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PVCC NUR171
Exam #1
| Question | Answer |
|---|---|
| Lymphatic Vessels | Bring fluid from interstitial space back to blood vessels. Empty into the subclavian veins. |
| Spleen Functions | Produces antibodies, filters old RBCs, and destroys old RBCs |
| Splenectomy procedure and risk | Removal of the spleen which results in an increased risk for infection due to the removal of the immunity functions of the spleen. |
| Thrombocytes | Platelets with coagulation factors |
| Universal donor | O-; can donate to all blood types |
| Blood type A or B can donate to... | AB |
| Can Rh+ donate to Rh- | NO...Rh- cannot receive + blood. |
| Can Rh- donate to Rh+ | Yes. |
| Only IV fluid hung with blood products | Normal Saline |
| Time for s/s to appear for a reaction to donated blood products. | 15-20 minutes. RN must stay with pt during this time to verify no adverse reaction to blood. |
| S/S of blood transfusion reaction | Chills, Fever, SOB, Tachycardia, back pain, HA, chest pain, hypotension. |
| If s/s of hemolytic reaction occur when a patient is receiving blood transfusion... | STOP infusion immediately, notify physician and notify blood bank. Incident report may be needed, per agency policy. |
| Length of time a unit of blood can hang | 4 hrs. Must then discard. If greater duration is required or fluid overload occurs, may call blood bank and have unit split into smaller units. |
| Procedure when additional fluids are needed during blood transfusion. | RN will need to start another line. Additional fluids may NOT be piggybacked. |
| Pre-transfusion check | 2 RNs needed to positively identify patient and blood unit ID. Blood hung on pump. |
| IV gauge for blood transfusion | IV gauge 18-20 |
| Liver function | Produces bile, Metabolizes, Synthesizes coagulation factors VII, IX, X, and prothrombin. Stores Vitamins and glycogen. |
| Lymph nodes to be concerned about | Greater than 1 cm, hard, and immobile. |
| Hematology diagnostic tests | Blood chemistry, Hematologic studies, Bone marrow aspiration/biopsy, Coagulation studies, Bone scan, Schilling test. |
| When use of radioisotopes during diagnostic test is required, RN needs to assess for what type of allergy. | Shellfish allergy |
| Hematocrit should be about __x greater than hemoglobin | 3x |
| HgB value when blood transfusion is usually required. | 9 |
| Lovenox dosing is based on.. | Patient's weight |
| INR normal value | 1-2; patient's with cardiac issues may be 2.5-3.5 |
| Platelet normal value | 150,000-400,000. |
| Increase in platelet value = | Blood clot, affects on the cardiac and respiratory system due to higher blood viscosity. |
| Decrease in platelet value = | Increased risk for bleeding |
| Primary blood dyscrasias | Problem with the blood...i.e sickle cell |
| Secondary blood dyscrasias | A cause other than defect in blood...i.e malnutrition, drugs, disease processes. |
| Sickle cell is more prevalent in... | African Americans |
| Sickle cell can cause | Clots which lead to hypoxia which leads to tissue necrosis. |
| Anemia | Result of decreased production, increased RBC destruction, or blood loss |
| Polycythemia | Results from hypoxia, erythropoietin, secreting tumors, kidney disease, genetic defects. Increases blood viscosity = clot. |
| Hypochromic Anemia | Iron or vitamin deficiency. Most common anemia. |
| Pernicious Anemia | Lack of intrinsic factor. Occurs with GI issues. TX: B12 shots monthly for the rest of their life. |
| Erythroblastosis Fetalis Anemia | Pregnant mother with Rh- blood, is exposed to baby's Rh+ blood. The mother produces antibodies and attacks fetus' blood. AKA hemolytic anemia |
| Secondary Anemia | Caused by bleeding, trauma, leukemia, cancer, kidney disease. |
| Anemias caused by genetic factors | Sickle Cell Anemia or Spheroidal |
| Aplastic Anemia | Caused by malfunctioning bone marrow. |
