QB 4 Flashcards
What should the diet with heart failure patients be like ?
Sodium restriction, potentially fluid restriction
The client with heart failure should be instructed to reduce sodium intake in order to avoid fluid overload. Processed meats such as salami, cold cuts and bacon are high in sodium and should be avoided. Fresh fruit and vegetables are recommended to manage blood pressure in the client with heart failure. Whole wheat items are high in fiber and low in sodium. Even though some clients with heart failure may be prescribed a fluid restriction, 4 oz of liquid with every meal would not be contraindicated.
Content Refresher
The client requires a therapeutic diet to reduce complications from heart failure. The U.S. Department of Agriculture recommends less than 2300 mg of sodium for all adults and adults with heart failure should consume less than 2000 mg. Smoked, cured, salted, or canned foods should be avoided, while fresh vegetables, lean meats and fish, and unsalted seeds and nuts should be encouraged.
The U.S. Department of Agriculture recommends less than _____________ mg of sodium for all adults and adults with heart failure should consume less than _____________mg.
2300; 2000
What is hypoxia and what are the normal acid base balance indicators ?
Hypoxia is a condition in which there is an insufficient level of oxygen in the cells, tissues, and organs to meet their metabolic demands. Adequate oxygen must be available for gas exchange to occur so supplemental oxygen is used. It may be administered using the client’s respiratory ability (via nasal cannula, venturi mask, non-rebreather mask) or, in extreme cases, be delivered mechanically. Normal acid-base balance is indicated by a pH of 7.35 to 7.45, PaCO 2 of 35 to 45 mm Hg (4.7 to 5.9 kPa), PaO 2 of 80 to 100 mm Hg (11 to 13 kPa), oxygen saturation of 95 to 100%, HCO 3 of 22 to 26 mEq/L (22 to 26 mmol/L), and base excess of −2 to +2 mEq/L (−2 to +2 mmol/L).
Complications of Immobility
Immobility influences the cardiovascular (venous status, orthostatic hypotension), musculoskeletal (osteoporosis, contractures, atrophy of muscles), respiratory (atelectasis), urinary (infection, retention, calculi), metabolic (metabolic rate decreases), gastrointestinal (constipation), and integumentary (breakdown) systems. Immobility also influences the client’s psychological well-being.
Physical activity is important to prevent skin breakdown, respiratory tract infections, and to support client mobility.
TRUE OR FALSE
ABSOLUTELY TRUE
______________tube feedings are indicated for clients who have a functioning gastrointestinal tract, but may have swallowing problems or are at risk for aspiration.
Enteral
What does the nurse need to do before administering tube feedings?
Think safety
Before administering enteral tube feedings, the nurse needs to verify tube placement. Initially, a chest x-ray is the recommended method of determining accurate placement. Prior to instillation of feedings or water, the nurse needs to verify tube placement by aspirating gastric content and determining pH consistent with acidic stomach contents.
In addition, the nurse needs to verify tube length when completing each nursing assessment and prior to feeding.
What is the only sure way to verify enteral tube placement ?
X ray
matter that has been drawn from the body by suction
Aspirate
What color is gastric aspirate usually ?
Gastric aspirate normal pH
Intestinal gastric pH normal
Respiratory aspirate pH normal
gastric aspirate is usually cloudy and green but may also be off-white, tan, bloody or brown
gastric pH - usualyl less than or equal to 4
intestinal aspirate pH - usually greater than 4
respiratory aspirate pH - usually greater than 5.5
Which assessment by the nurse indicates that a client’s nasogastric (NG) tube may be malpositioned?
- The nasogastric tube aspirate is cloudy and green.
- The pH of the nasogastric tube aspirate is 3.
- Air injected through tube is auscultated over the epigastrum.
- The external length of the nasogastric tube has increased.
1) INCORRECT – Gastric aspirate is commonly cloudy and green, tan, off-white, or brown .
2) INCORRECT – Gastric aspirate pH ranges from 1 to 5.
