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Nurs 120- MCA I > Week 1 > Flashcards

Week 1 Flashcards

1
Q

Inflammatory Response
- __________ response to cell injury
-Establishes an environment for healing and repair
-Inflammation is ______________________________ , but infection is not always present with inflammation – (think sprained ankle)

A

-Sequential response to cell injury
-Establishes an environment for healing and repair
-Inflammation is always present with infection, but infection is not always present with inflammation – (think sprained ankle)

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2
Q

Inflammatory Response

Cellular Response
-Neutrophils & monocytes
- _____________ first to arrive – phagocytize bacteria and other foreign objects
-Dead neutrophils and bacteria are ____
- Monocytes transform into _____________ and clean the area for healing…
-_______________ arrive later – humoral and cell mediated immunity

A

-Neutrophils & monocytes
- Neutrophils first to arrive – phagocytize bacteria and other foreign objects
-Dead neutrophils and bacteria are pus
- Monocytes transform into macrophages and clean the area for healing…
-Lymphocytes arrive later – humoral and cell mediated immunity

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3
Q

Inflammatory Response

Vascular Response
-Initial vascular ____________ followed by chemical mediated (histamine)
_____________ /capillary permeability (redness, swelling, heat)

A

-Initial vascular constriction followed by chemical mediated (histamine)
vasodilation/capillary permeability (redness, swelling, heat)

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4
Q

Chemical mediators
- Complement system – ___________ ___________ mediates inflammation
-______________ & Leukotrienes – (think of meds used to treat inflammation – leukotriene inhibitors)

A
  • Complement system – enzyme cascade mediates inflammation
    -Prostaglandins & Leukotrienes – (think of meds used to treat inflammation – leukotriene inhibitors)
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5
Q

Clinical manifestations of inflammation
See table 11-3 (Local Manifestations of Inflammation)

-______, redness, ______, swelling, loss of function (due to pain & swelling)

-Increase and “shift to the left” (______)

-Fever!
-Fever may not be present in ___________________ individuals (Cancer or those receiving chemo, HIV/AIDS, transplant recipients on immunosuppressant medications, older adults)

-Even small increases in ______ in compromised individuals should be a “red flag” to investigate and be concerned about

A

-Heat, redness, pain, swelling, loss of function (due to pain & swelling)

-Increase and “shift to the left” (WBCs)

-Fever!
-Fever may not be present in immunocompromised individuals (Cancer or those receiving chemo, HIV/AIDS, transplant recipients on immunosuppressant medications, older adults)

-Even small increases in temp in compromised individuals should be a “red flag” to investigate and be concerned about

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6
Q

Inflammation treatment

-RICE
_______
_______
____________________________
_____________

-Drug therapy
_________
__________

A

-RICE
Rest
Ice
Compression & immobilization
Elevation

-Drug therapy
NSAIDS
Tylenol

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7
Q

WOUND HEALING

Regeneration - ___________ of lost cells and tissues with the same type

Repair - Lost cells replaced with _____________________ – scar formation

Primary, secondary, tertiary - intention healing

A

Regeneration - Replacement of lost cells and tissues with the same type

Repair - Lost cells replaced with connective tissue – scar formation

Primary, secondary, tertiary - intention healing

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8
Q

WOUND HEALING COMPLICATIONS

Review Table: 11-7 (Complications of Wound Healing)

Adhesions
Contractions
Dehiscence
Evisceration
Fistula
Infection
Hemorrhage
Hypertrophic scars
Keloid

A

Adhesions
Contractions
Dehiscence
Evisceration
Fistula
Infection
Hemorrhage
Hypertrophic scars
Keloid

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9
Q

________________________ is the most common acute hyperglycaemic emergency in people with diabetes mellitus

A

Diabetic ketoacidosis (DKA)

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10
Q

Diabetic Ketoacidosis (DKA) results from ____________ deficiency, leading to hyperglycemia, metabolic acidosis, and ketosis.

It commonly occurs in uncontrolled type 1 diabetes (T1DM) but can also affect poorly controlled type 2 diabetes (T2DM) under stressful conditions.

A

insulin

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11
Q

Rights of Delegation:

A

Right task, circumstance, person, directions and communication, and supervision and evaluation

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12
Q

Why do you ice? (RICE) for inflammation

A

Causes vasoconstriction

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13
Q

Why do you elevate for inflammation?

A

Stops pooling/ fluid accumulation

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14
Q

Tylenol does what?

reduces:

A

fever & pain

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15
Q

NSAIDS like ibuprofen

they reduce:

A

inflammation, pain, & fever

Inflammation = primary

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16
Q

__________ is a separation of an incision

___________ is protrusion of abdominal viscera through an incision.

A

Dehiscence is a separation of an incision

Evisceration is protrusion of abdominal viscera through an incision.

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17
Q

Immunity is the body’s ability to:

A

resist disease.

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18
Q

Immunity serves three functions

  • __________ – prevents invasion of microorganisms and infection
  • _______________ – damaged cellular substances are digested and removed
  • ____________ – mutations continually arise, recognized as foreign
A
  • Defense – prevents invasion of microorganisms and infection
  • Homeostasis – damaged cellular substances are digested and removed
  • Surveillance – mutations continually arise, recognized as foreign
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19
Q

Antigens are substances that elicit :

A

an immune response

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20
Q

Antigens are usually __________ , but also large polysaccharides, lipoprotiens, and nucleic acids

A

proteins

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21
Q

Innate immunity – ___________________ , primary role is against pathogens
-Non-specifi c response – not antigen specific

A

present at birth

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22
Q

Acquired Immunity - 2 types

A

Active

Passive

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23
Q

Active acquired immunity
- Results from __________________________ & development of antibodies & sensitized lymphocytes
- Naturally or through _____________
- Takes time to develop but lasts a long time

A
  • Results from invasion of foreign bodies & development of antibodies & sensitized lymphocytes
  • Naturally or through vaccinations
  • Takes time to develop but lasts a long time
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24
Q

Passive acquired immunity
- Host ___________________ rather than making them
- From mother to fetus
- Injection of gamma globulin (serum antibodies) – think rabies …
- Benefits – ____________ immunity
- Drawback – ____________ immunity

A
  • Host receives antibodies rather than making them
  • From mother to fetus
  • Injection of gamma globulin (serum antibodies) – think rabies …
  • Benefits – immediate immunity
  • Drawback – short lived immunity
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25
Q

B Lymphocytes - _____________ !

A

Antibodies

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26
Q

T Lymphocytes
-Primarily responsible for immunity to ____________________ , tumor cells (Cancer), fungi.