| Anemia is more prominent in... | Women then children, especially pregnant women. |
| High risk groups for anemia | Pregnant women, women, children, poor dietary intake, PUD, long term ASA use, colon cancer. |
| Signs and symptoms of anemia | Pallor, fatigue, weakness, dyspnea, brittle nails, pica, headache. |
| Iron supplements | Best on empty stomach, vitamin C increases absorption. SHOULD NOT be given with milk or antacid. |
| Vitamin that increases iron absorption | Vitamin C |
| Considerations when giving IV iron | Could have anaphylactic reaction. MUST do test dose first. Requires a separate IV site |
| Considerations when giving IM injection of iron | Deep IM injection using z-track. Change the needle and aspirate. |
| Dietary sources of iron | Dark green leafy vegetables, Beans and peas, dried fruits, eggs, nuts, raisin, seafood, spinach, whole grain |
| Dietary sources of B12 | Eggs, meat, poultry, shellfish, milk and milk products. |
| Dietary sources of Folate | Fruits and vegetables. |
| Dilantin use related to folate | Dilantin (used for seizure control) does not allow patient to absorb folate. |
| Patients who may have trouble absorbing folate... | Pts using dilantin, ETOH, or hemodialysis. |
| Treatment for polycythemia vera | Removal of blood, IV fluids |
| Possible complications of polycythemia vera | Stroke, MI, embolism, infection (due to immature WBC), bleeding (platelets are immature), poor perfusion, stasis ulcers. |
| Hemophilia | Genetic disorder which could cause excessive bleeding. |
| Increase in WBC precursors with accumulation in bone marrow or lymph tissue is sign of... | Leukemia |
| Blasts | Immature WBCs |
| Decrease in WBCs | Neutropenia, lymphocytopenia |
| Increase or decrease in WBCs causes and increase in... | Risk for infection. (When WBCs increase rapidly there is decreased immune function due to immature cells) |
| Neutropenia | Decrease in neutrophils. Caused by cancer, immunosuppressive disease/therapy, HIV, Lupis |
| Leukopenia | Decrease in WBC |
| Increase in WBC is what kind of infection | Bacterial |
| Decrease in WBC is what kind of infection | Fungal or viral |
| Patients with leukopenia need to have what type of precautions | Reverse isolation: no kids, keep in room as much as possible, no sick visitors or staff, wash fruits and veggies thoroughly (cooked is best), monitor temp every 4 hours, mask gown when leaving room. |
| Precautions for radiation therapy site. | No soap or lotion can be applied to area. Wash with warm water only. |
| Signs and symptoms of leukemia | Fever or night sweats, frequent infections, feeling weak or tired, headache, bleeding/bruising, bone and/or joint pain, swollen lymph nodes, weight loss |
| Blood tests for leukemia | CBC, platelets and HCT/HgB. Bone marrow biopsy. |
| Side effects for chemo | Bruising, fatigue, infection, bleeding, hair loss, nausea, vomiting, diarrhea, anorexia |
| Monoclonal antibodies | Used for tx of CLL(Chronic lymphocytic leukemia. Binds to leukemia cells and enables immune system to kill cell. |
| Interferon | Slows growth of cells. Mostly used for GI/Colon cancer |
| Biological therapy side effects | Rash/swelling at injection site, anemia, flu like symptoms. Not as severe as with chemo/radiation. |
| Radiation and chemo must occur before ... | Bone Marrow Transplant |
| Radiation therapy side effects | Fatigue, redness, dryness, tenderness at the site of therapy. |
| If there is an order for wound care on a radiation site, the nurse needs to .... | Talk to the radiologist before performing wound care. |
| Side effects of Bone Marrow Transplant | Infection, bleeding, s/e from high doses of chemo and radiation (which must occur before BMT) |
| Hodgkin's lymphoma | Malignant. |
| Lymphatic cancer is usually... | Systemic |
| Lymphoma signs and symptoms | Fatigue, night sweats, temperature, swollen lymph nodes (greater than 1 cm, hard, and immobile). |
