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Foundation 2 Final > units 1 & 2 and exam questions > Flashcards

units 1 & 2 and exam questions Flashcards

1
Q

pt on ventilator and hyperventilated is at risk for what?

A
  • acid deficit

* respiratory alkalosis

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2
Q

following assessment of pt w/ pneumonia, RN identifies ineffective airway clearance based on what?

A

•crackles and wheezing in lower lungs

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3
Q

pt w/ pneumonia has temp that fluctuates w/ periods of diaphoresis. What intervention is a priority?

A

•provide fluids of at least 3L/day

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4
Q

pt w/ asthma can’t take deep breaths…decreased sounds in base and no wheezes..what is RN priority?

A

•measure O2

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5
Q

what is appropriate expected outcome of elderly recovering from pneumonia?

A

•ability to perform ADLs w/o dyspnea

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6
Q

which breathing impaired patient is priority?

A

•HR of 120 bpm b/c trying to get more O2

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7
Q

pt pulls out chest tube…what is appropriate RN action?

A
  • notify MD
  • prepare for reinsertion
  • apply occlusive dressing
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8
Q

pt fasting for 5 days…which acid/base imbalance is expected?

A

•metabolic acidosis

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9
Q

3 day hx of N/V in ER… confused, irritable, shallow resp. RR of 6…blood gases are expected to reveal?

A

*losing stomach acid

•metabolic alkalosis

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10
Q

taking magnesium hydroxide…which RN action most appropriate?

A

•check renal fxn

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11
Q

how can RN help minimize pt’s s/s of GERD regards to lifestyle changes?

A

•provide resources for smoking cessation support group

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12
Q

pt w/ larger burns is at risk to develop stress ulcer…stress ulcers are evidenced by…

A

•hemorrhage

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13
Q

Pt has rigid abdomen, shallow breath, tachycardia…what is RN priority action?

A

*perforation

•keep pt NPO in prep for surgery

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14
Q

pt diagnosed w/ ulcer asks RN what is next…how does RN respond?

A

•most ulcers treated w/ medication

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15
Q

pt w/ fractured rib is at risk for what?

A

•respiratory acidosis b/c can’t take in breaths as efficiently

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16
Q

pt has CT in place following surgery…what requires action?

A

•continuous bubbling in water-seal chamber

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17
Q

RN should report what assessment finding in pt w/ emphysema?

A
  • cyanotic lips

* would expect fatigue, crackles, and barrel shaped chest

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18
Q

which outcome demonstrates effectiveness of peri-operative teaching

A

•client demonstrates correct use of incentive spirometer

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19
Q

before nurse brings pt to OR, pt reports that site hasn’t been marked. What is priority action?

A

•call surgeon to mark site

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20
Q

nurse assesses pt just brought to PACU. BP was 136/80, but now in PACU it’s 110/80; UOP was 20 mL/hr, but now it’s 10 mL/hr. What is priory intervention?

A
  • kidney’s not perfused enough
  • not enough circulating volume
  • pt has FVD
  • priority action is to increase IV as ordered to 100 mL/hr, then investigate what’s going on
  • LOC is NOT priority for FVD
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21
Q

adverse side effect of inhalation anesthetics

A

•malignant hyperthermia

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22
Q

malignant hyperthermia

A
  • acute, life-threatening complication of drugs (anesthetics)
  • causes increased Ca2+ levels in muscles
  • causes increased muscle metabolism
  • leads to metabolic acidosis (not enough O2 to cells), cardiac dysrhythmias, high body temp
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23
Q

s/sx malignant hyperthermia

A
  • tachycardia/pnea
  • elevated body temp
  • muscle rigidity
  • skin mottling
  • cyanosis
  • myobloinuria (muscle protein in urine)
  • rise in tidal CO2 and decrease in O2 sat
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24
Q

Which allergy is greatest concern during surgical procedure?

A

•kiwi b/c proteins similar to those in latex

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25
Q

For pt taking Lasix, what is the best way to detect adverse effect?