T-helper & T-Cytotoxic
- T-Helper – help identify and activate the cell and humoral mediated immune response
(think HIV and inability to mount immune response)
- T-cytotoxic – have antigen specificity and sensitized by exposure to antigens, release
chemicals to kill cells

A

intracellular viruses

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27
Q

T-helper & T-Cytotoxic

  • T-Helper – help identify and activate the ________________________________ response
    (think HIV and inability to mount immune response)
  • T-cytotoxic – have _____________________ and sensitized by exposure to antigens, release
    chemicals to kill cells
A
  • T-Helper – help identify and activate the cell and humoral mediated immune response
    (think HIV and inability to mount immune response)
  • T-cytotoxic – have antigen specificity and sensitized by exposure to antigens, release
    chemicals to kill cells
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28
Q

NK (Natural Killer) Cells

  • Large ______________ with numerus granules
  • No prior sensitization required
  • Primarily kill _______________ cells, tumor cells, transplanted graft tissue
  • Significant role in immune surveillance for _____________ cells
A
  • Large lymphocytes with numerus granules
  • No prior sensitization required
  • Primarily kill virus infected cells, tumor cells, transplanted graft tissue
  • Significant role in immune surveillance for malignant cells
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29
Q

Cytokines
-Soluble factors secreted by WBCs and other cells
-Immune cell interactions depend/rely on cytokines, which act as ____________
- _____ different known cytokines
-Proinflammatory, antiinflammatory
-Stimulate _______________

A

-Soluble factors secreted by WBCs and other cells
-Immune cell interactions depend/rely on cytokines, which act as messengers
-100 different known cytokines
-Proinflammatory, antiinflammatory
-Stimulate hematopoiesis

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30
Q

Hypersensitivity Reactions Type-I

_____________________
— Mast cells, basophils, histamine, leukotrienes, prostaglandins

A
  • Immunoglobulin (IgE)
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31
Q

Drug Classes to Treat __________________
- Antihistamines, Sympathomimetic/decongestants, corticosteroids, antipruritic, mast cell-stabilizing, leukotriene receptor antagonists (inhibitors)

A

Allergic Disorders

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32
Q

Humoral Immunity
- ___cells
- Antibody mediated immunity (Immunoglobulins [IgM, IgG, etc…)

*Primary exposure (IgM) – ______________as the body is first encountering antigen
- B-cells differentiate into plasma cells when exposed to antigens & create/release antibodies
- Some stimulated B-cells remain and are called memory cells
- Memory cells allow for rapid production if antigen is encountered a second time

*Secondary exposure (IgG) – ________________ & more significant response due to previous exposure

A
  • B-cells
  • Antibody mediated immunity (Immunoglobulins [IgM, IgG, etc…)

*Primary exposure (IgM) – takes time as the body is first encountering antigen
- B-cells differentiate into plasma cells when exposed to antigens & create/release antibodies
- Some stimulated B-cells remain and are called memory cells
- Memory cells allow for rapid production if antigen is encountered a second time

*Secondary exposure (IgG) – much faster & more significant response due to previous exposure

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33
Q

Cell Mediated Immunity
- ___cells
- Response to specific __________
- Primary importance in: Intracellular antigens (virus), fungi, transplant rejections, tumor/cancer cell

A
  • T-cells
  • Response to specific antigens
  • Primary importance in: Intracellular antigens (virus), fungi, transplant rejections, tumor/cancer cell
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34
Q

Autoimmunity
- Response against _________
-Immune system unable to recognize _________________
- Human Leukocyte Antigen System (HLA)
- Unique to each person
- Crucial to organ/tissue transplantation
- Goal is to get best match for transplant

A
  • Response against oneself
    -Immune system unable to recognize self from other (attacks self)
  • Human Leukocyte Antigen System (HLA)
  • Unique to each person
  • Crucial to organ/tissue transplantation
  • Goal is to get best match for transplant
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35
Q

Treat autoimmune disorders by:

A

suppressing the immune system

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36
Q

ORGAN TRANSPLANT

Life saving procedure!
- 123,000 people on organ waiting list!
- Fewer than _______ receive transplants annually

_____________ is required
- HLA compatibility required or best match
- Identical twins only people who will perfect HLA compatibility

A

Life saving procedure!
- 123,000 people on organ waiting list!
- Fewer than 30,000 receive transplants annually

Tissue typing is required
- HLA compatibility required or best match
- Identical twins only people who will perfect HLA compatibility

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37
Q

Transplant/organ/tissue Rejection

Hyperacute rejection
- Occurs within ______
- ______________ are rapidly destroyed
- Preexisting antibodies to transplanted tissue
- Organ __________ necessary
- Rare – better testing

A
  • Occurs within 24hrs
  • Blood vessels are rapidly destroyed
  • Preexisting antibodies to transplanted tissue
  • Organ removal necessary
  • Rare – better testing
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38
Q

Transplant/organ/tissue Rejection

Acute rejection
- occurs when? __________
- ______-mediated immunity
- _____________ with immunosuppressive medication
- Long-term use of immunosuppressive drugs
- Risk for infection!!! – teach patient to take precautions

A
  • First 6-months
  • Cell-mediated immunity
  • Reversible with immunosuppressive medication
  • Long-term use of immunosuppressive drugs
  • Risk for infection!!! – teach patient to take precautions
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39
Q

Immunosuppressive therapy - [organ transplant]
- duration _________
- Many immunosuppressive drugs have side-eff ects
- Corticosteroids!
- Biggest complications from immunosuppression – _________________

A
  • Life-long
  • Many immunosuppressive drugs have side-eff ects
  • Corticosteroids!
  • Complications from immunosuppression – risk for infection
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39
Q

Transplant/organ/tissue Rejection

Chronic rejection
- Occurs when? ___________
- Organ is infiltrated with large numbers of __________ cells
- Results in scarring and fibrosis
- No definite therapy, difficult to manage, not associated w/ optimistic prognosis of acute rejection

A
  • Months to years
  • Organ is infiltrated with large numbers of T and B cells
  • Results in scarring and fibrosis
  • No definite therapy, difficult to manage, not associated w/ optimistic prognosis of acute rejection
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40
Q

Graft-versus-host disease
- Most commonly seen in ____________________ transplants
- Graft rejects host _______ days after transplant
- Little can be done – donor T-cells attack host cells
- Immunosuppression

A
  • Most commonly seen in Hematopoietic stem cell transplants
  • Graft rejects host (7-30) days after transplant
  • Little can be done – donor T-cells attack host cells
  • Immunosuppression
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41
Q

Pathogens - microorganism that causes _________

Major pathogens
- _________________________________

A

Pathogens - microorganism that causes disease

Major pathogens
-Bacteria, viruses, fungi, protozoa, prions

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42
Q

Infections can be:
- Local, disseminated, systemic

A
  • Local, disseminated, systemic
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43
Q