| PICC and central line dressing changes are... | STERILE |
| Thrombocytopenia | Deficient number of platelets |
| Teach pts with thrombocytopenia to avoid.. | ETOH, ASA, and NSAIDS |
| Symptoms of thrombocytopenia | Sudden onset of petechiae, malaise, fatigue, general weakness. |
| Epistaxis | Nose bleed |
| PICCS are usually used for about....weeks before changing. | 6 weeks. Keep clean, flush, and perform sterile dressing changes. |
| Ferrous sulfate and antacids must be taken at least __ hours apart. | 2 hours |
| Prior to surgery, any abnormal labs need to be reported to... | The surgeon/physician |
| Clinical signs of stress | Nausea, vomiting, diarrhea, increased pulse, increased respiratory rate, increased blood pressure, diaphoresis |
| Anxiety can impair... | Cognition, decision making, and coping skills. Pts will not learn while anxious. |
| Perhaps the strongest positive coping mechanism... | Hope |
| Pre-op assessment includes.. | Health history and physical. Ask about Medications, family history, allergies, past reactions to anesthesia, past surgeries, infections (especially airway), COPD, asthma, smoking history, skin integrity. |
| Postoperative delirium can occur with... | Dehydration, hypothermia, and adjunctive medications. |
| Problems affecting the neck or lumbar spine need to be relayed to PCP because... | They can affect airway management and anesthesia delivery. |
| Patient's with diabetes mellitus are especially at risk for... | Hypo/hyperglycemia, ketosis, cardiovascular alterations, delayed wound healing, infection. |
| Assessment for pts with diabetes mellitus prior to surgery.. | Serum glucose tests morning of surgery (baseline). Clarify with physician if insulin should be taken. |
| Drugs to check with doctor before giving the morning of surgery. | Insulin, thyroid meds, steroids |
| Abruptly stopping replacement corticosteroids could cause... | Addisonian crisis |
| Given oral meds when pt is NPO | May take meds with sip of water. Document appropriately. |
| IF a pt is NPO, the RN needs to double check to see if there is an order for... | IV fluids. If not the RN needs to call the physician and see if one needs to be ordered. |
| Implications of obesity on surgical procedures. | Stresses cardiac and pulmonary systems, increased risk of wound dehiscence and infection, slower recovery from anesthesia (meds hide in the adipose tissue), slower wound healing. |
| Considerations for underweight pts | May need to provide extra padding to prevent pressure ulcers. |
| Legal preparations prior to surgery. | Informed consent, signature for blood transfusion, advance directives and power of attorney. |
| If MPOA is approving a procedure over the phone... | 2 RNs need to witness |
| Immediately prior to transportation to holding room for surgery, the nurse should have the patient....prior to medication administration. | VOID :) |
| All patients are urged to stop smoking .....weeks before surgery. | 4-6 weeks |
| Patients prone to latex allergies may also be allergic to... | Avocados, bananas, peaches. Have asthma or hay fever. |
| Pre-op labs and diagnostic tests | Blood studies (CBC, electrolytes, coagulation, blood type and match), UA, EKG, CXR |
| Pre-op teaching | Deep breathing, incentive spirometry, splint incision, turn, reposition (prevent atelectasis/pneumonia). Leg exercises and antiembolic SCDs. |
| Role of the Scrub Nurse | Provides the surgeon with required instruments, sponges, drains, and other equipment, anticipating what will be needed. Prepares sterile tables prior to surgery. |
| Holding area | Complete preoperative preparations |
| Circulating nurse | Manages/coordinates patient care in the OR, protects safety/health needs, ensures rights are protected (controlling cleanliness, temp, humidity, and lighting). |
| The circulating nurse and the scrub person are responsible for accounting for all..... | Sponges and instruments at the close of surgery. |