A
  • intake and output
  • Lasix is diuretic
  • pt was in FVE, so now if give too much could become FVD
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26
Q

During hot summer day, elderly pt tells clinic nurse that he isn’t drinking or voiding much. HR is 100 bpm. BP is 90/60. What action does nurse take first?

A

•worried about dehydration- inc. HR and dec. BP
•give pt a drink b/c not an emergency
*BEST way to rehydrate is PO

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27
Q

Physical assessment of client w/ cardiac dysrhythmia reveals hypoactive bowel sounds, dizziness, decreased DTRs, etc. Lab result consistent with this is…

A

•hypokalemia

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28
Q

b/c nurse is aware extracellular dehydration can occur in elderly w/ gastroenteritis (diarrhea/vomit), it’s important to assess for…

A 
*pt is FVD
•hyperthermia
•dec. UOP
•dec. diastolic BP 
•furrowed tongue/confusion
•NOT tenting skin b/c elderly skin ALWAYS tents
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29
Q

Which nursing measure is most important to implement to decrease wound infection?

A

•change surgical dressing using sterile technique

*asking for measure to take, not to assess

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30
Q

For pt w/ hypernatremia, nurse must implement…

A

•seizure precautions

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31
Q

Pt receiving .45% NS (hypotonic), if given in excess it could cause which effect on cells

A
  • swell and lyse

* dilute blood, so fluid goes into cells

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32
Q

Elder pt presents w/ decreased DTRs, which question by nurse helps eliminate possible cause?

A

•use of laxatives regularly

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33
Q

what food source highest in B12

A
  • organ meat
  • OJ
  • spinach
  • eggs
  • milk products
  • fortified cereals
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34
Q

what is evidence of cardiovascular dysfunction in anemic

A
  • chronic fatigue
  • pallor
  • SOB
  • hypotension
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35
Q

what indicates pulmonary embolism

A

•stabbing chest pain

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36
Q

pt admitted to ICU w/ 25% total body surface area burn…no medical hx. Which IV fluid is contraindicated to administer?

A
  • in burns, develop systemic inflammatory response, which leads to capillary leak and third spacing
  • intravascular volume goes down
  • .45 % NS b/c it is hypotonic and would make third spacing worse
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37
Q

who is at most risk for FVD

A
  • infants

* elderly

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38
Q

single best indicator of fld. status

A

•daily weight

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39
Q

pt w/ aphasia presents w/ suspected CVA. Which finding indicates that it is a thrombotic stroke?

A

•two episodes of speech difficulty (indicates TIAs)

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40
Q

What is a predisposing factor for an embolic stroke?

A
  • Afib

* embolic stroke is sudden onset and often originates at heart

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41
Q

CN 10 (vagus) and CVA

A
  • gag reflex

* must put pt in high fowlers to promote safe swallowing

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42
Q

pt experiencing status epilepticus..what med does nurse admin

A
  • Ativan
  • stops unwanted ctx
  • also give dilantin IV drip to prevent further seizures
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43
Q

hyperventilation causes

A
  • cerebral vasoconstriction

* might trigger seizure activity b/c leads to less cerebral perfusion (O2)

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44
Q

after blood transfusion nurse should…

A

•stay w/ pt for 10-15 min

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45
Q

what is hypersensitivity rxn

A

•transfusion rxn to blood type

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46
Q

pt receiving IV K+. It is important for nurse to…

A
  • infuse faster than 24 hrs
  • NOT admin diuretic also
  • monitor IV site for s/s of extravasation
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47
Q

lab study helpful in dx of pernicious anmeia

A

•Schilling test

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48
Q

FVD subjective

A
  • dizzy- poor perfusion to brain
  • weak
  • lethargic
  • fatigue
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49
Q

FVD objective

A
  • hyperthermia
  • syncope
  • tachycardia/pnea- compensate to maintain CO
  • thready pulse- vasoconstriction in periphery
  • hypotension
  • oliguria
  • confusion
  • diminished cap. refill
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50
Q