____________ infections include Covid, Ebola

A

Emerging

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44
Q

Antibiotic _____________

  • MRSA = Methicillin Resistant Staph Aureus
  • VRE; VRSA = Vancomycin Resistant Enterococci & VR Staph Aureus
  • CRE = Carbapenem Resistant enterococci
A

Resistance

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45
Q

Health care providers contribute to the problem [Abx resistance]

  1. abx for _______ infections
  2. prescribing abx unnecessarily
  3. inadequate drug regimens
  4. using ________________ abx when not needed
A
  1. abx for viral infections
  2. prescribing abx unnecessarily
  3. inadequate drug regimens
  4. using broad spectrum abx when not needed
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46
Q

Patient contribute to the problem [Abx resistance]
1. __________ doses
2. not taking medication for _______________ of treatment
3. saving ________ abx

A
  1. skipping doses
  2. not taking medication for full duration of treatment
  3. saving unused abx
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47
Q

hospital-acquired infections - HAIs - Acquired through exposure in a healthcare setting
_______
_______
_______

A
  • c-Diff
  • VRE
  • MRSA
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48
Q

Fluid Compartments

Intracellular
- 2/3 of Decreases as we age
- body water is _____________

Extracellular
- Interstitial fluid – spaces between the cells
- Intravascular (plasma) – blood and vasculature

A

Intracellular
- 2/3 of Decreases as we age
- body water is INSIDE cells

Extracellular
- Interstitial fluid – spaces between the cells
- Intravascular (plasma) – blood and vasculature

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49
Q

Osmosis-

A

movement down a pressure gradient (From low to high conc.)

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50
Q

DKA = high serum osmolality! ↑ glucose concentration in serum → intracellular dehydration

A

high serum osmolality! ↑ glucose concentration in serum → intracellular dehydration

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51
Q

Hydrostatic pressure- __________________________________________

-Fluid pushed out through ‘leaky’ capillary blood vessel wall under high pressure

A

pressure exerted against the walls of the blood vessels/ capillaries

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52
Q

Colloidal oncotic pressure- caused by plasma proteins (mainly albumin)

-Cirrhosis – decreased intravascular oncotic pressure leads to ascites

A

Colloidal oncotic pressure- caused by plasma proteins (mainly albumin)

-Cirrhosis – decreased intravascular oncotic pressure leads to ascites

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53
Q

Fluid Spacing

Edema – Second spacing (fluid in the ___________ areas)
1+
2+
3+
4+

Third Spacing –______________________ of fluid
-Ascites, abdominal cavity

A

Edema – Second spacing (fluid in the interstitial areas)
1+
2+
3+
4+

Third Spacing – abnormal accumulation of fluid
-Ascites, abdominal cavity

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54
Q

Fluid volume regulation - Several mechanisms control fl uid volume deficits and excess

-Hypothalamic-Pituitary Regulation – ADH (anti-diuretic hormone)
- Renal/Kidneys – urination
- Adrenal – Cortical Regulation
>RAAS
- Cardiac (BNP) – Heart failure [MCA-2]
- Gastrointestinal (GI) – think Nausea/vomiting

A

-Hypothalamic-Pituitary Regulation – ADH (anti-diuretic hormone)
- Renal/Kidneys – urination
- Adrenal – Cortical Regulation
>RAAS
- Cardiac (BNP) – Heart failure [MCA-2]
- Gastrointestinal (GI) – think Nausea/vomiting

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55
Q

Fluid volume deficit / excess
-Nursing Actions: ______________
-IVs, PO, nausea, vomiting, excess urination, sweating (fever), weights!
-Monitor Lab values – _____
- Measure BP, tachycardia, CVP

A

-Nursing Actions: Track I’s & O’s
-IVs, PO, nausea, vomiting, excess urination, sweating (fever), weights!
-Monitor Lab values – BUN
- Measure BP, tachycardia, CVP

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56
Q

ELECTROLYTES

Sodium - Think ______

Potassium - Think ________

Calcium - Think ________

Phosphorus

Magnesium

A

Sodium - Think neuro

Potassium - Think cardiac

Calcium - Think muscle

Phosphorus

Magnesium

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57
Q

Fluid types

  • Hypertonic – _____ NS
  • Isotonic – _____ NS
  • Hypotonic – _____ NS
A
  • Hypertonic – 3.0% NS
  • Isotonic – 0.9% NS
  • Hypotonic – 0.45% NS
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58
Q

Electrolyte Replacement

____________________ . Usually best option [bananas]

IV
– Potassium
*NEVER EVER GIVE K+ _________ – CAN CAUSE CARDIAC ___________
*USUALLY THROUGH CENTRAL LINE
*RATE LIMITED
* Can cause peripheral irritation
* RATE LIMITED

A

PO – diet or supplements. Usually best option [bananas]

IV
– Potassium
*NEVER EVER GIVE K+ IV PUSH – CAN CAUSE CARDIAC ARYTHMIAS
*USUALLY THROUGH CENTRAL LINE
*RATE LIMITED
* Can cause peripheral irritation
* RATE LIMITED

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59
Q

Diabetes mellitus is a problem of:

A

glucose metabolism

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60
Q

Global cost of diabetes mellitus in 2015:

A

1.3 trillion

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61
Q

1 in 5 health care dollars is spent caring for people with : _______ in the US

A

Diabetes Mellitus

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62
Q

Insulin attaches to receptors on target cells, where it promotes ____________________________ through the cell membranes

A

Insulin attaches to receptors on target cells, where it promotes glucose transport into the cells through the cell membranes

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63
Q

Diabetes type 1

-_____________disease
-B cells ____________________

A

-Autoimmune disease
-B cells do not secrete insulin

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64
Q

While Type 1 diabetes cause is unknown/autoimmune and often occurs in children, type 2 diabetes:

A

is more common in adults; associated with lack of exercise/ poor diet

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65
Q

Symptoms in diabetes type 1 vs 2

A

type 1: quickly develop

type 2: gradual symptoms

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66
Q

Type 1 diabetics treatment:

A

daily insulin

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67
Q

Type 2 diabetics treatment:

A

often managed by exercise, healthy diet, or oral medications

If progresses, may be treated with insulin

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68
Q

Symptoms of type 1 + 2 diabetes

A

Thirst
weight loss
frequent urination
constant hunger
fatigue
blurry vision

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69
Q

Signs of hypoglycemia

A

headache
sweaty
hungry
shaky
confused
grumpy

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70
Q

Hyperglycemia signs

A

Tired
vomiting
stomach pain
rapid breathing, increased pulse
dry mouth
flushed face
fruity breath

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71
Q

Long term complications of Diabetes mellitus

A
  • Retinopathy & PVD
  • Peripheral neuropathy
  • Coronary Artery Disease
  • CVA & Nephropathy
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72
Q