| One of the most significant potential hazards to the pt in the OR is... | Electricity (electric shock and burns) |
| Time out or procedural pause | Before surgery or a procedure, surgeon and nurses will verify correct patient, surgical site, informed consent, etc. |
| General anesthetic | Produces analgesia, relaxes muscles, results in a sleep-like state. Patient will be intubated. |
| Regional anesthetic | Produces decreased sensation and pain in selected body parts by way of nerve blocks, intrathecal blocks (in brain), or epidural blocks. |
| Local anesthetic | Depresses superficial peripheral nerves and blocks conduction of pain impulses from their site of origin. |
| IV Conscious Sedation | Diazepam/Valium, Midazolam/Versed. Usually need RN present constantly during conscious sedation. |
| Cardiac meds need to be Ok by..... prior to discontinuation for a procedure. | Cardiologist |
| Skin staples | Reduces tissue handling and accomplishes wound closure faster than suturing. Usually removed within the first week after surgery. |
| Malignant hyperthermia | Reaction to anesthesia. Ask pts prior to surgery if they have any family member who have experienced this. Without antidote, the pt dies. |
| S/S of malignant hyperthermia | Increased temperature, rigid muscles |
| PACU Care | One on one. Monitor pain, vitals, drains, cardiac monitor, take vitals every 15 mins and document. |
| Loud, irregular respirations may indicate....after surgery. | May indicate obstruction of the airway, possibly from emesis, accumulated secretions, or patient positioning that allows the tongue to fall to the back of the throat. |
| If respiratory rate in decreased or O2 sats are 90-92... | Raise HOB and encourage patient to take deep breaths. |
| Decreasing BP and increased pulse rate in the post-op patient may signify... | Hemorrhage or shock |
| Sinus Bradycardia | All intervals of PQRST wave normal, just slow pulse. Monitor V/S |
| Sinus Tachycardia | All intervals of PQRST wave normal, just fast pulse. Monitor V/S. Assess pt for cause. |
| Atrial Fibrillation | Atria contracting spontaneously, ventricles can contract normal part of the time. Atrial rate may appear to be 350-600 while ventricle rate is 100-160 |
| 2 shock-able waves | V tach and V fib |
| Ventricular Fibrillation | DEADLY RHYTHM. Rapid uncoordinated firing of the ventricles. This rhythm does not generate a pulse. Interventions: Quickly check pulse, if no pulse, De-fibrillate immediately. |
| Before giving water or ice chips to post-op patient... | Assess for gag reflex. |
| When a pt is transferred from PACU to Med/Surg, assess condition every... | 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, then every 4 hours as needed. |
| If bleeding is noticed on a post-op bandage... | Circle blood and time bandage, then recheck every 15 minutes. |
| Before discharge from an ambulatory surgical center, the patient should... | Be able to void and ambulate independently (or up to baseline), be alert and oriented, have minimal nausea and vomiting, have a person to accompany them home. |
| If pt has flatulence or risk of paralytic ileus, or DVT, it is best to... | Get pt up and walking. Best way to prevent these issues. |
| Nutrition for post-op | Diet with significant amounts of protein and vit A and C help rebuild tissues and promote wound healing. Adequate carbs and fat are also needed to avoid depleting protein stores. |
| Time at which patients should void post-op | Within 6-8 hours. Janice gets nervous around 4 hours w/o voiding. |
| Inadequate urinary output may indicate ... | Hypovolemia, hemorrhage, electrolyte imbalance, inadequate circulation, hypoxia, or impending shock. |
| Paralytic ileus | Very painful, usually responds to TX with an NG tube, bowel rest, and IV. |
| If PO meds are crushed and inserted into NG tube... | Need to turn off suction for 30-50 minutes. |