FVD labs

A
  • increased Hct
  • increased serum osmolarity
  • increased urine specific gravity and osmolarity
  • hypernaturia
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51
Q

hypovolumetric shock

A
  • decreased oxygen to organ/pressure to organ
  • complication of FVD
  • tx w/ O2, fluids, vasoconstrictors (increase central flow first)
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52
Q

FVE subjective

A
  • confusion
  • SOB
  • lethargy
  • muscle weakness
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53
Q

FVE objective

A
  • tachycardia/pnea
  • bounding pulse
  • hypertension
  • weight gain
  • crackles
  • edema
  • JVD
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54
Q

FVE labs

A
  • decreased Hct, serum osmolarity
  • decreased BUN, creatinine, electrolytes
  • respiratory alkalosis (dec. CO2/inc. pH)
  • chest x-ray showing pulm. congestion
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55
Q

normal Na+

A

•135-145 mEq/L

*imbalances manifested in neuro abnormalities

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56
Q

s/sx hyponatremia

A
  • tachycardia
  • hypothermia
  • hypotension if r/t Na+ loss
  • hypertension if r/t H2O excess
  • headache
  • confusion/lethargy
  • weakness
  • increased GI motility
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57
Q

s/sx hypernatremia

A
  • tachycardia
  • hyperthermia
  • hypotension
  • restlessness
  • muscle twitch/weakness
  • seizure
  • coma
  • thirst
  • dry mucous membrane/skin
  • increased GI motility
  • edema
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58
Q

normal K+ level

A

•3.5-5 mEq/L

*imbalances manifested in cardiac abnormalities

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59
Q

s/sx hypokalemia

A
  • hypotension (ortho), weak irregular pulse, rep. distress
  • weakness, cramping, hypoactive reflex, paresthesia
  • confusion
  • bradycardia, inverted T waves
  • decreased GI motility (constipation)
  • polyuria
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60
Q

s/sx hyperkalemia

A
  • hypotension, weak irregular pulse
  • weakness, restlessness, paresthesia
  • confusion
  • peaked T waves
  • increased GI motility (diarrhea)
  • headache
  • palpitations
  • malaise
  • oliguria
  • nausea
  • inc. resp. rate
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61
Q

normal Ca2+ levels

A

•9-10.5 mg/dL

*imbalances manifested in skeletal muscle abnormalities

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62
Q

s/sx hypocalcemia

A
  • paresthesia
  • muscle twitch/SPASM
  • hyperactive DTRs
  • positive Chvostek’s/Trousseau’s
  • dec. HR, hypotension (dec. contractility)
  • inc. GI- hyperactive bowel, diarrhea, cramping
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63
Q

s/sx hypercalcemia

A 
•lethargy
•paresthesia 
•muscle WEAKNESS
•faster clotting time
*high risk for DVT
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64
Q

phosphorus levels

A

•3.0 - 4.5 mg/dL

*imbalances manifested in skeletal muscle abnormalities

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65
Q

s/sx hypophatemia

A
  • same as hypercalcemia
  • lethargy
  • paresthesia
  • muscle WEAKNESS
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66
Q

s/sx hyperphatemia

A
  • same as hypocalcemia
  • paresthesia
  • muscle twitch/SPASM
  • hyperactive DTRs
  • positive Chvostek’s/Trousseau’s
  • dec. HR, hypotension (dec. contractility)
  • inc. GI- hyperactive bowel, diarrhea, cramping
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67
Q

Mg2+ levels

A

•1.3-2.1 mEq/L

*imbalances manifested in skeletal muscles (DTRs)

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68
Q

s/sx hypomagnesemia

A
  • occurs in conjunction w/ hypocalcemia
  • HYPERACTIVE DTRs (spasm)
  • tetany
  • seizures
  • psychosis
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69
Q

s/sx hypermanesemia

A
  • renal dz
  • lethargy
  • HYPOACTIVE DTRs (weakness)
  • coma
  • bradycardia
  • hypotension
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70
Q

electrolyte imbalances due to use of laxatives

A
  • hypermagnesemia

* hypokalemia

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71
Q

acute seizure tx

A
  • lorazepan (Ativan)

