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UTA 3632 HESI Prep

UTA 3632 Foundations HESI Prep

QuestionAnswer
Crede's method pressure is put on the suprapubic area with each attempted void. The maneuver promotes bladder emptying by relaxing the urethral sphincter.
Goals should be relevant to patient needs, specific, singular, observable, measurable, and time limited.
Fall Risk Factors Age (>60); Hx of Fall; Elimination urgency, frequency, or incontinence; Medications; Equipment; Decreased mobility; Cognition concerns
Medications causing increased fall risk PCA/Opiates, Anticonvulsants, Antihypertensives, Diuretics, Hypnotics, Laxatives, Sedatives, and Psychotropics
Equipment causing increased fall risk Any Equipment That Tethers Patient (e.g., IV Infusion, Chest Tube, Indwelling Catheters, SCDs)
Patient-handling devices used to prevent lift injuries height-adjustable beds, ceiling-mounted lifts, friction-reducing slide sheets, and air-assisted devices
Physiological risk factors involve the physical functioning of the body; physical conditions that place increased stress on physiological systems, increasing susceptibility to illness in these areas.
Conditions treated with heat therapies Open wounds, rectal surgery, episiotomy, painful hemorrhoids, muscle tension, vaginal inflammation, wound debridement
Conditions treated with cold therapies Direct trauma (sprains, strains, fractures, muscle spasms), superficial laceration or puncture wound, minor burn, suspected malignancy in area of injury or pain, injections, arthritis and joint trauma
Physiological response to heat therapies Vasodilation, Reduced blood viscosity, Reduced muscle tension, Increased tissue metabolism, Increased capillary permeability
Physiological response to cold therapies Vasoconstriction, Local anesthesia, Reduced cell metabolism, Increased blood viscosity, Decreased muscle tension
Selective optimization with compensation theory concept that, as individuals age, they are able to compensate for some decreases in physical or cognitive performance by developing new approaches.
Negative feedback process senses an abnormal state such as lowered body temperature and makes an adaptive response such as initiating shivering to generate body heat.
Hypertension two elevated blood pressure measurements in a row
Normal pH of urine 4.6-8.0
Proteinuria Protein in Urine. Caused by renal disease
Glucosuria Glucose in Urine. Caused by diabetes mellitus or ingestion of high concentratiosn of glucose
Ketonuria Ketones in urine. Caused by poorly controlled Diabetes mellitus, dehydration, starvation, or excessive aspirin usage
Normal Specific gravity of urine 1.0053-1.030
Elevated Specific gravity of urine Dehydration, reduced renal blood flow, and increased ADH secretion.
Reduced Specific gravity of urine Overhydration, early renal disease, and inadequate ADH secretion.
Hematuria Erythrocytes, hemoglobin, or myoglobin in urine. Caused by damage to glomeruli or tubules, trauma, disease, or surgery of the lower urinary tract. Blood in a routine urine specimen in a woman may be a result of contamination with menstrual fluid.
Elevated WBC in urine urinary tract infection
Bacteriuria Bacteria in urine. Indicative of urinary tract infection.
Casts in urine renal alterations
Crystals in urine Result of food metabolism. Excess crystals such as uric acid or calcium phosphate result in renal stone formation.
Urine daily output 1200 to 1500 mL
Decreased urine output less than 30 mL for more than 2 consecutive hours
Respiratory acidosis s/s ph < 7.35, PaCO2 > 45 mm Hg, HCO3 normal (uncompensated) or > 26 mEq/L (compensated), Headache, light-headedness, decreased level of consciousness (confusion, lethargy, coma), cardiac dysrhythmia, warm and flushed skin, muscular twitching.
Respiratory acidosis causes Impaired gas exchange (e.g., COPD, Pneumonia), Impaired neuromuscular function (e.g., resp muscle weakness d/t hypokalemia, chest injury), Dysfunction of brainstem respiratory control (e.g., drug overdose, central sleep apnea)
Respiratory alkalosis s/s ph > 7.45, PaCO2 < 35mmHg, HCO3 normal (uncompensated) or < 22mEq/L (compensated), hyperventilation, light-headedness, paresthesias, excitement and confusion possibly followed by decreased LOC, cardiac dysrhythmias.
