Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
NURSING 2020
NURSING
| Question | Answer |
|---|---|
| A client diagnosed with cancer has his tumor staged and graded based on what factors? | How they tend to grow and the cell type |
| A client scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a negative biopsy report? | A wide excision of lump will be performed. |
| A fast growing lump on the breast is suggestive of | a malignant tumor |
| ovarian cancer among maternal grandmother, aunt and sister. The nurse knows that these cancers a likely associated with what etiology? | Inherited Gene Mutation |
| Food selections associated increase risk of Cancer | Foods high in fat and those that are smoked or preserved with salt or nitrates |
| When providing care for a client with stage 1V cancer, the nurse knows to include which intervention in the plan of care? | incorporating touching and listening |
| A client with cancer makes the following comment to the nurse: Why are your bathing me if i am going to die no matter what. What is the most appropriate response of the nurse? | Would you like to talk about what you are feeling |
| When the client complains of increased fatigue following radiotherapy, the nurse knows that is most likely related to which factor? | Radiation could result in myelosuppression. |
| To test for Trousseau's sign, place a blood pressure cuff around the arm, inflate the cuff to greater than the patient's systolic pressure, and | keep the cuff inflated for 1 to 4 minutes. Under these hypoxic conditions, a positive Trousseau's sign occurs when the hand and fingers go into spasm in palmar flexion |
| To test for Chvostek's sign, tap the face just below and in front of the ear to | trigger facial twitching of one side of the mouth, nose, and cheek |
| Palmar flexion indicating a positive | Trousseau's sign in hypocalcemia. |
| Facial muscle response indicating | a positive Chvostek's sign in hypocalcemia |
| Intestinal changes are first reflected as decreased peristalsis in hypercalcemia | Constipation, anorexia, nausea, vomiting, abdominal distention, and pain are common. ` |
| Bowel sounds are hypoactive or absent in hypercalcemia, assess | abdominal size by measuring abdominal girth with a soft tape measure in a line circling the abdomen at the umbilicus. |
| Drugs to prevent hypercalcemia include agents that inhibit calcium resorption from bone such as phosphorus, calcitonin (Calcimar), bisphosphonates (etidronate [Didronel, Etidrocal image, NOVO-etidronatecal image]), and | prostaglandin synthesis inhibitors (aspirin, NSAIDs). |
| Steatorrhea | the presence of excess fat in feces. Stools may be bulky and difficult to flush, have a pale and oily appearance and can be especially foul-smelling. |
| Cardiac changes associated with Hypomagnesemia | Low magnesium levels increase the risk for hypertension, atherosclerosis, hypertrophic left ventricle, and a variety of dysrhythmias |
| Low CA causes conduction problems, when serum magnesium levels are low, intracellular potassium levels are also low. | premature contractions, atrial fibrillation, ventricular fibrillation, and long QT intervals. |
| The patient has hyperactive deep tendon reflexes, numbness and tingling, and painful muscle contractions. Positive Chvostek's and Trousseau's signs may be present because | hypomagnesemia may occur with hypocalcemia.The patient may have tetany and seizures as hypomagnesemia worsens. Helpful to restore calcium levels as well |
| Reduced motility, anorexia, nausea, constipation, and abdominal distention are common with which electrolyte imbalance | A paralytic ileus may occur when hypomagnesemia is severe. |
| Drugs that promote magnesium loss such as high-ceiling (loop) diuretics, osmotic diuretics, aminoglycoside antibiotics, and drugs containing phosphorus are discontinued with | Hypomagnesium electrolyte imbalance, assess deep tendon reflexes at least hourly in the patient receiving IV magnesium to monitor effectiveness and prevent hypermagnesemia. |
| when hypomagnesemia is severe. | Magnesium is replaced intravenously with magnesium sulfate (MgSO4) |
| Cardiac changes include in Hypermagnesemia | |
| ECG changes show a prolonged PR interval with a widened QRS complex. Bradycardia can be severe, and cardiac arrest is possible. Hypotension is also severe | with a diastolic pressure lower than normal. Patients with severe hypermagnesemia are in grave danger of cardiac arrest. |
| Hypermagnesemia, Central nervous system changes result from depressed nerve impulse transmission. Patients may be | drowsy or lethargic. Coma may occur if the imbalance is prolonged or severe. |