3) INCORRECT – Injecting air through the NG tube while auscultating the epigastric area to detect air insufflation is an unreliable indicator of NG tube placement and is not evidence-based practice.
4) CORRECT– Increased length of the NG tube may indicate outward migration, and the NG tube tip may be malpositioned in the esophagus instead of the stomach.
The nasogastric tube position should be assessed each and every time prior to administering medications or nutritional support. The nurse should use a simple procedure to check location; when the tube is inserted, a small piece of adhesive tape is placed on the tube as an indication of the location. If this piece of tape is in a different location, or assessment of the tube location is questionable, the tube should not be used until an x-ray verifies placement. The health care provider may need to be notified for tube replacement.
_________________-control is essential for the entire body. Blood glucose levels affect cognition, cardiovascular health, nerve function, kidney function, retinal health, immune system function, and wound healing. This client is facing an amputation due to a long history of poor glycemic control, which resulted in severe peripheral vascular disease (PVD), decreased blood supply to the lower extremities, and death of tissue in the leg. Wounds do not heal in the presence of _____________-blood glucose levels
Glycemic; uncontrolled
Signs of Peripheral Vascular Disease include
pale or discolored skin, weak or absent pulses, reduced body hair, poor wound healing, and thick, opaque nails.
How does high blood glucose levels damage blood vessels ?
Excess blood sugar decreases the elasticity of blood vessels and causes them to narrow, impeding blood flow. This can lead to a reduced supply of blood and oxygen, increasing the risk of high blood pressure and damage to large and small blood vessels.
When caring for a client receiving a blood transfusion, the nurse should:
Teach client/family about procedure and signs/symptoms to report. Perform hand hygiene, wear gloves. Ensure normal saline IV fluid is running with 14- to 22-gauge catheter; set up infusion equipment with appropriate filter and tubing. Run transfusion slowly, observing client carefully for 15 minutes to observe for any adverse reaction. Monitor vital signs. Increase rate if vital signs are stable and client shows no signs/symptoms of reaction to blood product. Blood transfusion can result in fluid overload, a hemolytic reaction, an allergic reaction, infectious diseases, and a transfusion related acute lung injury.
During a blood transfusion, the client develops backpain and headache. What should the nurse do first ?
A headache and back pain are indications of a hemolytic transfusion reaction. The nurse knows that the only way to resolve this problem is to stop the transfusion immediately. After the transfusion is stopped, the client’s vital signs should be assessed. The health care provider should be notified and the blood product and tubing preserved in anticipation of returning it to the blood bank for analysis.
What to remember about incontinence
Causes and risk factors
It is not a normal part of aging
Remember, To urinate, the brain signals the muscular bladder wall to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincters to relax. As the sphincters relax, urine exits the bladder through the urethra.
Incontinence is the unintentional loss of urine and is caused by different factors, including increased abdominal pressure (stress), increased need without control (urge), increased bladder distention (overflow), and cognitive impairments (functional).
Causes of incontinence include weakness of pelvic floor muscles, increased abdominal pressure, infections, over-distention of the bladder, sphincter weakness, and cognitive impairments.
Risk factors include obesity, smoking, gender (females are more likely to experience incontinence due to pregnancies), menopause, and cognitive disorders such as dementia.
Many types of urinary incontinence can be treated successfully with medications, education, bladder retraining, and/or surgery.
In a closed head injury, the brain has experienced an injury that can cause bleeding or edema within the cerebral tissue. Because the cranium is within a closed vault, the swelling and bleeding displace the cerebral contents, causing symptoms of_______________- intracranial pressure. The nurse will frequently assess for common symptoms of increasing intracranial pressure, which includes ___________________-
increased; nausea and changes in level of consciousness.
