmonary edema
Intermittent Claudication = arterial occulsion
_______ is pain in the arms or legs that occurs while walking or using the arms.
It can also feel like a cramp or fatigue in a muscle group of the lower extremity. Claudication is caused by too little blood flow to the legs or arms.
It can be a symptom of _______ In most cases, lifestyle changes, exercise, and medications can slow or reverse the symptoms.
Two drugs, cilostazol and pentoxifylline, are approved for treatment of intermittent claudication
Claudication
peripheral artery disease
(PAD).
Match
Serous
Purulent
Clear, watery plasma
Thick yellow tinged
Serous Clear, watery plasma
Purulent Thick Yellow Tinged
Partial thickness burns
Which IV is given first
Albumin
D⁵W
Lactated Ringers solution
0.9 NS woth 20 mEq of potassium per 1,000 mL
Lactated Ringer’s
Replaces sodium & corrects metabolic acidosis, Both occur after burn
Albumin is ised as adjunct therapy
D⁵W isn’t given during first 24 hrs , due to pseudo-diabetes effect
Client after burn is Hyperkalemic, potassium would be contradicted
(Negative/ Positive) pressure wound therapy
Applies subatmospheric pressure
Increase local blood flow
Reduce drainage
Stimulate Granulation Tissue
Negative
Tropin levels (increase/ decrease) with ischemia and necrosis of cardiac muscle
Increase
Fasciotomy is a procedure to relieve ____ syndrome
Compartment
S/S this skin disease include:
Painless, dry, flaky, rough patches of skin with bumps, maybe itchy
Usually on Hands, Feet, Face, Chest, Neck
Caused by: Stress, exacerbated by hot showers and lack of moisturizer
Atopic dermatitis aka eczema
Skin disease
Proliferative inflammatory disease, well-demarcated erythematous, papules and plaques covered in Silvery Scales. (Usually appear on knees, elbows, extremities, scalp)
Psoriasis
High levels of ____ in blood can suggest a autoimmune disease such as Rheumatoid Arthritis, Scleroderma, Systemic lupus erythematous
Rheumatoid Factor
(RF) is a protein produced by the immune system that can attack healthy tissue in the body
Sever itching in both hands worse at night.
Gray-brown burrows with epidemal curved ridges and follicular papules.
Is indicative of….
Scabies
Normal albumin levels
What does albumin do?
Causes hypo/hyper
S/S hypo/hyper
3.5 - 5
Basically, same as K
Albumin keeps blood in veins
Causes
Hypo:
Liver / Kidney disease, malnutrition
Hyper:
Dehydration/ diarrea
S/S
Hypoalbuminemia
Swelling, dry/itchy skin, thin hair,
Hyper: No specific s/s
During IV infusion of a chemotherapeutic vesicant drug, the nurse observes that there is a lack of blood return from the IV catheter.
What would the nurse do first
Stop Administration of Drug
IV catheter with no blood return is most likely occluded or not patent.
Infiltration or extravasation of vesicant drug into tissues can cause severe damage
vesicant drug….
Causes blisters or necrosis
_____ causes blanching, cyanosis, coldness, numbness, and throbbing pain in the hands when client is exposed to COLD or STRESS
Raynaud’s Phenomenon
______, also known as ringworm of the body, is a fungal skin infection
. It’s a common, contagious, but not serious infection that can often be treated with an over-the-counter topical fungicidal medication.
Tinea corporis
82 yrs resident LTC reports
Burning, Stabbing Pain left flank wraps around to abdomen
Next day, small red vesicular lesions around left flank.
Which disease may it be
Herpies zooster
Shingles
Post-herpetic neuralgia is..
a lasting pain in the areas of your skin where you had shingles