Respiratory alkalosis causes Hypoxemia, Acute pain, Anxiety, psychological distress, prolonged sobbing, Inappropriate mechanical ventilator settings, Stimulation of brainstem respiratory control: head injuries, meningitis, gram-negative sepsis, salicylate overdose
Metabolic acidosis s/s ph < 7.35, HCO3 < 22 meq/L, PaCO2 normal (uncompensated) or < 35 mm Hg (compensated), Decreased LOC (lethargy, confusion, coma), abdominal pain, cardiac dysrhythmias, compensatory hyperventilation
Metabolic acidosis causes Increase of metabolic acid (e.g., ketoacidis, hypermetabolic state, oliguric renal disease, cirulatory shock, ingestion of acid) or Decrease of base (e.g., diarrhea, pancreatic fistula or intestinal decompression, renal tubular acidosis)
Metabolic alkalosis s/s ph > 7.45, HCO3 > 26 meq/L, PaCO2 normal (uncompensated) or > 45 mm Hg (compensated), Light-headedness, paresthesias; possible excitement and confusion followed by decreased LOC, cardiac dysrhythmias (may be caused by hypokalemia)
Metabolic alkalosis causes Increase of base (e.g., Admin NaHCO3, blood transfusion, ECV deficit) or decrease of metabolic acid (e.g., vomiting, gastric suctioning, hypokalemia, excess aldosterone)
Primary prevention Health promotion, specific protection
Secondary prevention Early dx/prompt tx and Disability limitations
Tertiary prevention Restoration and rehabilitation
Dysphagia interventions 30-min rest before eating, upright to eat, chin-down position, place food in strong side (if unilateral), thicken fluids, feed slowly, small bites. If cough/choke, remove food & provide oral suction if necessary.
Nutrition needs of immobile patient high-calorie, high-protein diet. Avoid calcium foods d/t increased risk for urinary calcification.
Allostatic load Stress resistance stage; chronic arousal with presence of powerful hormones causing excessive wear and tear on the person.
Delayed gastric emptying concern aspiration risk if 250 mL or more remains in the patient's stomach on each of two consecutive assessments.
Blood pressure cuff too small causes false-high reading
Blood pressure cuff too large causes false-low reading
Assessment for Orthostatic vital sign changes Both blood pressure & pulse taken in each position: lying, sitting, and standing.
Anticipated vital changes with fluid volume deficit Orthostatic hypotension & tachycardia (decreased BP and increased pulse upon standing)
Correlation btwn weight loss/gain & fluid 1 kg body weight lost/gained is equivalent to appx 1 L of fluid
Elderly problem that contributes to fluid volume deficit Decreased hepatic blood flow decreases drug metabolism, increasing drug effect.
Lab test to monitor increase in free, unbound drug molecules Serum protein - if decreased, drugs don't bind and remain free.
Pitting edema scale 1/2 the number of mm: 1+ if 2mm, 2+ if 4mm, 3+ if 6mm, or 4+ if 8mm.
Never given IV Push Potassium
Potassium-rich foods Potato, Grapefruit
Calorie requirements for average adult 20-35 calories/kg/day
Normal serum protein 6.4-8.3 g/dl
Decreased serum protein indicator of malnutrition
High Protein Foods Milk, Eggs (including deserts: angel food cake, custard, cheesecake), Cheese, Meat/Poultry/Fish
When to begin feeding supplements when bowel sounds are present (usually within 24 hrs of PEG tube insertion)
Cheyne-Stokes respiration Respiratory rate and depth are irregular with alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth then reverses.
Kussmaul's respiration Respirations are abnormally deep, regular, and increased in rate. Common in diabetic ketoacidosis.
Biot's respiration Respirations are abnormally shallow for two to three breaths followed by irregular period of apnea.
Normal Temp (adult) 36° to 38° C (96.8° to 100.4° F)
Degree Fever becomes harmful 39° C (102.2° F)
Heatstroke 40° C (104° F) or more
Hypothermia below 35° C (95° F), usually caused by prolonged exposure to cold
Farenheit to Celsius conversion (°F−32)×5/9
Celsius to Fahrenheit conversion (9/5×°C)+32
Normal Heart Rate (Infant) 120-160
Normal Heart Rate (Toddler) 90-140
Normal Heart Rate (Preschooler) 80-110
Normal Heart Rate (School-aged) 75-100
Normal Heart Rate (Adolescent) 60-90
Normal Heart Rate (Adult) 60-100
Normal Respiratory Rate (Newborn) 35-40
Normal Respiratory Rate (Infant 6 mos) 30-50
Normal Respiratory Rate (Toddler 2yrs) 25-32
Normal Respiratory Rate (Child) 20-30
Normal Respiratory Rate (Adolescent) 16-20
Normal Respiratory Rate (Adult) 12-20
Normal BP (Newborn) 40 (mean)
Normal BP (1 month) 85/54
Normal BP (1 year) 95/65
Normal BP (6 years) 105/65
Normal BP (10-13 yrs) 110/65
Normal BP (14-17 yrs) 119/75
Normal BP (18 yrs or older) <120/<80
Prehypertension Systolic 120-139 OR Diastolic 80-89
Stage 1 hypertension Systolic 140-159 OR Diastolic 90-99
Stage 2 hypertension Systolic ≥160 OR Diastolic ≥100
Hypotension Systolic BP falls to 90 mm Hg or below
Antitussive Reduces frequency of coughs
Classes of antihypertenisives Beta 1 blockers, Beta 1 & 2 blockers, Alpha-Beta blockers, ACE inhibitors, Angiotensin II Receptor Blocers, Calcium Channel Blockers
Beta blocker considerations Weight loss drugs & alcohol can lessen effect.