| Hypermagnesemia has no direct effect on the lungs; however, | when the respiratory muscles are weak, respiratory insufficiency can lead to respiratory failure and death. |
| All oral and parenteral magnesium is discontinued. When kidney failure is not present, giving | giving magnesium-free IV fluids can reduce serum magnesium levels. High-ceiling (loop) diuretics such as furosemide (Lasix, Furoside image) can further reduce serum magnesium levels. |
| With worsening acidosis or with acidosis and hyperkalemia (elevated blood potassium levels), heart rate decreases, T waves become tall | QRS complexes are widened. Peripheral pulses may be hard to find and are easily blocked. Hypotension occurs with vasodilation. |
| If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and | not under voluntary control, a pattern called Kussmaul respiration. |
| This causes vasodilation and makes the skin and mucous membranes | warm, dry, and pink. With respiratory acidosis breathing is ineffective, and skin and mucous membranes are pale to cyanotic. |
| Metabolic Alkalosis | Oral ingestion of bases: Antacids Parenteral base administration: Blood transfusion Sodium bicarbonate Total parenteral nutrition |
| Alkalosis Central Nervous System Signs and Symptoms | Increased activity Anxiety, irritability, tetany, seizures Positive Chvostek's sign Positive Trousseau's sign Paresthesias |
| Alkalosis: Neuromuscular Signs and Symptoms | Hyperreflexia Muscle cramping and twitching Skeletal muscle weakness |
| Alkalosos:Cardiovascular Signs and Symptoms | Cardiovascular Signs and Symptoms |
| Alkalosis: Respiratory Signs and Symptoms | Increased rate and depth of ventilation in respiratory alkalosis Decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis |
| Acidosis: Central Nervous System Signs and Symptoms | Depressed activity (lethargy, confusion, stupor, coma) |
| Acidosis: Neuromuscular Signs and Symptoms | Hyporeflexia Skeletal muscle weakness Flaccid paralysis |
| Acidosis: Respiratory Signs and Symptoms | Kussmaul respirations (in metabolic acidosis with respiratory compensation) Variable respirations (generally ineffective in respiratory acidosis) |
| Acidosis: Integumentary Signs and Symptoms | Warm, flushed, dry skin in metabolic acidosis Pale-to-cyanotic and dry skin in respiratory acidosis |
| hypo-osmolar | has fewer particles than water <280 mOsm ◦result of excess water intake or edema |
| hyper-osmolar | has more particles than water •> 295- hyperosmolar ◦ result of severe diarrhea, increase salt, inadequate water intake, diabetes, ketoacidosis, sweat |
| Hypotonic | If fluid < 240mOsm, the fluid is... |
| Hypertonic | If fluid > 340 mOsm, the fluid is... |
| Isotonic solution | ▪ (D5W), which has 250 mOsm, ▪ Normal saline solution (0.9% NaCl) which has 310 mOsm ▪ Lactated Ringers solution which has 275 mOsm ▪ Ringers solution which has 310 mOsm ▪ With fluid volume loss, IV isotonic solutions are usually indicated |
| Dextrose in water (D5W) | Becomes hypotonic solution when used continuously or administered rapidly • Dextrose rapidly metabolized to water and CO2 • Should only be given via IV never subQ |
| Crystalloids | •Includes D5W approximately 250 mOsm/L, saline (NSS) approximately 310 mOsm/L, and lactated Ringer's solution approximately 310 mOsm/L •Used for replacement and maintenance fluid therapy |
| Colloid | Volume expander • Includes dextran solutions, amino acids, hetastarch and Plasmat |
| Dextran | not a substitute for whole blood; has no O2 carrying properties |
| Dextran 40 | interferes with platelet function and can prolong bleeding |
| Plasmanate | commercially prepared protein product ▪ used instead of plasma or albumin to replace body proteins |
| Blood and Blood Products | whole blood, packed RBCs, plasma, and albumin • 1 unit of packed RBCs contains whole blood without plasma ◦ elevates hematocrit by 3 points |
| Advantage of using packed RBC's | 1. decreased chance for causing circulatory overload 2. smaller risk of a reaction to plasma antigens 3. possible reduction in the risk of transmitting serum hepatitis |
| Whole blood | ◦ should not be used to treat anemia unless anemia is severe ◦ elevates the hemoglobin by 0.5- 1g |
| Lipids | Total Parenteral Nutrition (TPN) or hyperalimentation (HA) is normally implemented for clients who require long-term IV therapy |
| Water lost daily | ◦ 400-500mL through skin by normal evaporation ◦ 400-500mL from breathing ◦ 100-200mL in feces ◦ 1000-1200mL in urine |