Esophageal cancer impacts the client’s ability to ______________–. A nursing diagnosis that addresses the risk for _____________is appropriate. Additionally, the client’s ___________status will be compromised due to the problem with swallowing. A nursing diagnosis that addresses weight management is essential. Pain management is an appropriate intervention because of the diagnosis and location of the pathology.
swallow; aspiration; nutritional
the following are highly suggestive that infection may be present:
abrupt onset of fever; high fever, greater than 102°F to 105°F (38.9°C to 40.6°C), without chills; respiratory symptoms; malaise, muscle and joint pains, photophobia, headache; nausea, vomiting, diarrhea; lymph node enlargement; and meningeal signs.
The nurse should consider that an older adult with an infection will have atypical manifestations, such as delirium, falls, and incontinence.
Risk factors for Otitis Media
Name at least 5
Risk factors for otitis media include respiratory infection, influenza, bottle-fed infants, Down syndrome, children who attend day care, those with cleft palates or poor immune systems, allergies, post-nasal drainage, sinus infections,
cystic fibrosis, asthma, family history of ear infections, and male gender.
What to remember about Rhabdomyolosis ?
For the client with rhabdomyolysis, administration of crystalloid IV fluid is the primary treatment. Rhabdomyolysis is characterized by the release of massive quantities of myoglobin from damaged muscle cells, as well as the release of intracellular potassium due to cell lysis. Administration of IV fluid is essential to preserving kidney function and promoting excretion of myoglobin and potassium.
Administration of mannitol, an osmotic diuretic, is an appropriate intervention for the client diagnosed with rhabdomyolysis in order to to promote excretion of substances, including myoglobin and potassium.
In rhabdomyolysis, intravenous hydration coupled with diuresis is thought to decrease the risk of myoglobin-associated acute tubular damage and acute kidney injury. Alkalinizing the urine with bicarbonate-containing fluids to a urine pH greater than 6.5 may reduce the aggregation of myoglobin in the kidney.
Content Refresher
When caring a client with rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), intravenous fluids and blood volume expanders are used to improve tissue perfusion. Intravenous calcium chloride, bicarbonate, insulin, and glucose may be needed to reduce serum potassium levels. Symptoms include dark, reddish urine; a decrease in urinary output; weakness; and muscle aches. Osmotic diuretics may be given to reduce fluid overload.
A breakdown of muscle tissue that releases a damaging protein into the blood.
This muscle tissue breakdown results in the release of a protein (myoglobin) into the blood. Myoglobin can damage the kidneys.
Symptoms include dark, reddish urine, a decreased amount of urine, weakness, and muscle aches.
Early treatment with aggressive fluid replacement reduces the risk of kidney damage.
What condition is this?
Rhabdomyolosis
What to remember about Anorexia Nervosa
characterized by a BMI of 17.5 or lower, anorexia nervosa is a clinical syndrome in which the client has an irrational fear of weight gain, preoccupation with food, a very restricted diet (e.g., eating 6 peas), refusal to eat, and a disturbed body image. Evaluate laboratory serum and electrolyte levels. Assess nutritional status and weight. Assess vital signs, especially blood pressure. Assess for arrhythmias. Monitor food and fluid intake, daily weights, skin condition, and rest/activity levels. Observe the client before, during, and after meals. Avoid discussion about food, especially while eating, and require consumption of food within a limited amount of time. Insert and provide feedings through a nasogastric tube, if prescribed.
The client with anorexia nervosa should be closely monitored for complications such as electrolyte imbalances, dehydration, cardiac arrhythmia, menstrual problems, and anemia. In cases of severe electrolyte derangement, the client should be attached to a cardiac monitor and replacement electrolytes given intravenously. The nurse should collaborate with an interdisciplinary team to address the client’s psychosocial and mental health issues, if applicable.
