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NCLEX: Fundamentals Of Nursing > Set 8 > Flashcards

Set 8 Flashcards

1
Q

The nurse should culture a wound _________ starting antibiotic treatment

A

Before

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2
Q

What part of the wound should be swabbed?

A

VIABLE tissue (NOT slough or Eschar)

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3
Q

PPE for wound irrigation

A

Gown, gloves, and eye protection

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4
Q

For wound irrigation, the nurse should use a ___ mL piston syringe and a ___ gauge catheter or needle

A

35; 19

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5
Q

Sterile dressing change wound care key points

A
  • Use clean gloves (off the wall) to remove old dressing, THEN set up sterile field and apply sterile gloves
  • With moistened gauze, clean from the wound and then away to prevent introduction of new bacteria (the wound itself is considered sterile)
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6
Q

Guideline for removing staples

A

Remove every other staple (allows nurse to see if wound is dehiscing)

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7
Q

Removing sutures guidelines

A
  • use STERILE suture removal kit
  • grasp the knot of suture with forceps and gently lift
  • make cut on suture below knot, close to the skin, and pull
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8
Q

A Penrose drain is an example of

A

An open drain

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9
Q

Wound drain that drains freely and deposits fluid onto the surface of the skin or a dressing

A

Open drain

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10
Q

Examples of closed drains for wounds

A

JP drain, hemovac, anything set to suction

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11
Q

Closed drains function through

A

Negative pressure (via suction or negative pressure created through the closed system)

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12
Q

Diabetic foot care

A
  • wear professionally fit shoes
  • inspect feet DAILY in a mirror
  • apply moisturizer to feet, but NOT between the toes
  • wear cotton, NOT synthetic socks
  • cut toenails straight across, do NOT round the edges
  • do NOT use heating pads on feet
  • do NOT soak feet; check temp of shower water with wrist or elbow
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13
Q

What are three different types of solution osmolarity?

A

Hypertonic, isotonic, hypotonic

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14
Q

Solution with a higher tonicity of the fluid than the body

A

Hypertonic

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15
Q

__________ solutions cause fluid to move out of cells, shriveling them

A

Hypertonic

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16
Q

__________ fluids have the same tonicity as the body’s fluid

A

Isotonic

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17
Q

Examples of isotonic fluids

A

NS, LR

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18
Q

__________ solutions are lower in tonicity than the fluid in the body

A

Hypotonic

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19
Q

_________ solutions cause fluid to move inside the cells leading to swelling and possible bursting/lysis

A

Hypotonic

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20
Q

Examples of hypertonic fluids

A

D10W, 3% sodium chloride, 5% sodium chloride

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21
Q

Examples of hypotonic fluids

A

1/2NS, 0.45%NS, 0.225%NS

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22
Q

Any fluid put into the body including drinks, IV fluids, IV flushed, liquid medications, gastric lavage, bladder irrigation, etc.

A

Intake

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23
Q

Any fluid that comes out of the body including urine, emesis, blood, wound drainage, chest tube drainage, etc.

A

Output

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24
Q

__________ losses can be measured (ex: urine, blood)

A

Sensible

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25
Q

__________ losses are things that cannot really be measured like water lost through respiration and the sweat that comes out of skin

A

Insensible

26
Q

When calculating I&Os, ice chips are recorded as

A

Half their volume (ex: 100 mL of ice = 50 mL of water)

27
Q

S/S of fluid volume deficit

A
  • Hypotension
  • Tachycardia
  • Weak, thready pulse
28
Q

Labs associated with fluid volume deficit

A

Elevated: Hct, blood osmolality, BUN, urine specific gravity, urine osmolality

29
Q

Treatment for fluid volume deficit

A

IV fluids, usually isotonic

30
Q

S/S of fluid volume overload

A
  • weight gain
  • edema
  • tachycardia
  • hypertension
  • dyspnea, crackles in lungs
  • JVD
  • bounding pulses
31
Q

Labs associated with fluid volume overload

A

Decreased: Hct, Hgb, serum osmolality, urine specific gravity (dilute everything)

32
Q

Treatment for fluid volume overload

A

Diuretics, paracentesis

33
Q

Weight gain to report to provider

A

1-2 lbs in 24 hr
OR
3 lb in a week

34
Q

Calcium normal range

A

9-10.5 mEq/L

35
Q

What are some of the causes for Hypercalcemia?

A

Prolonged immobility, hyperparathyroidism

36
Q

What are some of the causes for hypocalcemia?

A

Hypoparathyroidism, decreased vitamin D intake, diarrhea

37
Q

Positive Chvostek and Trousseau’s signs indicate

A

Hypocalcemia

38
Q

Magnesium normal range

A

1.5-2.5 mEq/L

39
Q

Deep tendon reflexes are __________ with hypermagnesemia and __________ with hypomagnesemia

A

Decreased; increased

40
Q

A patient with hypomagnesemia is at risk for

A

Seizures

41
Q

Potassium normal range

A

3.5-5 mEq/L

42
Q

What does the nurse need to assess in a patient with a potassium imbalance?

A

Cardiovascular function

43
Q

Sodium normal range

A

135-145 mEq/L

44
Q

What should the nurse assess in patients with sodium imbalances?

A

Neurological status

45
Q

Patients with hyponatremia are at risk for

A

Seizures

46
Q

Normal pH

A

7.35-7.45

47
Q

pH less than 7.35

A

Acidosis

48
Q

PH above 7.45

A

Alkalosis

49
Q

Normal PCO2

A

35-45

50
Q

The higher the CO2, the more _________. The lower the CO2, the more _________.

A

Acidic; basic (opposite of pH and bicarbonate)

51
Q

Normal HCO3

A

21-28

52
Q

Acid base imbalance characterized by pH greater than 7.45 and PaCO2 less than 35

A

Respiratory alkalosis

53
Q

Major cause of respiratory alkalosis

A

Hyperventilation (r/t anxiety, pain, neurological disorder or injury)

54
Q

Acid base imbalance characterized by pH less than 7.35 and PaCO2 greater than 45

A

Respiratory acidosis

55
Q

Causes of respiratory acidosis

A

Air trapping disease (COPD), oversedation (anesthesia, opioids, Benzos, mechanical ventilation)

56
Q

Treatment for respiratory alkalosis

A

Calm the patient down, have patient breathe into cupped hands or paper bag to rebreathe CO2 to increase amount in blood

57
Q

Treatment for respiratory acidosis

A

Encourage patient to breathe more frequently, adjust ventilator settings, sternal rub to arouse patient if over sedated, administering antidote for overdose (flumazenil, naloxone)

58
Q

Acid base imbalance characterized by pH greater than 7.45 and HCO3 greater than 28

A

Metabolic alkalosis

59
Q

Causes of metabolic alkalosis

A

Antacid overdose, vomiting, excessive GI suctioning (such as by NGT)

60
Q

Acid base imbalance characterized by pH less than 7.35 and HCO3 less than 21

A

Metabolic acidosis

61
Q

Metabolic acidosis is common in patients with

A

DKA, kidney failure, excessive diarrhea

62
Q

Treatment for metabolic acidosis

A

Depends on cause: Antiemetics (if d/t vomiting), stop antacids, insulin for DKA

NCLEX: Fundamentals Of Nursing (14 decks)

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