| 3L/day of D5W can cause | hypoosmolality and water intoxication |
| Dehydration can result if: | If only hypertonic solutions are given |
| If K+ levels are < 3.0 mEq | 200-400 mEq of Kcl are administered to increase serum K+ level 1 mEq |
| How can K+ NOT be given? | CANNOT be given as an IV push or IV bolus due to cardiac arrest resulting from excessive K+ |
| How can K+ be given? | -orally (liquid, powder, tablet) with a full glass of water (K+ is irritating to the gastric and intestinal mucosa) IV and is combined with an anion (ex chlorine or bicarbonate) |
| When to notify a HCP about urine output on a pt on K | <600mL/day |
| How to immediately decrease K+ levels | sodium bicarbonate, calcium gluconate or insulin and glucose may be prescribed |
| Treatment for severe hyperkalemia | Sodium polystyrene sulfonate (Kayexalate) with sorbitol • works by exchanging an Na+ ion for K+ion |
| 2 Categories of Diuretics | K+ wasting drugs and K+ sparing drugs |
| K+ wasting drugs | excrete K+and other electrolytes in the urine |
| K+ sparing drugs | retain K+ but excrete NA+ and Cl- in the urine |
| Hypochloremia | <95 ◦ S&S: tremors, twitching, slow/shallow breathing ◦ Severe symptoms: decreased BP |
| Hyperchloremia | >108 ◦ S&S: weakness, lethargy, deep/rapid breathing ◦ Severe symptoms: unconsciousness |
| Hypophosphatemia | Can be caused by parathyroid hormone (PTH) stimulation of renal tubes to excrete Phosphorus (and increase Calcium by causing Calcium to leave the bone |
| Function of phosphate | bone and teeth formation ◦ neuromuscular activity ◦ important component of nucleic acids ◦ assists in energy transfer in cells ◦ helps maintain cellular osmotic pressure ◦ supports acid-base balance of body fluids |
| Why is it common practice to give bypass surgery or MI pts Magnesium Sulfate orally | To prevent ventricular arrhythmias early in the postop phase |
| Treatment for Hypermagnesemia | Calcium gluconate |
| Hypermagnesemia | Can be caused from an excess intake of Magnesium salts, laxatives, and antacids ◦ Has sedative effect on the neuromuscular system ▪ results in loss of deep tendon reflexes ◦ Hypotension and heart block can result |
| Treatment for Hypomagnesemia | IV Magnesium sulfate may be given |
| respiratory acidosis deals with | increased CO2 cause by decreased ventilation |
| metabolic acidosis deals with | decrease in bicarbonate caused by increased fixed acids or loss of bicarbonate |
| respiratory acidosis causes | asthma, COPD, morbid obesity, airway obstruction, over-sedation |
| respiratory acidosis effects | increased CO2, normal or increased bicarbonate, increase potassium, increase sodium and decreased chloride |
| sodium increased in prolonged respiratory acidosis because | hydrogen pushes out while sodium is pulled into the cell |
| metabolic acidosis causes | ketoacidosis, lactic acidosis, toxin intake, renal failure and diarrhea/GI disorder |
| metabolic acidosis effects | decreased CO@, decreased bicarbonate, increased postassium or decrease, increase sodium and decrease chloride |
| metabolic acidosis is classified according to whether or not | there is an increase in the anion gap |
| Anion Gap | AG= [NA] -([Cl] + [HCO3]) |
| normal range for the anion gap is | AG= 9-16 mEq/L |
| acidosis with high anion gap | ketoacidosis, lactic acidosis, toxin intake, salicylate poisoning and advanced renal failure |
| acidosis with normal anion gap | diarrhea, other GI loss of bicarbonate, mild to moderate renal disease and dilutional |
| respiratory alkalosis causes | hyperventilation because of anxiety, pain, sepsis, toxins |
| respiratory alkalosis effects | decreased CO2, bicarbonate and potassium slightly |
| metabolic alkalosis causes | vomiting, dieretics, laxative abuse, renal filtration failure, mineralocorticoids |
| metabolic alkalosis effects | decrease i hydrogen, potassium and increase in CO2, bicarbonate and sodium |
| A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective? | "Metabolic acidosis can occur due to diabetic ketoacidosis" |
| During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because | Small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults |
| An older woman was admitted to the medical unit with GI bleeding and fluid volume deficit. Clinical manifestations of this problem are | a. weight loss b. dry oral mucosa e. decreased central venous pressure |
| The nursing care for a patient with hyponatremia and fluid volume excess includes | Fluid restrictions |
| The nurse should be alert for which manifestations in a patient receiving a loop diuretic? | weak irregular pulse and poor muscle tone |