* diazepam (Valium)

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72
Q

long term seizure tx

A
  • phenytoin (Dilantin)

* also given during acute via IV to prevent progression into status epileptics

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73
Q

L hemispheric stroke consequences

A
  • language, math, and analytic thinking
  • expressive, receptive, global aphasia
  • agnosia- inability to recognize objects
  • alexia- reading diff.
  • agraphia- writing diff.
  • hemianopsia, hemiplegia, hemiparesis
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74
Q

R hemispheric stroke consequences

A
  • abnormalities in spatial perception, proprioception, and judgment/impulse control
  • hemianopsia, hemiplegia, hemiparesis
  • depth perception- overestimate
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75
Q

recombinant tissue plasminogen activator (rtPA)

A

•thrombolytic NZ (Activase)
•can be used to reverse ischemic stroke (thrombolitic/embolitic) if given w/ 3-4.5 hrs of initial sx
*only used for clot in brain (not used for DVT)

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76
Q

normal Hgb levels

A
  • m: 14-18 g/dL

* f: 12-16 g/dL

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77
Q

Hgb levels in anemia

A

•mild: 10-14 g/dL
•moderate: 8-10 g/dL
•severe: < 8 g/dL
* < 10 g/dL when clinical manifestations show

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78
Q

normal Hct levels

A
  • m: 50-57 ml/dL (50-54%)

* f: 37-48 ml/dL (37-48%)

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79
Q

normal WBC levels

A
  • 5,000-10,000/uL
  • elevated evidence of infection
  • decreased evidence of immunosuppression
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80
Q

folic acid food sources

A
  • beans/legumes
  • citrus fruits/juice
  • fortified bread, cereals, pasta, etc
81
Q

iron food sources

A
  • red/organ meat
  • leafy greens
  • egg yolks
  • almonds
  • legumes
  • dried fruit
82
Q

fresh frozen plasma transfusion

A
  • anti coagulated clear liquid portion of blood separated from whole blood by centrifugation
  • used to reverse excessive anticoagulation
  • clotting factor deficiencies associated w/ hemorrhagic tendency
83
Q

packed RBC transfusion

A
  • whole blood with ⅔ of plasma removed
  • severe anemia
  • moderate blood loss
  • less danger of fluid overload
  • transfusion of choice
  • should not exceed 4 hrs transfusing
84
Q

whole blood transfusion

A
  • massive blood loss

* pt needs O2-carrying capacity and vol. increase

85
Q

normal pH

A

•7.35-7.45

86
Q

normal PCO2

A

•35-45 mmHg

87
Q

normal HCO3

A

•22-26 mEq/L

88
Q

compensated

A

•pH normal
•acid/base components may be abnormal, but they are balanced
*most abnormal is reason

89
Q

uncompensated

A
  • pH and one other value abnormal

* buffer/regulatory mechanisms have not begun to correct imbalance

90
Q

partially compensated

A
  • all values abnormal abnormal
  • CO2 and HCO3 in same direction
  • evidence buffer/regulatory mechanisms have begun to respond
91
Q

partially compensated respiratory acidosis

A
  • pH down

* CO2 and HCO3 up

92
Q

partially compensated respiratory alkalosis

A
  • pH up

* CO2 and HCO3 down

93
Q

partially compensated metabolic acidosis

A

•all down

94
Q

partially compensated metabolic alkalosis

A

•all up

95
Q

respiratory acidosis labs

A
  • pH < 7.35
  • CO2 > 45
  • HCO3 normal (22-26)
96
Q

respiratory acidosis etiology

A
  1. respiratory depression
  2. inadequate chest expansion
  3. airway obstruction
  4. reduced alveolar capillary diffusion of gases
97
Q

respiratory acidosis s/sx

A
  • dyspnea, tachypenic
  • anxiety/irritability/disorientation
  • hypoventilation -> hypoxemia (b/c no where for O2 to bind)
  • hypotension
  • tachycardia
  • headache
  • hypERkalemia -> dysrhythmias
98
Q