Pre-diabetes

-Not high enough for diabetes diagnosis
-ADA criteria: fasting plasma glucose level from __________ mg/dL
-increase risk for developing type 2 diabetes
-Prevent by : __________________________

A

-Not high enough for diabetes diagnosis
-ADA criteria: fasting plasma glucose level from 100- 125 mg/dL
-increase risk for developing type 2 diabetes
-Prevent by regular exercise and healthy weight

73
Q

About ___% of DM population has type 1 DM

A

5

74
Q

Type 1 DM

Bodies makes ____________ against pancreatic ________ … cause not entirely known

Classic signs and symptoms: weightloss, weakness, fatigue, 3 P’s (__________________________________________)

A

Bodies makes antibodies against pancreatic β-cells… cause not entirely known

Classic signs and symptoms: weightloss, weakness, fatigue, 3 P’s (polyuria, polydipsia, polyphagia)

75
Q

Only treatment for T1DM is:

A

insulin

76
Q

Treatment/ management of T1 DM

  • ____________________
  • __________
    -Diet and exercise – to control glucose levels and prevent
    complications

YOU CANNOT TREAT T1DM WITH DIET & EXERCISE ALONE!! (this is different from T2DM)

A

-Glucose monitoring - continuous glucose monitoring (CGM)
-Insulin
-Diet and exercise – to control glucose levels and prevent
complications

YOU CANNOT TREAT T1DM WITH DIET & EXERCISE ALONE!! (this is different from T2DM)

77
Q

Insulin therapy delivery options

A

-Consider insulin pump
- Injections

78
Q

Types of insulin

A
79
Q

Insulin function

-promotes entry of amino acids into the cell for protein synthesis
-enhances lipogenesis (fat storage)
-Facilitating entry of glucose into cells for energy
-stimulate glycogenesis (glucose > glycogen to be stored in liver / muscle cells)
-inihibts glycogenolysis (glycogen > glucose )

A

-promotes entry of amino acids into the cell for protein synthesis
-enhances lipogenesis (fat storage)
-Facilitating entry of glucose into cells for energy
-stimulate glycogenesis (glucose > glycogen to be stored in liver / muscle cells)
-inihibts glycogenolysis (glycogen > glucose )

80
Q

Insulin type

Lantus / detemir is

A

long-acting

81
Q

Insulin type

Lispro / Novolog is

A

rapid acting

82
Q

Rapid-acting (bolus)
- Lispro (Humalog), Aspart (Novolog)
- Injected ___________ minutes before meal
- Onset of action 15 minutes

Short-acting (bolus)
- Regular (Humulin, Novolin, Velosulin)
- Injected _____________ minutes before meal
- Onset of action 30 to 60 minutes

A

Rapid-acting (bolus)
- Lispro (Humalog), Aspart (Novolog)
- Injected 0 to 15 minutes before meal
- Onset of action 15 minutes

Short-acting (bolus)
- Regular (Humulin, Novolin, Velosulin)
- Injected 30 to 45 minutes before meal
- Onset of action 30 to 60 minutes

83
Q

Long-acting (basal) Lantus (glargine)
-Injected _______ at bedtime or in am
-Released steadily and continuously
-Onset ________ hours
-No peak action
-Duration ____________
-Cannot be _________ with any other insulin or solution

A

-Injected daily at bedtime or in am
-Released steadily and continuously
-Onset 1-1 ½ hours
-No peak action
-Duration 20-24 hours
-Cannot be mixed with any other insulin or solution

84
Q

Sites for insulin subcutaneous injection

A

thights
biceps
abdominal
buttocks

85
Q

Fastest absorption of insulin injections

A

Abdomen [preferred]
arms
thighs
buttocks

86
Q

Administration of insulin (cont’d)

-Hand washing with soap adequate
-Do not _____ needle
- _________ degree angle depending on fat thickness of patient
-Insulin pens preloaded with insulin now available

A

-Hand washing with soap adequate
-Do not recap needle
-45- to 90-degree angle depending on fat thickness of patient
-Insulin pens preloaded with insulin now available

87
Q

Insulin pump

-___________ ______ infusion
-Battery operated device
-Connected via plastic tubing to a catheter inserted into sub-Q tissue in abdominal wall

A

-Continuous sub-Q infusion
-Battery operated device
-Connected via plastic tubing to a catheter inserted into sub-Q tissue in abdominal wall

88
Q

Problems with insulin therapy

-Hypoglycemia
-Allergic reactions
-Lipodystrophy
-Somogyi effect
-Dawn phenomenon

A

-Hypoglycemia
-Allergic reactions
-Lipodystrophy
-Somogyi effect
-Dawn phenomenon

89
Q

Mnemonic for hypoglycemia signs

A

TIRED

Tachycardia
Irritable
Restless
Excessive hunger
Diaphoresis + Depression

90
Q

HYPOGLYCEMIA

Treatment
- Remain with patient!
- Treat sooner rather than later if hypoglycemia suspected
- Conscious or unconscious?
- PO vs IV/IM – THINK Aspiration, can they swallow??

-Monitor and repeat treatment every 15 minutes until BG > 70 or 80

  • Call for help early!
  • Consider cause and address it! [Too much insulin, insufficient carbs, etc]
A

Treatment
- Remain with patient!
- Treat sooner rather than later if hypoglycemia suspected
- Conscious or unconscious?
- PO vs IV/IM – THINK Aspiration, can they swallow??

-Monitor and repeat treatment every 15 minutes until BG > 70 or 80

  • Call for help early!
  • Consider cause and address it! [Too much insulin, insufficient carbs, etc]
91
Q

HYPOGLYCEMIA TREATMENT

If alert enough to swallow “Rule of 15” [measure every 15 mins]

(choose 1)
___________
____________
____________
____________

Avoid foods with fat (Decrease absorption of sugar)

A

-3-4 glucose tabs
-4 to 6 oz fruit juice
-Regular soft drink
-1 c skim milk

92
Q

PROBLEMS WITH INSULIN THERAPY

Somogyi effect
-Rebound effect in which too much insulin causes ___________
-Usually during hours of sleep (2-3 am)
-Counter-regulatory hormones released causing rebound hyperglycemia and ketosis
-Prevent by giving a protein and carb snack at _________

A

-Rebound effect in which too much insulin causes hypoglycemia
-Usually during hours of sleep (2-3 am)
-Counter-regulatory hormones released causing rebound hyperglycemia and ketosis
-Prevent by giving a protein and carb snack at bedtime

93
Q

PROBLEMS WITH INSULIN THERAPY

Dawn phenomenon

-Characterized by _______________ present on awakening in the ________
-Due to release of counter-regulatory hormones in predawn hours (5-9 am)

A

-Characterized by hyperglycemia present on awakening in the morning
-Due to release of counter-regulatory hormones in predawn hours (5-9 am)

