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med surge exam 2 pre
| Question | Answer |
|---|---|
| What are common causes of dehydration | Vomiting/diarrhea, GI suction, diuretics, fever, sweating, burns, poor fluid intake. |
| What findings indicate dehydration? | Dry mucous membranes, decreased urine output, hypotension, tachycardia/weak pulse, poor skin turgor |
| What are manifestations of fluid volume excess? | crackles, edema, bounding pulse, distended neck veins, hypertension, weight gain, shortness of breath. |
| Treatment for fluid volume excess? | Restrict fluids/sodium, diuretics, (ex. Lasix), elevate HOB, weights, slow IV rate as ordered. |
| Give an example of a hypotonic IV fluid. | 0.45% NS. |
| Give an example of an isotonic IV fluid. | 0.9% NS (normal saline) or LR |
| Give an example of a hypertonic IV fluid. | D5NS or 3% saline. |
| What is the normal sodium range? | 135-145 mEq/L. |
| What is the normal potassium range? | 3.5-5 mEq/L. |
| What is the normal calcium range? | 9-11 mg/dL. |
| What is the normal magnesium range? | 1.5-2.5 mEq/L. |
| What is hyponatremia? | Sodium level less than 135 |
| What findings are expected with hyponatremia? | Headache, confusion, seizures, and weakness. |
| What is hypernatremia? | Sodium levels higher than 145 mEq/L. |
| What findings are expected with Hypernatremia? | thirst, dry mucosa, restlessness/ irritability, mental status changes. |
| What is Hypokalemia? | Potassium levels below 3.5 mEq/L. |
| What finding is expected with hypokalemia? | Muscle weakness, cramps, constipation/ileus, dysrhythmias. |
| What is Hyperkalemia? | Potassium levels above 5.0 mEq/L |
| What finding is most concerning with hyperkalemia? | Irregular pulse/ dysrhythmias. |
| Which electrolyte imbalance causes the highest risk for dysrhythmias? | Potassium Imbalance |
| What is hypocalcemia? | Calcium levels below 9 mg/dL. |
| What finding is associated with hypocalcemia? | tetany, numbness/tingling, muscle cramps. |
| What does a positive Chvostek sign indicate? | Hypocalcemia. |
| What does a positive Trousseau sign indicate? | Hypocalcemia. |
| What is Hypercalcemia? | Calcium levels above 11mg/dL. |
| What findings are expected with hypercalcemia? | Weakness, decreased reflexes, constipation, confusion. |
| What is Hypomagnesemia? | Magnesium below 1.5. |
| What findings are expected with hypomagnesemia? | tremors, increased reflexes, dysrhythmias. |
| What is hypermagnesemia? | magnesium levels above 2.5 |
| What findings are expected with Hypermagnesemia? | lethargy, hypotension, decreased reflexes, respiratory depression |
| What are common local IV complications? | Infiltration, extravasation, phlebitis, thrombosis, hematoma, local infection. |
| What is the priority action for Infiltration, extravasation, phlebitis, thrombosis? | Stop the infusion and remove the IV. (Then follow workplace policy and procedures) |
| What findings suggest infiltration has occurred? | Coolness, swelling/edema, taut skin, decreased/absent blood return, sluggish infusion. |
| What findings suggest phlebitis? | Redness, warmth, pain, palpable cord along vein. |
| What findings suggest circulatory overload during IV therapy? | Crackles, dyspnea, chest pain, hypotension, cyanosis. |
| What is the priority action for circulatory overload? | Decrease IV rate and place pt in high Fowlers position. |
| What findings suggest an air embolism? | Sudden dyspnea, chest pain, hypotension, cyanosis. |
| What is metabolic acidosis and a common cause? | Low ph+ low HCO2. causes include: DKA, renal failure, and diarrhea. |
| What is metabolic alkalosis and a common cause? | High ph + high HCO2. causes include vomiting. NG suction, excess antacids/diuretics. |
| What is Respiratory acidosis and a common cause? | Low ph + High CO2. causes include hypoventilation, COPD, opoids. |
| What is respiratory alkalosis and a common cause? | High ph+ low CO2. causes include hyperventilation, anxiety, pain. |
| ABG: pH 7.3, CO2 55 what is the problem? | Respiratory acidosis. |
| ABG: pH 7.5, CO2 30 what is the problem? | Respiratory Alkalosis. |
| ABG: pH 7.25, HCO2 18 what is the problem? | Metabolic acidosis. |
| ABG: pH 7.52, HCO2 32 what is the problem? | Metabolic alkalosis. |
| What preoperative teaching helps prevent postoperative respiratory complications.? | incentive spirometry, coughing/deep breathing exercises. |
| What preoperative interventions helps prevent DVT? | Leg exercises, early ambulation, administer SCD"s as ordered. |
| What is the priority assessment immediately post-op? | Airway/breathing. |
| What finding indicates readiness for discharge from PACU? | O2 sat greater than 90% and stable vitals. |
| What is the priority action for wound evisceration? | Cover with sterile dressings moistened with sterile normal saline. |
| What is the nurse's role in informed consent? | Witness the client's signature after verifying it's voluntary and the client is informed. |
| When is informed consent invalid? | If the client is sedated/received analgesia before signing. |
| What electrolyte should be monitored closely with Lasix (Furosemide) | Potassium. |
| What is a key teaching point for pt's taking coumadin (warfarin)? | Bleeding precautions and consistent vitamin K intake. |
| Who is at high risk for surgery complications. | Older adults, Chronic illness, malnutrition, obesity, smokers, diabetes/immunocompromised. |
| What is an example of elected surgery? | Hernia repair. |
| What is a urgent surgery? | Surgery needed within 24 hours. |
| What is an important nursing consideration when teaching older adults? | Allow extra time, use clear simple instructions, verify understanding. |
| What are risk factors for hypovolemic shock? | Hemorrhage/ severe dehydration, burns, fluid loss. |
| What are manifestations of hypovolemic shock? | Hypotension, tachycardia, cool clammy skin, weak pulse, decreased urine output, altered mental status. |
| Where are most body fluids found? | Intracellular |
| A 76-year-old patient with skin tenting and decreased urine output is most likely experiencing which fluid or electrolyte disorder? | Dehydration |
| Which electrolyte is most critical to healthy cardiac rhythm? | Potassium |
| Which interventions should the nurse initiate for a patient with fluid excess? | -Monitor weight -Place in Fowler position -Restrict fluid -sodium |
| What are good food sources of calcium? | -Canned salmon -Spinach - Yogurt |
| The nurse attempts to flush the patient’s IV cannula with saline but meets resistance. Which action is best? | Remove and replace the cannula |
| Which IV fluid is hypertonic? | 5% dextrose in 0.9% sodium chloride |
| Which medication when given intravenously can cause a life-threatening arrhythmia? | Potassium |
| A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? | -Bounding pulse -Crackles in lungs |
| Which of these is a role of the LPN/LVN in the preoperative phase? | -Assist with data collection -Reinforce patient teaching -Provide emotional support to patients -Include families in preoperative care |
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Cartoy890