respiratory acidosis tx

A

•O2; patent airway; enhance gas exchange via…

  • positioning
  • breathing technique
  • vent support
  • bronchodilators
  • mucolytics
99
Q

respiratory alkalosis labs

A
  • pH > 7.45
  • PaCO2 < 35 mmHg
  • HCO3 normal (22-26)
100
Q

respiratory alkalosis etiology

A 
•hypoxemia stimulated hyperventilation 
-emphysema; pneumonia
•impaired lung expansion (ascites, scoliosis, preggo)
•Salicylates (aspirin) OD
•CNS trauma/tumor
•excessive exercise/stress/pain
•anxiety
•diabetes
101
Q

respiratory alkalosis s/sx

A
  • Tachypnea; hyperpnea, tachycardia
  • Giddiness, dizziness, syncope, convulsions, or coma
  • Weakness, paresthesias, tetany
  • Hypokalemia
  • Hypocalcemia
102
Q

respiratory alkalosis tx

A
  • O2 therapy
  • anxiety interventions
  • rebreathing techniques
103
Q

metabolic acidosis labs

A
  • pH < 7.35
  • PaCO2 normal (35-45)
  • HCO3 < 22
104
Q

metabolic acidosis etiology

A 
•renal failure
•DMKA
•lactic acidosis
•ingested toxins (aspirin, antifreeze)
•carbonic anhydrase inhibitors (Diamox)
*over-production/under-elimination of H+
*underproduction/over-elimation HCO3
105
Q

metabolic acidosis s/sx

A
  • Tachypnea (hyper) “Kussmaul’s”
  • Hypotension- poor tissue perfusion as condition worsens
  • Drowsiness,confusion, or coma
  • Headache, dec. DTRs & muscle tone
  • Altered GI: anorexia, N/V
  • Hyperkalemia
106
Q

metabolic acidosis tx

A
  • DKA- admin insulin
  • GI losses- admin antidiarrheals; rehydrate
  • low serum HCO3- admin NaHCO3
107
Q

metabolic alkalosis labs

A
  • pH > 7.45
  • PaCO2 normal (35-45)
  • HCO3 > 26
108
Q

metabolic alkalosis etiology

A
  • hypokalemia (diuresis, steroids)
  • gastric fluid loss
  • overcorrection of acidosis w/ NaCO3
  • massive transfusion w/ whole blood
  • hyperaldosteronism
  • licorice intoxication
109
Q

metabolic alkalosis s/sx

A
  • Tachycardia, Hypoventilation (compensatory)
  • Dysrhythmias
  • Paresthesias, muscle weakness, confusion
  • Hypokalemia
  • Hypocalcemia
110
Q

metabolic alkalosis tx

A
  • GI loses- antiemetics, fluids, electrolytes

* K+ depletion- discontinue causative agent (diuretic)

111
Q

hypoventilation

A 
•not breathing enough (getting rid of enough CO2)
•rapid/shallow breaths
•vasodilation
•hypercapnia
*blood becomes ACIDIC
112
Q

hyperventilation

A 
•deep, labored, rapid breathing
•vasconstriction
•hypocapnia 
•Kussmaul respirations
*blood becomes BASIC
113
Q

diuretics and alkalosis

A

•diuretics cause loss of fluid not containing HCO3

114
Q

normal PaO2

A
  • 80-100 mmHg

* amount of O2 dissolved in arterial blood

115
Q

normal SaO2

A
  • 96-100%

* amnt O2 dissolved in blood

116
Q

good indicator of metabolic acidosis during hyperventilation

A

•severe diarrhea

117
Q

good indicator of respiratory alkalosis during hyperventilation

A

•anxiety

118
Q

atelectasis

A
  • alveolar collapse

* causes a reduction in gas exchange b/c reduces surface area

119
Q

thoracentesis

A
  • surgical perforation of chest wall and pleural space w/ large-bore needle
  • used to obtain specimens, admin meds, remove fld/air
  • local (conscious) sedation
120
Q

empyema

A

•infection in pleural space causing collection of pus

121
Q

bubbling w/in CT system

A
  • always occurs when CT is connected to continuous suction
  • bubble w/ only water seal indicates air passing thru chamber w/ higher intrathoracic pressure (exhale, cough, sneeze)
  • excessive bubbling may indicate leak
122
Q