94
Q

DM T1 - COMPLICATIONS

-Death
- Hypoglycemia (related to excess exogenous insulin injection or insufficient carbohydrate consumption after insulin injection)
- Diabetic Ketoacidosis (DKA)
- Micro & Macrovascular Complications (SAME AS FOR T2DM)
- Angiopathies, Nephropathies, Retinopathies, Nephropathies, Infections, Amputations

A

-Death
- Hypoglycemia (related to excess exogenous insulin injection or insufficient carbohydrate consumption after insulin injection)
- Diabetic Ketoacidosis (DKA)
- Micro & Macrovascular Complications (SAME AS FOR T2DM)
- Angiopathies, Nephropathies, Retinopathies, Nephropathies, Infections, Amputations

95
Q

DM T1 - COMPLICATIONS

Psychological – anxiety, depression, body image, others

Integumentary – skin injection site atrophy, infection

A

Psychological – anxiety, depression, body image, others

Integumentary – skin injection site atrophy, infection

96
Q

DM T1 - DIABETIC KETOACIDOSIS (DKA)

-Caused by profound deficiency of ___________

Characterized by
- Hyperglycemia > ______ mg/dl
-Ketosis (blood & urine)
-Acidosis
-Dehydration

-Most likely occurs in type 1

A

-Caused by profound deficiency of insulin

Characterized by
- Hyperglycemia > 300 mg/dl
-Ketosis (blood & urine)
-Acidosis
-Dehydration

-Most likely occurs in type 1

97
Q

___________________

-Not enough insulin
-High blood glucose
-A major cause of complications

A

HYPERGLYCEMIA

98
Q

DM T1 - DIABETIC KETOACIDOSIS (DKA)

Anticipated labs

-POC blood glucose - Glucose ≥ 250
-Electrolytes & Confirmatory serum glucose (>250)
- Expect low K+ ; Potassium! Must be > than 3.3 mEq/L to administer insulin
> THIS ONLY APPLIES TO IV ADMINISTRATION OF INSULIN – THIS IS NOT RELEVANT TO SUB-
Q INJECTIONS
- WBC – anticipate elevated WBC

A

Anticipated labs

-POC blood glucose - Glucose ≥ 250
-Electrolytes & Confirmatory serum glucose (>250)
- Expect low K+ ; Potassium! Must be > than 3.3 mEq/L to administer insulin
> THIS ONLY APPLIES TO IV ADMINISTRATION OF INSULIN – THIS IS NOT RELEVANT TO SUB-
Q INJECTIONS
- WBC – anticipate elevated WBC

99
Q

DM T1 - DIABETIC KETOACIDOSIS (DKA)

Anticipated pharmacotherapy

IV Regular Insulin! – required treatment
- Initially IV push insulin, followed by IV insulin infusion (usually only takes place in ED or ICU)
- Antiemetic – to control N/V
- IV Potassium replacement; May need to replace potassium PRIOR to giving iv insulin; Insulin drives potassium into cells – can create hypokalemia!! Must replace potassium first if ≤ 3.3 mEq/L
- Sodium biacarb (NaHCO3 ) IV push if severe acidosis

A

Anticipated pharmacotherapy

IV Regular Insulin! – required treatment
- Initially IV push insulin, followed by IV insulin infusion (usually only takes place in ED or ICU)
- Antiemetic – to control N/V
- IV Potassium replacement; May need to replace potassium PRIOR to giving iv insulin; Insulin drives potassium into cells – can create hypokalemia!! Must replace potassium first if ≤ 3.3 mEq/L
- Sodium biacarb (NaHCO3 ) IV push if severe acidosis

100
Q

THE ONLY INSULIN THAT CAN BE GIVE IV IS ____________ INSULIN

A

REGULAR

101
Q

Rising ketones means need to _________________ and contact provider!!

A

increase insulin

102
Q

Diabetes Mellitus Type 2

-_________ Onset
-Some insulin produced
-Changes in lifestyle may be sufficient
-____% hereditary
-Prevalence increases with age
-Most common type
-Severe Complication: HHS

A

-Gradual Onset
-Some insulin produced
-Changes in lifestyle may be sufficient
-90% hereditary
-Prevalence increases with age
-Most common type
-Severe Complication: HHS

103
Q

Which type of Diabetes is most common?

A

Type 2 DM

104
Q

Severe complication of type 2 DM

A

HHS - Hyperosmolar hyperglycemic state

105
Q

Symptoms of type 2 DM

A

May have classic symptoms of type 1

-Fatigue
-Recurrent infections
-recurrent vaginal yeast or monilial infections
-Prolonged wound healing
-Visual changes (blurred vision)

106
Q

DM Type 2- Three methods of diagnosis

-Fasting plasma glucose level > ____ mg/dl

-Random or casual plasma glucose ≥ ____ mg/dl plus symptoms

-Two-hour OGTT (Oral Glucose Tolerance Test)level ≥ 200 mg/dl using a glucose load of 75 g (norm: > 140 and <200)

A

-Fasting plasma glucose level >126 mg/dl

-Random or casual plasma glucose ≥ 200 mg/dl plus symptoms

-Two-hour OGTT (Oral Glucose Tolerance Test)level ≥ 200 mg/dl using a glucose load of 75 g (norm: > 140 and <200)

107
Q

Oral meds for DB Type 2 works on 3 defects:

-___________ resistance

-_____________ insulin production

-______________hepatic glucose production

A

-Insulin resistance

-Decreased insulin production

-Increased hepatic glucose production

108
Q

DM T2 - ORAL MEDS - BIGUANIDES

-First line of treatment for DM Type 2
-Metformin plus lifestyle changes to decrease weight and increase activity

Biguanides
-Reduce glucose ___________________
-Enhance insulin ____________ at tissues
-Improve glucose ____________ into cells
-Does not promote weight gain

A

-Reduce glucose production by liver
-Enhance insulin sensitivity at tissues
-Improve glucose transport into cells
-Does not promote weight gain

109
Q

-First line of treatment for DM Type 2 -

A

Biguanides/Metformin + life style changes

110
Q

DM T2 - ORAL MEDS - SULFONYLUREAS

-Glucotrol (Glipizide); Amaryl (Glimepiride)
-Sulfonylureas
-↑ Insulin production from __________
-↓ Chance of prolonged hypoglycemia

A

-↑ Insulin production from pancreas
-↓ Chance of prolonged hypoglycemia

111
Q

DM T2 - ORAL MEDS - THIAZOLIDINEDIONE

Avandia (rosiglitazone).
Actos (pioglitazone)
Thiazolidinedione
-Improves insulin _________
-Most effective in those with insulin __________