ACE Inhibitor considerations Can cause serious congenital problems, hyperkalemia, and angioedema. Shouldn't be suddenly stopped or taken with NSAIDs (aspirin/ibuprofen).
Classes of diuretics Loop (fruosemide/Lasix), Thiazide (HCTZ), Potassium Sparing
Diuretic considerations Can cause significant hypokalemia. Sulfonamide dirivitives, assess for allergies.
Classes of Antianginal Nitrates (Nitroglycerin)
Considerations for Nitrates After 1 sublingual nitroglycerin, wait 5 min and administer a 2nd one if pain is not resolved or is worse.
Classes of Antilipidemics Statins (lipitor), Fibric acid derivatives, Niacin derivatives, Bile acid sequestrants, Cholesterol Absorption Inhibitor
Nursing Considerations for Statins Pregnancy category X (do not give). Inhibited by grapefruit juice.
Positive inotropic drugs Heart failure drugs (Digoxin)
Considerations for Digoxin Check apical pulse bef admin. Use Atropine as antidote for bradycardia.
Classes of coagulation modifiers Anticoagulants (Heparin, Levonox, Coumadin/warfarin), Antiplatelets (Aspirin, Plavix), Thrombolytic
Coagulation Modifier considerations Monitor for bleeding. Monitor coagulation labs (PT/INR, PTT) and CBC (rule out anemia)
Psychotherapeutic classes Antipsychotics (Throazine, Haldol, Geodin), Antidepressants (Elavil, MAO inhibitors, Prozac, Zoloft, Cymbalta, Wellbutrin), Antimanics (Lithium), Anxiolytics (Benzodiazepines-Ativan, Valium, Xanax) Sleep aids (Lunesta, Ambien)
Considerations for Antipsychotics Tardive dyskinesia (workm-like twisting & writhering of tongue and face, lip smaking, tounge protrusion)
Considerations for SSRIs If stopped suddenly will result in headache and dizziness for up to a week after discontinuation. Risk for serotonin syndrome, no St. John's Wort or Triptans (migraine meds)
Classes of Substance abuse drugs Opiods (Morphine), Stimulants (Meth), Depresants (Marijuana), Alcohol (ETOH), Nicotine
Classes of Antiepileptic Drugs Antiepileptics (Dilantin, Cerebyx, Tegretol, Depakote, Ativan, Neurontin)
Classes of Antianemics Hematinic (iron, B12, Folic acid, epoetin alfa)
Considerations for Iron Fruit juice (vitamin C) increases absorption. Food, milk, or antacids decrease absorption. Can cause constipation.
Drugs used to manage inflammation, pain and fever NSAID (Aspirin, Ibuprofen, Naproxen, Tylenol), Opioids (Morphine, Demerol, Dilaudid, vicoden) Nonopioid Analgesic (tramadol)
Considerations for NSAIDS GI bleeding
Considerations for Opioids Monitor respiratory status, for orthostatic hypotension, and constipation.
Drugs affecting adrenal & thyroid glands Glucocorticoids (Hydrocortisone, Prednisone, Flonase), Mineralcorticoids (fludrocortisone), Thyroid Agents (Synthroid), Antithyroid Agents (methimazole, propranolol)
Glucocorticoid considerations Risk for Cushingoid appearance when used for 2 wks or longer. Don't stop abruptly (physiological crisis/death).
Normal WBC count 5000-10000/mm3
Normal Bowel Sounds 5-35/min
mL/oz 30mL/1oz
oz/cup 8oz/1cup
Five stages of dying Denial, Anger, Bargaining, Depression, Acceptance
Final Stages of Dying s/s Extremities cool; mottling of the legs; perspiration, increased sleeping, disorienation; incontinence, upper airway secretions; noisy respirations; restlessness; decreased intake of food & fluids; nausea
Homan's sign A positive sign is demonstrated when the client complains of pain in the calf upon dorsal flexion of the foot. Warning sign of possible thrombophlebitis.
Technique for deep-breathing hands on abdomen above belly button, breath in and make hands go up.
Autonomy An individual's right of self-determination and freedom of decision making.
Beneficence Doing good for clients and providing benefit balanced against risk.
Nonmaleficence Doing no harm to clients.
Justice Being fair to all and giving equal treatment, including distributing benefits, risks, and costs equally.
Fidelity Being loyal and faithful to commitments and accountable for responsibilities.
Veracity Telling the truth and not intentionally deceiving or misleading clients.