CT complications

A
  • redness/swelling/purulence/bleeding
  • tracheal deviation
  • sudden/increased dyspnea
  • SaO2 < 90%
  • drainage > 70 mL/hr
  • crepitus
  • accidental disconnect (immediately submerge in sterile H2O or cover w/ vasoline gauze)
123
Q

COPD complications

A
  • hypoxemia
  • hypercarbia
  • respiratory acidosis
  • respiratory infection
  • dysrhythmias
  • HF
  • decrease resp. drive (NEVER give > 2 L)
124
Q

indication of tension pneumothorax

A

•tracheal deviation to side opposite of pneumothorax

125
Q

1 preventable cause of prematures dz/death

A

•tobacco use

126
Q

how does atelectasis reduce gas exchange

A

•reduced alveolar surface

127
Q

pt w/ 2 chest tubes on R side; clients trachea is pointing toward L upper chest. What’s RN’s best action

A

•notify MD/rapid response team

128
Q

elderly w/ pneumonia has symptoms of

A
  • altered mental status

* dehydration

129
Q

which pathophysiological mechanisms of lung parenchyma allows pneumonia to develop?

A

•inflammation

130
Q

atelectasis and brochiectasis indicate…

A

•collapse of a portion of the airway

131
Q

what finding confirms diagnosis of asthma

A

•inspiratory and expiratory wheezing

132
Q

7 y/o tachypneic, afebrile, RR=38, and nonproductive cough. PT most likely has

A

•acute asthma

133
Q

19 y/o in ED w/ acute asthma attach; RR=44 bpm; acute resp. distress. Which action should RN take first

A

•nebulizer tx

134
Q

79 y/o w/ bacterial pneumonia who is vegetarian and OCD about germs, What is predisposing factor for pneumonia?

A

•age

135
Q

what data significant from pt w/ pneumonia

A
  • quality of breath sounds
  • chest pain
  • color of nail beds
136
Q

pt w/ bacterial pneumonia is to be started on IV abx. what must be completed first?

A

•sputum culture to determine which abx to use

137
Q

what should be included in plan of care for pneumonia pt?

A

•frequent linen changes b/c likely diaphoretic and at risk for skin breakdown

138
Q

pleuritic chest pain is…

A

•moderate pain that worsens on inspiration

139
Q

which measure most likely to reduce pleuritic chest pain?

A

•teach pt to splint rib cage b/c talking about pain

140
Q

what indicates presence of resp infection in pt w/ asthma

A

•cough productive of yellow sputum

141
Q

30 y/o male w/ stab wound has CT inserted b/c…

A

•CT serve as method of draining blood/fld

142
Q

what are expected findings of CT after thoractomy

A
  • 50 mL drainage in chamber

* drainage system below pt chest

143
Q

continuous bubbling in suction control chamber requires…

A

•no action

144
Q

antiacids

A 
•increase pH of gastric contents
•deactivate pepsin
•buffer acids
•best given on empty stomach
•aluminum -> constipation
•magnesium -> diarrhea
*Sodium Bicarbonate, Maalox, Mylanta
145
Q

histamine receptor antagonists

A
  • antagonize (block) production of histamine

* do not impact reflux as much as reduce acid production and promote healing of inflamed tissue

146
Q

proton pump inhibitors

A

•primary tx for GERD
•long-acting inhibition of gastric acid by impacting proton pump of parietal cells in mucosa
•given IV to treat/prevent stress ulcers
*Prilosec, Zantac, Prevacid