A

-Improves insulin sensitivity
-Most effective in those with insulin resistance

112
Q

DM T2 - ORAL MEDS - MISCELLANEOUS
Byetta (exenatide); Victoza (liraglutide)
-Increases __________ secretion
-Decreases ___________ secretion (decreases BG)
-Incretin mimetic:
–Reduces food intake
–Slows gastric emptying
-Not to be used with insulin

A

-Increases insulin secretion
-Decreases glucagon secretion (decreases BG)
-Incretin mimetic:
–Reduces food intake
–Slows gastric emptying
-Not to be used with insulin

113
Q

DM T2 - ORAL HYPOGLYCEMIA

-Monitor serum glucose levels
-Teach patient signs and symptoms of hyper/hypoglycemia
-Altered liver, renal function will affect medication action
-Avoid OTC meds without MD approval
-Assess for GI distress and sensitivity
-Know appropriate time to administer med

A

-Monitor serum glucose levels
-Teach patient signs and symptoms of hyper/hypoglycemia
-Altered liver, renal function will affect medication action
-Avoid OTC meds without MD approval
-Assess for GI distress and sensitivity
-Know appropriate time to administer med

114
Q

-Always ___________ the administration of glucose tablets, juice, Glucagon, and D50 in the Medication Record.

-Record in the nursing notes the signs and symptoms displayed, treatment administered, initial and subsequent glucose reading and notifications to the attending physician.

A

document

115
Q

DM T2 – COMPLICATIONS HYPEROSMOLAR HYPERGLYCEMIC SYNDROME (HHS)

-Life-threatening syndrome
-Less common than DKA
-Most frequently seen in patients over 60 years with DM type 2
-Two factors that precipitate hyperglycemia leading to HHS
↑ ______ intake
↑ insulin ____________

A

-Life-threatening syndrome
-Less common than DKA
-Most frequently seen in patients over 60 years with DM type 2
-Two factors that precipitate hyperglycemia leading to HHS
↑ CHO intake
↑ insulin resistance

116
Q

DM T2 – HYPEROSMOLAR HYPERGLYCEMIC SYNDROME (HHS) - symptoms

-Blood glucose > _____mg/dl
-Hypotension
-Mental changes
-Dehydration
-Hypokalemia
-Hyponatremia

A

-Blood glucose > 600 mg/dl
-Hypotension
-Mental changes
-Dehydration
-Hypokalemia
-Hyponatremia

117
Q

The most important patient outcome of DM is the reduction of glucose to near-normal
levels. (A1C < ____ )

A

7

118
Q

DM - PATIENT EDUCATION

-Storage and dose preparation
-Syringes
-Blood glucose monitoring
-Interpretation of results
-Frequency of testing
-Blood glucose therapy goals

A

-Storage and dose preparation
-Syringes
-Blood glucose monitoring
-Interpretation of results
-Frequency of testing
-Blood glucose therapy goals

119
Q

DM - NUTRITIONAL THERAPY

Alcohol
-High in calories/No nutritive value
-Promotes hypertriglyceridemia
-Detrimental effects on ______
-Moderate use can cause severe hyperglycemia whereas severe alcohol use can lead to hypoglycemia

A

-High in calories/No nutritive value
-Promotes hypertriglyceridemia
-Detrimental effects on liver
-Moderate use can cause severe hyperglycemia whereas severe alcohol use can lead to hypoglycemia

120
Q

DM - EXERCISE

-Purpose - reduce the amount of _________ needed
-Should be individualized
-After medical clearance
-Slowly- gradual progression
-Monitor ________________ levels before, during, and after exercise
-If BG >250 caution zone (check urine for ketones)

A

-Purpose - reduce the amount of insulin needed
-Should be individualized
-After medical clearance
-Slowly- gradual progression
-Monitor blood glucose levels before, during, and after exercise
-If BG >250 caution zone (check urine for ketones)

121
Q

DM - NURSING DIAGNOSES

-Ineffective therapeutic regimen management
-Risk for injury
-Risk for infection
-Powerlessness
-Imbalanced nutrition: More than body requirements

A

-Ineffective therapeutic regimen management
-Risk for injury
-Risk for infection
-Powerlessness
-Imbalanced nutrition: More than body requirements

122
Q

5 Rights of Delegation

A
  1. The right task
  2. Under the right circumstances
  3. To the right person
  4. With the right directions and communication; and
  5. Under the right supervision and evaluation
123
Q

Steps of the delegation process

_______________ the delegation, based on pt needs & available resources.

____________ directions to the delegate including any unique patient requirements and characteristics as well as clear expectations regarding what to do, what to report, and when to ask for assistance.

__________________________ of the delegation, including the level of supervision needed for the particular situation and the implementation of that supervision, including follow-up to problems or a changing situation.

____________ and feedback to consider the effectiveness of the delegation, including any need to adjust the plan of care.

A

Assess and plan the delegation, based on pt needs & available resources.

Communicate directions to the delegate including any unique patient requirements and characteristics as well as clear expectations regarding what to do, what to report, and when to ask for assistance.

Surveillance and supervision of the delegation, including the level of supervision needed for the particular situation and the implementation of that supervision, including follow-up to problems or a changing situation.

Evaluation and feedback to consider the effectiveness of the delegation, including any need to adjust the plan of care.

124
Q

insulin hormone is released by beta cells of the pancreas with each meal

-It’s a hypoglycemic agent that lowers blood sugar levels by aiding the passage of __________ into the _______.

-It enhances ________________ (fat storage) and prevents the breakdown of fats for energy.

A

-It’s a hypoglycemic agent that lowers blood sugar levels by aiding the passage of glucose into the cells.

-It enhances lipogenesis (fat storage) and prevents the breakdown of fats for energy.

125
Q

Insulin is produced by:

A

beta cells in the islets of Langerhans in the pancreas

126
Q

GLUCAGON

Hormone released by _______________________

A

alpha cells of the pancreas

127
Q

GLUCAGON

→ a hyperglycemic agent that increases blood sugar levels by triggering the liver to :

A

convert glycogen → glucose

128
Q

type 1 DM may be brought on by:

A

virus or toxins

129
Q

with type 1 DM, the body cannot ________ insulin

with type 2 DM, the body cannot _________ insulin

A

with type 1 DM, the body cannot make insulin

with type 2 DM, the body cannot respond to insulin

130
Q

Three P’s symptom more common with

A

type 1 DM

type 2 may also have this, but more mild usually

131
Q

___________ therapy essential is essential for both type 1 and 2 DM

A

nutrition

132
Q

Do not give insulin before _________________ . Insulin is SAFER to take after.

A

taking BG levels

133
Q

Peaks + plates.

Give FOOD during ________ since the highest risk for low sugar is during those

A

PEAKS

134
Q

Draw up CLEAR (regular, Humulin R) then CLOUDY (NPH, Humulin N) into the syringe.