The client with anorexia nervosa is at risk for fluid and electrolyte imbalance, particularly ______kalemia, and subsequent ___________cardiac output and cardiac ________________. The serum potassium level should be closely monitored.
hypokalemia; decreased; dysrhythmias
signs and symptoms of compartment syndrome (increased pain,
increased pain (especially after pain med administration)
decreased pulses in extremity,
paresthesia,
paralysis,
pale or discolored skin
The nurse knows that the goal of checking capillary refill is to assess _______________.
peripheral circulation
Pressure will compress the blood vessels and restrict blood flow, causing pallor. Release of the pressure will permit return of blood flow and color. The nurse will provide further teaching to the client that the application of pressure should result in skin pallor.
Evidence of a __________________-family includes blaming and using substances or alcohol to cope with stressful life situations.
dysfunctional
What is a crisis ?
A crisis is specific event in which a client is unable to cope. This may be due to ineffective coping, which leads to increased stress, decreased resources, and inability to prevent the specific event. During a crisis, there is an initial period of shock, followed by an inability to function, and then a tremendous emotional response. Complications associated with crisis include inability to carry out activities of daily living, increased anxiety, and impaired personal relationships.
Potassium Chloride administration
NEVER GIVEN VIA IV PUSH AS CAN CAUSE CARDIAC ARREST
Potassium chloride (KCl) is administered slowly via an IV infusion pump. The typical infusion rate of KCl is 10 mEq/hour. Faster infusion rates are only considered under close supervision in a critical care area and only via a central venous access device. If the client is at risk for fluid volume overload, the nurse consults with the health care provider and pharmacy to increase the medication concentration, such as to 10 mEq/50 mL or 10 mEq/100 mL.
Content Refresher
Monitor the client’s ECG during potassium chloride (KCl) infusion, as this medication may cause dysrhythmias, including heart block, as well as cardiac arrest. Do not administer more than 10 mEq of KCl per hour intravenously. Monitor the IV site for signs of phlebitis.
During labor induction, what is the usual contraction pattern?
Contractions that occur every 2-3 minutes, lasting for 90 seconds or less
STOP INFUSION IF FETAL DISTRESS OR HYPERTONIC CONTRACTIONS BEGIN
(contractions that last more than 90 seconds or occur more frequently than every 2 minutes)
______________-is a manifestation of severe hypothyroidism. Manifestations of hypothyroidism are associated with a ___________-of the metabolism and include lethargy, weight gain, and intolerance to _________temperatures.
Myxedema; slowing; cold
Symptoms of Myxedema
slowing of the metabolism
lethargy,
weight gain
intolerance to cold temperatures.
Possible goiter from constant thyroid stimulation to get the thyroid gland to produce T3 and T4 MOST COMMON SIGN IN HASHIMOTO’S
Slow heart rate
Thinning and brittle hair
Constipation
Memory loss
Myxedema: swelling of the skin (eyes and face) that gives it a waxy appearance
Dry skin
Depression
Menstrual problems (irregular or heavy periods)
The nurse views the cardiac monitors for clients on the unit and notes the presence of elevated T waves. Which client is likely to have this appear on the ECG? (Select all that apply.)
- A client with Cushing syndrome who has hypertension and a pathologic fracture of the spine.
- A client with alcoholic liver cirrhosis who has severe ascites and shallow respirations.
- A client who was in a house fire and suffered extensive burns on the arms, trunk, and face.
- A client who reports severe vomiting for 3 days and shows symptoms of mild dehydration.
- A client who has been on prednisone for 6 months.
1) INCORRECT - Elevated T waves indicate hyperkalemia. Cushing disease is caused by an overproduction of corticosteroids. Hypercortisolism is associated with increased blood glucose levels, increased sodium levels, and decreased levels of potassium and calcium. This client will not likely have an elevated T wave.
2) CORRECT– Clients with liver failure may have an underproduction of bicarbonate, leading to metabolic acidosis. Ascites pushes on the lungs, decreasing lung capacity. Shallow respirations lead to buildup of CO2 and respiratory acidosis. Hyperkalemia is associated with acidosis. This client will likely have an elevated T wave.
3) CORRECT – There is a release of intracellular potassium because of cell destruction from the burns, which will increase serum potassium. This client will likely have an elevated T wave.
