VN 22 CLO 4 & 5- Done Flashcards
What is an intervention for the prevention of post-op elius?
encourage ambulation
Most common fluid imbalance in adults?
dehydration
Client has manifestations of respiratory alkalosis, what would be the nurses first action?
Find and correct the cause of tachypnea
ABG’S
Ph: 7.35-7.45
PaCo2: 45-35
Hco3: 22-26
What solution is given to NPO client w/bowel obstruction?
isotonic
What nursing intervention should a nurse perform to promote the dignity & self-esteem of a dying client?
keep client clean & well groomed
What do we do to prevent the drying of oral mucous membranes in a dying client?
-oral care
-ice chips
-petroleum jelly
What type of solution is normal saline?
crystolloid
What type of solution replaces circulating blood?
colloid
Client is thirsty, has dry mucous membranes, decreased urine output, fever rough tongue, sodium level above 145, do we give pt salt tabs?
no, restrict sodium
Client complaints of horseness for 4 months could be a sign of?
cancer
What do we monitor when taking care of a Hypertensive pt, to ensure they don’t suffer injury due to lack of regulation of BP?
monitor postural changes of BP
Pt with malignant HTN(BP is ridiculously high), and complaints of a sudden headaches. what does the nurse do?
notify physician
Older people on digoxin are at an increased risk for what?
toxicity
What is a contraindication to ultrasonography is what?
-chewing gum
-smoking
Comatose pt blood sugar of 30 mg/dEq, what would be ordered?
50% glucose IV stat
Pt w/CVA prescribed w/heparin what do we worry about?
hemorrhage
What do we assess for anyone having a contrast test ?
allergy to iodine
A pt w/neuro disorder we see a change in VS , what does the nurse do?
report to the physician
What is the priority for seizure?
protect from injury (safety)
What’s the difference between an ischemic and hemorrhagic stroke
ischemic: block, emboli
hemorrhagic: bleeding
What is a good nursing intervention to reduce the risk of aspiration for someone receiving tube feedings?
keep the client in semi fowlers position at all times
PT with DKA, what type of insulin do they need?
regular
Nursing interventions for seizures?
-keep pt safe from injury
What would you anticipate when preparing a client for appendicitis surgery? What are nursing interventions?
-maintain NPO status
-deliver IV fluids
-obtain surgical consent
What do you check when administering insulin to type 1 diabetics?
-duration of insulin (peak)
-accuracy of dosage
-type
After a cardiac catheterization, we want to make sure we educate pt to report what?
numbness, tingling, or pain in the extremity
What’s the #1 nursing instruction we can give to a pt w/pre hypertension?
avoid salt
What do we avoid with an aneurysm?
-straining
-coughing
-heavy lifting
Self-management of HF, what do we avoid with dietary?
avoid intake of processed or commercially prepared foods
Procedure w/contrast what do we ask for?
allergy to iodine, shellfish or shrimp
Why don’t we stop anticonvulsant meds abruptly?
can trigger status epileptics
When do you take Sumitriptan?
take at the onset of the headaches
What med do we avoid giving to a pt with an aneurysm?
opioids
What is a nursing intervention for pt w/hiatal hernia before surgery?
sitting upright 2hrs after eating
With Rouxney gastric bypass, what is the main thing to do?
-small meals, gradually increasing them
-avoiding liquids before and during meals
Why don’t we encourage prolonged used of laxatives?
Can slow down bowel function “sluggish”
What do we avoid in any type of abdominal surgery?
heavy lifting
When we add fiber-rich foods what do we need to recommend?
add fiber gradually
What are we concerned with pts that have diarrhea?
-hypokalemia (increase potassium-rich foods)
-dehydration