  • “You want clear days before cloudy ones.”
  • This prevents contamination of the clear insulin.
  • Think R→N or RN like nurse!
A

Draw up CLEAR (regular, Humulin R) then CLOUDY (NPH, Humulin N) into the syringe.

  • “You want clear days before cloudy ones.”
  • This prevents contamination of the clear insulin.
  • Think R→N or RN like nurse!
135
Q
  • Rotate injection sites within the same area.
    [some facilities _________________________]
A

do not recommend this anymore

136
Q

Open vials stored _________ at room temperature

unused insulin can be stored in fridge until exp. date.

A

Open vials stored 1 month at room temperature

unused insulin can be stored in fridge until exp. date.

137
Q

Biguanides: ______________

  • MOA: ↓ glycogenesis, ↑ insulin sensitivity, ↑ glucose uptake
  • Side Effects: lactic acidosis, GI upset, anorexia
  • Stop 1-2 days before contrast dyes and 48hrs after!
A

“glucose be gone!”

138
Q

Sulfonylureas: end in “____”

  • MOA: ↑ insulin production in pancreas, ↓ glycogenolysis and gluconeogenesis
  • Side Effects: weight gain, hypoglycemia
  • Avoid __________!
A

Sulfonylureas: end in “-ide”

  • MOA: ↑ insulin production in pancreas, ↓ glycogenolysis and gluconeogenesis
  • Side Effects: weight gain, hypoglycemia
  • Avoid alcohol!
139
Q

SGLT2: end in “-lozin” → you’re________________ in urine, glucose is “flozin” through the kidneys
- MOA: ↓ renal glucose reabsorption, ↑urinary glucose excretion
- Side Effects: risk for UTI’s, hypoglycemia

A

SGLT2: end in “-lozin” → you’re “lozin” glucose in urine, glucose is “flozin” through the kidneys
- MOA: ↓ renal glucose reabsorption, ↑urinary glucose excretion
- Side Effects: risk for UTI’s, hypoglycemia

140
Q

GLP1: end in “-tide” → they _________________________
- MOA: stimulate release of insulin, slow gastric emptying, ↑ satiety
- Side Effects: nausea/vomiting, diarrhea, hypoglycemia
- Never give with insulin!

A

GLP1: end in “-tide” → they “tide” you over = ↓ hunger
- MOA: stimulate release of insulin, slow gastric emptying, ↑ satiety
- Side Effects: nausea/vomiting, diarrhea, hypoglycemia
- Never give with insulin!

141
Q

DPP-4 Inhibitors: end in “-liptin”
- MOA: ↑ insulin synthesis and release from pancreas
- Side Effects: lower potential for hypoglycemia because it is glucose dependent

A

DPP-4 Inhibitors: end in “-liptin”
- MOA: ↑ insulin synthesis and release from pancreas
- Side Effects: lower potential for hypoglycemia because it is glucose dependent

142
Q

TZD/Thiazolidinedione: end in ______
- MOA: ↑ insulin sensitivity, ↑ insulin secretion, block fatty acid release
- Side Effects: severe (anemia, CHF, fracture), rarely used

A

TZD/Thiazolidinedione: end in “-zone”
- MOA: ↑ insulin sensitivity, ↑ insulin secretion, block fatty acid release
- Side Effects: severe (anemia, CHF, fracture), rarely used

143
Q

“Shaky, pale, cool, and clammy = time to ____________________!”

A

give the patient candy

144
Q

Interventions and Education for DM:

A
  • Yearly dilated eye exams
  • Yearly kidney function tests (creatinine, albuminuria)
  • Daily foot care and examination
145
Q

Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct?

A Insulin is not used to control blood glucose in patients with type 2 diabetes.

B Complications of type 2 diabetes are less serious than those of type 1 diabetes.

C Changes in diet and exercise may control blood glucose levels in type 2 diabetes.

D Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

A

C Changes in diet and exercise may control blood glucose levels in type 2 diabetes.

146
Q

After change-of-shift report, which patient should the nurse assess first?

A 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12%

B 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL

C 40-year-old who is pregnant and whose oral glucose tolerance test is 202 mg/dL

D 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain

A

B 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL

[Hypoglycemic state >70; can lead to unconsciousness, seizures, death..]
Other pts not priority here

147
Q

The nurse has administered 4 oz of orange juice to an alert patient ̀hose blood glucose ̀as 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?

A Give the patient 4 to 6 oz more orange juice.

B Administer the PRN glucagon (Glucagon) 1 mg IM.

C Have the patient eat some peanut butter with crackers.

D Notify the health care provider about the hypoglycemia.

A

A) Give the patient 4 to 6 oz more orange juice.

148
Q

A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam:

A Every 2 years.

B As soon as possible.

C When the patient is 39 years old.

D Within the first year of diagnosis.

A

B As soon as possible.

Recommended at time of diagnosis, and then annually

149
Q

A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the
nurse implement first?

A Infuse 1 liter of normal saline per hour.

B Give sodium bicarbonate 50 mEq IV push.

C Administer regular insulin 10 U by IV push.

D Start a regular insulin infusion at 0.1 units/kg/hr.

A

A Infuse 1 liter of normal saline per hour.

With DKA, priority is to infuse IV fluids, then other actions after

150
Q

Which finding indicates a need to contact the health care provider before the nurse
administers metformin (Glucophage)?

A The patient’s blood glucose level is 174 mg/dL.

B The patient has gained 2 lb (0.9 kg) since yesterday.

C The patient is scheduled for a chest x-ray in an hour.

D The patient’s blood urea nitrogen (BUN) level is 52 mg/dL

A

D The patient’s blood urea nitrogen (BUN) level is 52 mg/dL

[BUN indicates possible renal failure.. metformin should not be given with renal failure]

151
Q

Which information will the nurse include in teaching a female patient who has peripheral
arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs?

A Choose flat-soled leather shoes.

B Set heating pads on a low temperature.

C Use callus remover for corns or calluses.

D Soak feet in warm water for an hour each day.

A

A Choose flat-soled leather shoes.

152
Q

A 32-year-old patient ̀ith diabetes is starting on intensive insulin therapy. Which type of insulin
̀ill the nurse discuss using for mealtime coverage?

A Lispro (Humalog)
B Glargine (Lantus)
C Detemir (Levemir)
D NPH (Humulin N)

A

A Lispro (Humalog)

[Rapid/ short acting insulin for meal coverage]

153
Q

A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for
the nurse to monitor for symptoms of hypoglycemia?

A 1400
B 0000
C 1000
D 1600

A

C 1000

10 am - it is rapid-acting and peaks in 1-3 hours

154
Q

A patient with diabetes has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of:

A Polyuria.
B Severe dehydration.
C Decreased serum potassium.
D Rapid, deep respirations.