147
Q

prolonged use of proton pump inhibitors

A
  • may mask symptoms
  • may cause pneumonias and C-diff
  • increase risk of hip fractures in elderly b/c of Ca2+ loss
148
Q

Dumping syndrome

A
  • vasomotor response to food ingestion due to stomach being no longer able hold contents and “dumping” mass amounts into small intestine
  • reduced circulatory volume b/c trying to supply intestines
  • s/s of tachycardia, hypotension, dizziness
  • compilation of GERD and PUD
  • high protein diet, avoiding wheat and dairy
149
Q

perforation

A
  • deep ulcer goes thru lining of stomach or duodenum

* can cause peritonitis

150
Q

s/sx perforation

A 
•severe epigastric pain spreading across abdomen
•hypotension
•round, board-like abdomen
•hyperactive or diminished bowel sounds
•rebound tenderness
*surgical emergency
151
Q

RN interventions for GI bleed

A
  • ABCs
  • vital signs (prevent hypovolemic shock)
  • fld replacement
  • NG tube lavage
  • manage pain
  • admin meds
152
Q

NG tube gastric lavage

A
  • NS instilled and then removed with blood

* pt on L side to limit flow out of stomach

153
Q

Why would a client with gastric ulcers need to be cautious about using OTC cold remedies?

A
  • OTC medications may have aspirin in them
  • OTC medications may contain NSAIDs
  • Drug interactions may occur causing deepening of the stomach ulcers
154
Q

why do NSAIDs cause bleeding

A

•inhibit prostaglandin production
•prostaglandins are responsible for providing mucosal layer of stomach
*nothing to protect stomach

155
Q

chronic gastritis can cause

A
  • Pernicious anemia
  • Sickle cell anemia
  • Gastric ulcers
  • Electrolyte imbalance
  • Cancer of the stomach
156
Q

role of parietal cells

A
  • intrinsic factor that helps absorb B12
  • destroyed in chronic gastritis
  • require B12 injection for life
  • also secrete HCl (diminished in older adult)
157
Q

GERD in elderly

A

•may not have s/s of reflux b/c diminished parietal cell HCl production
*more severe complications b/c immunocompromised
•atypical chest pain
•ENT infections; Barrett’s esophagus
•pulmonary symptoms
•sleep apnea
•asthma

158
Q

The danger of aspiration is increased if regurgitation occurs when the client

A

•lying down

159
Q

dysphagia indicates ____; and assessment by RN should include ____

A
  • stricture of the esophagus

* when it occurs in pt

160
Q

interventions for anti-acid admin

A
  • give on empty stomach
  • monitor for constipation
  • don’t give w/ other drugs
  • assess pt for hx of HF or renal dz first
161
Q

febrile nonhemolytic transfusion rxn

A

•most common
•fever w/in 2 hrs
•chills, headache, flushing, anxiety, muscle pain
*due to sensitization to blood products

162
Q

septic transfusion rxn

A

•rapid onset of fever/chills
•hypotension
*due to contamination

163
Q

acute hemolytic transfusion rxn

A 
•fever/chills/anxiety immediately
•N/V
•dyspnea
•tachycardia/tachypnea
•hypotension
*due to incompatibility
164
Q

allergic transfusion rxn

A 
•flushing
•urticaria (hives)
•itching
•wheezing
*due to sensitivity
165
Q

thrombocytopenia

A
  • low platelet count

* recipient of platelet transfusion

166
Q

s/sx increased ICP

A
  • widening of pulse pressure

* decreased HR

167
Q

preventing post-op DVT

A

•have pt. perform dorsal/plantar flexion qh

168
Q

spirometer

A
  • expands lungs during INHALATION

* prevents respiratory acidosis

169
Q

tx for tachycardia/hypotension

A

•IV fluid bolus

170
Q

narcan

A

•reverses respiratory depression r/t OPIOIDS

171
Q

A/B imbalance caused by aspirin OD

A
  • respiratory alkalosis

* metabolic acidosis

172
Q

duodenal ulcer

A
  • upper portion of duodenum

* evening pain 1.5-3 hrs after meal

173
Q

blood transfusion rate

A

•2 mL/min

174
Q

CT drainage

A

•100-300 mL post insertion
•report > 70 mL/hr after 4 hrs post-op
*keep device below chest