| Which patient is at greatest risk for developing hypermagnesemia? | 42-year-old woman with systemic lupus erythematosus and renal failure |
| It is important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy | a. Confusion d. Circumoral numbness e. Positive Chvostek's sign |
| The nurse expects the long-term treatment of a patient with hyperphosphatemia secondary to renal failure will include | Calcium supplements |
| The lungs act as an acid-base buffer by | a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load |
| A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse determines that these results indicate | Respiratory Alkalosis |
| The typical fluid replacement for the patient with a fluid volume deficit is | Lactated Ringer's |
| The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to | instruct the patient to change positions, raise arm, and cough |
| The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? | Providing straws and offering fluids between meals |
| The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? | Flattened neck veins when the client is in the supine position |
| A client with a diagnosis of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles B/L . Which order takes priority at this time? | IV push. Administer furosemide (Lasix) 40 mg |
| You have been floated to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately? | Potassium |
| A client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the first-year student nurse whom you are supervising? | Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally |
| A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would you be sure to monitor? | Hyponatremia: SIADH causes a relative sodium deficit due to excessive retention of water |
| a client's blood pressure and heart rate have decreased, and when his face is assessed, one side twitches. What action should you take at this time? | Check the client's pupillary reaction to light; A positive Chvostek sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. |
| why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response? | "The client's skeletal muscles are weak because of the low phosphorus" which may lead to acute muscle breakdown (rhabdomyolysis). |
| Serum magnesium level of 0.8 mEq/L Although all of these laboratory values are outside of the normal range, the magnesium level is furthest from normal. With a magnesium level this low, | the client is at risk for ECG changes and life-threatening ventricular dysrhythmias |
| Which action should you delegate to a UAP for the client with diabetic ketoacidosis? | 2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes |
| You are admitting an older adult client to the medical unit. Which assessment factor alerts you that this client has a risk for acid-base imbalances? | Chronic renal insufficiency |
| Risk factors for acid-base imbalances in the older adult include | chronic kidney disease and pulmonary disease. |
| The UAP reports to you that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should you suspect? | Respiratory alkalosis:most likely hyperventilating and blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH |
| A client is admitted to your unit for chemotherapy. To prevent an acid-base problem, which finding would you instruct the UAP to report? | Repeated episodes of nausea and vomiting |
| The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate has decreased. What is your best response? | "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." |
| The client has an order for hydrochlorothiazide (HCTZ, Microzide) 10 mg orally every day. What should you be sure to include in a teaching plan for this drug? | 1. "Take this medication in the morning." 4. "Inform your prescriber if you notice weight gain or increased swelling." 5. "You should expect your urine output to increase." |
| Which blood test result would you be sure to monitor for the client taking HCTZ? | Potassium |
| To correct hypovolemic shock with dehydration, the client needs IV fluids that are | isotonic and will increase intravascular volume, such as normal saline. |
| A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (SATA) | A. Decreased Skin turgor B. Concentrated urine D. Low-grade fever E. Tachypnea |
| client experiencing dyspnea, weakness, weight gain of 2 lb, and 1+ B/L edema of the lower extremities, Temperature (99* F), pulse 96, RR 26, o2 sat 94% on 3 L 02 via nasal cannula, and BP 152/96. Which manifestations of fluid volume excess is expected | A. Dyspnea B. Edema D. Hypertension E. Weakness |