Confidentiality The prohibition of some disclosures of information gained in certain relationships without the consent of the original source of the information.
Privacy A right of limited physical or informational inaccessibility.
Serous Wound Drainage clear, watery plasma
Purulent Wound Drainage thick, yellow, green, tan, or brown
Serosanguineous Wound Drainage pale, red, water: mixture of serous and sanguineous
Sanguineous Wound Drainage Bright red: indicates acive bleeding
Dehiscence Separation of the edges of a wound, revealing underlying tissues.
Eschar Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed.
Evisceration Protrusion of visceral organs through a surgical wound.
Induration Hardening of a tissue, particularly the skin, because of edema or inflammation.
Secondary intention Wound closure in which the edges are separated; granulation tissue develops to fill the gap; and, finally, epithelium grows in over the granulation, producing a larger scar than results with primary intention.
Tinnitus Ringing heard in one or both ears.
Reactive hyperemia redness when tissue is relieved of pressure. abnormal if lasts > 1hr and tissue does not blanch.
Mottling irregular or patchy discoloration of the skin.
Dependent rubor redness that occurs when an area is lower than the heart. most common in legs.
Hydrocolloid dressings dressings that are adhesive and occlusive. The wound contact layer of this dressing forms a gel as fluid is absorbed and maintains a moist healing environment. They support healing in clean granulating wounds and autolytically debride necrotic wounds.
Hydrogel dressings dressing hydrates wounds and absorbs some smaller amounts of exudate. Hydrogel dressings are for partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation-damaged skin.
Debridement removal of dead tissue from a wound.
Self-adhesive, transparent film dressings dressing traps moisture over wound. ideal for small superficial wounds such as partial-thickness wounds or to protect high-risk skin.
Wet-to-dry dressings Mechanically debride tissue. Moistened guaze placed on the wound and allowed to dry. It adheres to the wound tissue and debrides necrotic or infected tissue as it is removed.
Autolytic debridement synthetic dressings placed over a wound to allow eschar to be self-digested by action of enzymes in wound fluids. (e.g., transparrent film & hydrocolloid.
Erikson's Infancy (birth to 18 months) Trust vs. Mistrust Feeding Children develop a sense of trust when caregivers provide reliabilty, care, and affection. A lack of this will lead to mistrust.
Erikson's Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt Toilet Training Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt.
Erikson's Preschool (3 to 5 years) Initiative vs. Guilt Exploration Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt.
Erikson's School Age (6 to 11 years) Industry vs. Inferiority School Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority.
Erikson's Adolescence (12 to 18 years) Identity vs. Role Confusion Social Relationships Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self.
Erikson's Young Adulthood (19 to 40 years) Intimacy vs. Isolation Relationships Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation.
Erikson's Middle Adulthood (40 to 65 years) Generativity vs. Stagnation Work and Parenthood Need to create/nurture things that will outlast them. Success = feelings of usefulness and accomplishment, while failure = shallow involvement in the world.
Erikson's Maturity(65 to death) Ego Integrity vs. Despair Reflection on Life Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair.
Normal Glucose Normal <100 mg/dL
Normal HbA1c Normal 5-7%
Normal LDL Cholesterol Normal <130 mg/dL
Normal HDL Cholesterol Normal men, 35-65 mg/dL; women, 35-80 mg/dL
Normal Triglycerides Normal <150 mg/dL
Normal Serum Albumin Normal 3.5 to 5.5 g/dL
Normal Serum Transferrin Normal 170 to 250 mg/dL
Normal Prealbumin Normal 15 to 25 mg/dL
Normal C-reactive protein (CRP) Normal <0.1 mg/dL
Normal Daily Oral Fluid Intake 1100-1400 mL
Normal Total Daily Fluid Intake/Output 2200-2700 mL
Normal Daily Urine Fluid Output 1200-1500 mL
Normal Osmolality 280-300 mOsm/kg
Normal BUN 10-25 mg/dL
Normal Sodium 136-145 mEq/L
Normal Potassium 3.5-5.0 mEq/L
Normal Chloride 98-106 mEq/L
Normal Calcium 8.4-10.5 mg/dL
Normal Magnesium 1.5-2.5 mEq/L
Normal Phosphate 2.7-4.5 mg/dL
Normal pH 7.35-7.45
Normal PaCO2 35-45 mm Hg
Normal PaO2 80-100 mm Hg
Normal HCO3 22-26 mEq/L
Normal O2 Sat 95-100%
Normal Hemoglobin Normal males—14 to 18 g/dL, females—12 to 16 g/dL
Normal Hematocrit Normal males—37% to 49%, females—36% to 46%
Normal RBC 4.7 to 6.1 million/mm3, males; 4.2 to 5.4 million/mm3, females
Normal WBC 5000-10,000/mm3
Normal Iron 60-90 g/100 mL
Created by: camellia