175
Q

s/sx hyperglycemia

A 
•3 P's
•polyphagia
•polydispia
•polyuria 
*hot and dry, sugar's high
176
Q

s/sx hypoglycemia

A 
•TIRED
•tachycardia
•irritability
•restless
•excessive hunger
•diaphoresis
*cold and clammy, need some candy
177
Q

fiber and hypothyroidism

A
  • encourage fiber rich foods, NOT laxatives

* laxatives impede absorption of Synthroid

178
Q

normal BP

A

•120/80 mmHg

179
Q

pre-HTN

A

•121-139/81-89 mmHg

180
Q

HTN

A

•140/90 mmHg (and above)

181
Q

IVP

A
  • intravenous pyelography
  • used to diagnose calculi, tumors, cysts
  • view of kidney, bladder, and tract
  • requires bowel prep so view is not obstructed
182
Q

concern about contrast dye

A
  • nephrotoxic
  • major concern for kidney failure in dehydrated or renal compromised pts
  • pt’s taking metformin at risk for lactic acidosis
183
Q

pre-contrast dye procedures to prevent complications

A
  • adequate hydration before/after
  • IV hydration for renal insufficient pts
  • diuretics after for renal insufficient
  • discontinue metformin 48 hrs prior
  • if have minor dye allergy can admin steroids/antihistamines prior
184
Q

CAUTION (clinical manifestations of cancer)

A
  • Change in bowel/bladder habits
  • A sore that doesn’t heal
  • Unusual bleeding/discharge
  • Thickening of lump presence
  • Indigestion/dysphagia
  • Obvious changes in warts/moles
  • Nagging cough/hoarseness
185
Q

peripheral neuropathy

A
  • nerves that carry messages to the brain and spinal cord from the rest of the body are damaged or diseased
  • s/sx: pain, impaired movement, paresthesias, weakness, diminished sensation
186
Q

glycosylated hemoglobin (HgbA1c) levels

A
  • 4%-6% in non-diabetic
  • 6%-8.5% in diabetic (<7 target for diabetic)
  • best indicator of avg blood glucose for pat 120 days
  • used to evaluate effectiveness of tx
187
Q

hyperkalemia etiology (MACHINE)

A 
Meds (ACEI, steroids, beta blocker)
Acidosis
Cellular destruction
Hemolysis; hypoaldersteronism
Intake- excessive
Nephron failure
Excretion impaired
188
Q

HTN tx (ABCD)

A

ACEIs
Beta blockers
CCBs
Diuretics

189
Q

risk factors for primary

A
  • no true known cause
  • high Na+ and fat
  • obesity
  • stress
  • etoh
  • inactivity
  • caffeine
  • vit D deficiency
190
Q

solutions to treat hypo volumetric shock

A
  • 0.9% NaCl

* lactated ringers

191
Q

thyroid storm

A 
•fever
•hypertension
•abdominal pain
•tachycardia
*exaggerated hyperthyroidism
192
Q

priority intervention for calculi

A

•relieving pain

193
Q

casts

A
  • protein structures in renal tubules

* presence in urine indicated kidney infection

194
Q

gastric distention during NG suction indicates

A

•NG tube not patent

*report to MD immediately

195
Q

prior to an infusion, what prevents against blood group incompatibility AFTER blood has arrived

A

•comparing ID #s on blood and pt wristband

196
Q

blood glucose during DKA

A

•increases

197
Q

pt has high T3 and T4 and low TSH. What is RN priority intervention?

A

•monitor apical pulse

-b/c once give Propanorol, the HR will decrease

198
Q

renal calculi in L kidney…which assessment finding indicates development of complication

A

•pt reports severe pain at L CVA

199
Q

hypothyroidism…which problem is a priority?

A

•depression and withdrawal

Foundation 2 Final (2 decks)

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