4) INCORRECT - A loss of acid from vomiting leads to metabolic alkalosis, which is associated with hypokalemia. This client likely will not likely have an elevated T wave.
5) INCORRECT - Excessive and long-term use of corticosteroids leads to hypokalemia. This client will not likely have an elevated T wave.
Cushing disease is caused by an overproduction of corticosteroids. Hypercortisolism is associated with___________blood glucose levels,_________- sodium levels, and _____________levels of potassium and calcium
increased; increased; decreased
What to remember about MRIs
noninvasive, painless, diagnostic scanning technique in which a client is placed into a magnetic field to obtain clear and differentiated images of the brain, spine, extremities, joints, heart and vasculature, abdomen, and pelvis. The images are used to plan and direct surgical treatment, detect abnormalities, identify tumors, and their response to treatment. Prior to an MRI, the nurse should question the client about implanted metal devices such as orthopedic hardware, implanted pacemakers and defibrillators, heart valves, intrauterine devices, and cochlear implants. Assess the client for understanding of the procedure and its role in the diagnosis or treatment plan, the client’s level of anxiety and anticipated claustrophobia, client’s allergies, body tattoos (especially with red coloring), permanent cosmetics, transdermal patches with foil backing, and implanted metal objects.
An MRI is contraindicated for clients with actual or suspected metallic foreign body in the eye. The client who experienced an Motor vehicle crash may have an eye injury that involves metal. A magnetic resonance imaging (MRI) scan is not recommended because the object may be metal and be pulled or moved by the strength of the magnet. This could cause additional damage and possibly jeopardize this client’s vision.
Postpartum:
During the first 24 hours, temperature can increase to 100.4°F (38°C) as a result of ______________effects of labor.
dehydrating
After delivery though the body knows that the fetus is no longer in the uterus and begins to change in order to accommodate a non-pregnant state. Excess fluid in the vascular system is eliminated, which can lead to temporary dehydration. Evidence of postpartum dehydration includes a low-grade fever, which can be quickly corrected by the client increasing oral fluid intake.
What is stoma prolapse ?
What is a stenosed stoma?
What is a retracted stoma ?
Characteristics of a normal stoma
A prolapsed stoma is protruding and indicates that the bowel is protruding through the stoma.
A stenosed stoma appears narrow and flat.
A retracted stoma appears sunken and inverted.
A normal stoma is nearly flush with the abdominal skin and is pink to beefy red in color
IV fluid infusions may have serious complications, particularly when used in clients with____________ and ______________ impairments.
renal and cardiac
Characteristics of the Transition Phase of Labor
uterine contractions every 2 to 3 minutes, lasting 60 to 90 seconds, and are strong in intensity. Dilation is 8 to 10 cm with effacement of 80 to 100%. Station is -1 to +2 and bloody show increases. The client may report backache and increasing pain. As fetal descent progresses, the client will have the urge to push and may experience defecation or the urge to urinate. Relaxation is difficult, and the client may be agitated and restless.
Symptoms of the transition stage include increased pressure in pelvis, which causes an intense desire to urinat
What to remember about involuntary psychiatric admission clients
An involuntary admission is court-ordered and requires medical certification from a health care provider (usually two) stating the client’s need for involuntary care and treatment in a psychiatric facility. A client who has been involuntarily admitted to a psychiatric facility has the right to legal counsel and can take the case before a judge who may (or may not) order that the client be released from the psychiatric facility.
Clients are admitted in this way when they are a danger to self or others and are unable to meet basic needs. Only voluntary clients have the right to demand and obtain release.
These clients are being held against their will until deemed safe. This client may not request and be granted release.
What is a T-Tube ?
A tube that may be inserted into the common bile duct during surgery when a common bile duct exploration is part of the surgical procedure. This ensures patency of the duct until the edema produced by the trauma of exploring and probing the duct has subsided. It also allows the excess bile to drain while the small intestine is adjusting to receiving a continuous flow of bile.