| A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client? | Tachycardia |
| an older PT in a LTC , he becomes weak and confused. He ate 40% of his breakfast/lunch. His temp is 38.3* C (100.9* F), pulse 92/min, RR 20, and blood pressure 108/60 mm, nonproductive cough with diminished breath sounds in the right lower lobe. What acti | monitor for orthostatic hypotension |
| A nurse is caring for a client who has a serum sodium level 133 mEq/L and serum potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? | Three tap water enemas |
| A nurse is caring for a client who has a serum potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? | ECG changes |
| A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? | Hyponatremia |
| A nurse is assessing a client who has hyperkalemia. the nurse should Identify which of the follwoing conditions as being associated with this electrolyte imbalance? | Diabetic Ketoacidosis |
| A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. which of the following arterial blood gas findings should the nurse expect | C. pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3 18 mEq/L Metabolic acidosis |
| A nurse is caring for a client who was in a MVA. The client reports chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax. Which of the following ABG findings should the nurse expect | A. pH 7.06 PaO2 86 mm Hg PaCO2 52 mm Hg HCO3 24 mEq/L Respiratory Acidosis |
| A nurse is obtaining ABG's for a client who has vomited for 24 hr. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hrs? | D. Metabolic alkalosis |
| A nurse is assessing a client who has pancreatitis. The client's ABGs reveal metabolic acidosis. Which of the following are expected findidngs? | E. Dysrhythmia F. Tachypnea |
| What are the two body fluid compartments in your body | Intracellular & Extracellular |
| What fluid compartments are extracellular? | Interstitial, Plasma & Transcellular |
| Where is interstitial fluid found? | Between cells |
| Where is transcellular fluid found? | In joints, mucous, GI tract secretions, etc. |
| Which is the largest body fluid compartment? | Intracellular fluid |
| Which is the largest extracellular body fluid compartment? | Interstitial |
| Which is the smallest body fluid compartment? | Transcellular |
| all particles want to move from an area of high concentration to low concentration? | Diffusion |
| If I have two identical cups of water, and I add 20tsp of lemonade to one cup and 10 tsp. of lemonade to the other cup which one is more concentrated with lemonade? | The one with 20tsp of lemonade is more concentrated because it has the most particles. |
| What will happen to the cells when they suck up too much water? | The cells will lyse (rupture.) |
| How many liters can a kidney filter per hour? | 1L |
| When the plasma is too dilute, where will the extra water go? | Water will leave the bloodstream and enter the tissues where there is a higher concentration of solutes. |
| In a person who is overhydrated, will the person initially have more water in their plasma or in their cells? | The person will initially have more water in their PLASMA than in their cells. |
| What will happen to the cells as they draw in more water? | The cells will enlarge and eventually rupture. |
| In order to counteract the effects of overhydration, should the person be given an IV that is hypertonic (greater than 300 mOsm) or hypotonic (less than 300 mOsm)? | Hypertonic (greater than 300 mOsm) |
| Patient recovering from bacterial infection has been suffering with diarrhea. He has not been able to eat or drink anything. Low BP=70/40, High Pulse-110bpm. WHAT IV SOLUTION IS GIVEN | • Give Isotonic solution (ringers solution). • The person has a high pulse rate and low blood pressure. • Since the person is severely dehydrated, but the water loss and particle loss are equal (diarrhea or vomiting) |
| age 24, has been suffering from food poisoning with vomiting and diarrhea. He has been drinking a lot of plain water, not Gatorade or Pedialyte. Skin and mucous membranes are dry, complaining of a headache. HR is normal, but he has BP=200/120. What IV | |
| A 35 year old patient recovering from food poisoning has been vomiting and eating only Saltine crackers. She has a moderately rapid pulse and moderately low blood pressure, what IV given | hypotonic solution. The salty crackers replaced the sodium lost from GI distress, but the salt replacement exceeded the water replacement, so her plasma is hypertonic |
Created by:
deleted user