A

D Rapid, deep respirations.

DKA is associated with Kussmaul breathing

155
Q

Fluid Volume Deficit - ______________

A

Hypovolemia

155
Q

DKA is associated with __________ breathing

A

Kussmaul

156
Q

Fluid Volume Excess -______________

A

Hypervolemia

157
Q

Inflammation

Heat is due to increased:

A

metabolism at the inflammatory site

158
Q

Inflammation

Redness is due to Hyperemia from _____________

A

vasodilation

159
Q

Inflammation

Swelling is due to

A

Fluid shifts to interstitial spaces;
fluid exudate accumulation

160
Q

__________ Intention: neatly approximated; surgical incision; leaves a fine scar

A

Primary

161
Q

____________ Intention: wounds from trauma, injury, infection, irregular margins; leaves a larger scar

A

Secondary

162
Q

__________ Intention: occurs with delayed suturing; leaves a deeper scar

A

Tertiary

163
Q

NSAIDs: 3 for 1; ibuprofen, aspirin, naproxen → reduces _______________________________________

Tylenol: 2 for 1; reduces _______________________

A

NSAIDs: 3 for 1; ibuprofen, aspirin, naproxen → reduces inflammation, reduces pain,
and reduces fever

Tylenol: 2 for 1; reduces fever and pain

164
Q

A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff:

A

Contracture

165
Q

Nurses can NOT delegate

A

initial assessment
education

165
Q

The nurse assesses a patient’s surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?

a. Obtain wound cultures
b. Document the assessment
c. Notify the HCP
d. Assess the wound every 2 hrs

A

b. Document the assessment

166
Q

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). The patient reports having no discomfort. What action by the nurse is
appropriate?

a. Apply a cooling blanket
b. Notify the HCP
c. Check the patient’s Temperature again in 4 hrs
d. Give acetaminophen (Tylenol) prescribed PRN for pain

A

c. Check the patient’s Temperature again in 4 hrs

Mild to moderate temperature elevations (<103° F) do not harm young adult patients
and may benefit host defense mechanisms. The nurse should continue to monitor
the temperature. Antipyretics are not indicated unless the patient is complaining of
fever-related symptoms, and the patient does not require analgesics if not reporting
discomfort. There is no need to notify the patient’s health care provider or to use a
cooling blanket for a moderate temperature elevation

167
Q

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)?

a. The patient who reports increased tenderness and swelling around a leg wound
b. The patient who was just admitted after suturing of a full-thickness arm wound
c. The patient who needs teaching about home care for a draining abdominal wound
d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

A

d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

LPN/LVN education and scope of practice include sterile dressing changes for stable
patients. Initial wound assessments, patient teaching, and evaluation for possible
poor wound healing or infection should be done by the registered nurse (RN).

168
Q

After receiving a change of shift report, which patient should the nurse assess first?

a. The patient who has multiple leg wounds with eschar to be debrided
b. The patient receiving chemotherapy who has a temperature of 102° F
c. The patient who requires analgesics before a scheduled dressing change
d. The newly admitted patient with a stage IV pressure ulcer on the coccyx

A

b. The patient receiving chemotherapy who has a temperature of 102° F

Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed
patient is a sign of serious infection and should be treated immediately with cultures
and rapid initiation of antibiotic therapy. The nurse should assess the other patients
as soon as possible after assessing and implementing appropriate care for the
immunosuppressed patient.

169
Q

A patient from a long-term facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. The nurse assesses impaired skin integrity
in this patient. How will the nurse document this?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV

A

c. Stage III

Stage III pressure ulcers are defined as full-thickness skin loss involving damage to or
necrosis of subcutaneous tissue that may extend down to, but not through,
underlying fascia. Stage I ulcers have intact skin with nonblanchable redness of a
local area with a change in skin temperature, tissue consistency, or sensation. Stage II
ulcers are partial thickness with a red-pink wound bed. Stage IV ulcers involve
extensive destruction of tissue with exposed bone, tendon, or muscle

170
Q

The nurse is evaluating the serum laboratory results on four clients. Which laboratory result should the nurse report first?

a. A client with bulimia and a potassium of 3.6 mEq/L
b. A client with osteoporosis and a calcium of 10 mg/dL
c. A client with renal failure and a potassium of 4.0 mEq/L
d. A client with dehydration and a sodium level of 149 mEq/L

A

d. A client with dehydration and a sodium level of 149 mEq/L

This answer is correct because the normal range for serum sodium is 135 to 145
mEq/L; therefore this client is experiencing hypernatremia. Because dehydration is
likely to cause serum sodium levels to increase further, this is the lab result the nurse
reports first

171
Q

What statement made by the client prescribed cyclosporine after a kidney transplant indicates the need for further education by the registered nurse (RN)?

a. I will need to take this drug for one year following the kidney transplant
b. It is important that I avoid large crowds and exposure to infection
c. I understand that I do not need to take this drug with grapefruit juice
d. I understand that with this drug there is a chance that my gum tissue might change

A

a. I will need to take this drug for one year following the kidney transplant

This answer is correct because the statement “I will need to take this drug for one
year following the kidney transplant” requires further education. Cyclosporine is an
immunosuppressant administered to individuals after an organ transplant to prevent
rejection. When administered to prevent organ rejection, the drug is prescribed for
life-long therapy.

172
Q

Phosphate and calcium always work:

A

inversely

High>Low < > < >

173
Q

Hypernatremia-

Hyponatremia-

A

Hypernatremia- big & bloated; polydipsia, edema [late signs: swollen/dry tongue, N/V, increased muscle tone)

Hyponatremia- Depressed & deflated; seizures/comas, tachycardia, weak pulse, resp. arrest

174
Q

Hyperkalemia-

Hypokalemia-

A

Hyperkalemia- heart is tight/contracted, hypotension, bradycardia, diarrhea, paralysis in extremities, muscle weakness

Hypokalemia- Low & slow heart, muscles, and GI; paralyzed intestines

175
Q

Hypercalcemia-

Hypocalcemia-

A

Hypercalcemia- Swollen & slow; kidney stones

Hypocalcemia- weak bones, bleeding, cardiac disrhythmia

176
Q

Hypermagnesia-

Hypomagnesia-

A

Hypermagnesia- calm & quiet heart & muscles & lungs & GI, bradycardia, hypotension

Hypomagnesia- Buck wild heart, muscles, GI ,eyes; tachycardia

177
Q

Hyperphosphatemia-

Hypophosphatemia-

A

Hyperphosphatemia- low calcium; diarrhea

Hypophosphatemia- high calcium; constipation

178
Q

Tetany is associated with _____________

A

hypocalcemia

Nurs 120- MCA I (19 decks)

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