| Hemo-vac output measured every ... | 8-12 hours. |
| Programming of PCA pumps need to be verified by... | 2 RNs |
| Trust vs. Mistrust | Newborn or infant |
| Autonomy vs Shame and Doubt | Toddler |
| Initiative vs Guilt | Preschool |
| Industry vs Inferiority | School-age |
| Identity vs Role Confusion | Adolescence |
| Intimacy vs Isolation | Young adult |
| Generativity vs Stagnation | Middle-age |
| Ego integrity vs. Despair | Old age |
| IS should be done every... while awake | 10x every hour |
| Turn, cough, deep breathe should be done .... | Every hour |
| Obese patients tend to breathe poorly when..... increasing the risk of hypoventilation and post-op pulmonary complications | Supine |
| Antidote for malignant hyperthermia | Dantrolene sodium (Dantrium) |
| S/S of shock | Pallor, cool moist skin, rapid breathing, cyanosis, rapid or weak pulse, low BP and concentrated urine. |
| Drugs that turn urine red. | Anticoagulant |
| Drugs that turn urine orange or orange-red | Pyridium |
| Drugs that turn urine green or blue-green color | Elavil or B-complex vitamins |
| Injectable componds that can turn urine/stool black or black-brown. | Injectable iron |
| Reasons for irrigating the bladder | To instill medication and to flush out old blood and clots (post TURP, injury, or bladder surgery. |
| TURP | Transurethral resection of the prostate. |
| TURBT | Transurethral resection for bladder tumor. |
| Monitoring irrigation fluid in I&O. | Irrigation fluid is intake. |
| Areas to avoid placing leads for EKG | Avoid bony prominences and fatty areas. |
| Rhythm strip | 6 second strip that can be printed from a monitor normally in lead II |
| Precordial leads | V1-V6 |
| Limb Leads | Leads I, II, III (White, black, and red) |
| Isoelectric line | Baseline on EKG |
| The normal running speed for EKG | 25mm/sec (Dr. may ask to increase speed if extreme tachycardia is present) |
| Artifact or wandering baseline occurs: | Look to see if patient is moving or jerking, if there is muscle tremors. If there is a loose cable or lead. |
| What position should a pt be in prior to EKG | Supine or semi-fowlers |
| When can magnets be placed over pace-maker for EKG. | Only place magnet over pacemaker with physician order and document. (also have emergency equipment ready) |
| Electrodes in good condition may be reused within... | 24 hours |
| The limb electrodes may be placed on... | Lower extremities or on rib cage (avoid bony prominences or fatty tissue) |
| Cardiac Alert System | Goal is to obtain 12 lead EKG within 5 minutes of admission to ED or per hospital policy. This is in place to increase door-to-ballon times and improved patient care. |
| Normal Sinus Rhythm | Normal rate, normal rhythm |
| Arrhythmia | Abnormal heart rhythm |
| How to determine heart rate from 6 sec strip | Count R waves and multiply by ten. i.e. 4 waves x 10 = 40. |
| Bradycardia | HR less than 60 |
| Tachycardia | HR more than 90 |
| Atrial Fibrillation. | Heart is quivering. Fast irregular activity can cause blood clots and stroke. May require medication. |
| Ventricular Fibrillation | Lethal. Requires immediate defibrillation |
| Asystole | AKA Flatline. No rhythm and no pulse=legally dead. |
| MI on EKG | Diagnosed by ST elevation and/or reciprocal changes. |
| Myocardial ischemia on EKG | Flipped T waves. May be caused by lack of O2 to heart or previous MI. |
| Pulse-less Electrical Activity (PEA) | Perform CPR. Electrical activity is occurring but no heart beat. |
| Purpose of a chest tube | To expand the lung to normal negative intrathoracic pressure. |
| Pneumothorax (pneumo) | Pressure builds in pleural space = shrinks lung. |
| Two types of pneumothorax | Open (sucking chest wound) and Closed. |
| Which is more dangerous, and open or closed pneumothoroax? | Closed. It allows pressure to build and will eventually cause a tension pneumothorax. |
| Hemothorax | Blood in pleural space. |
| Pleural effusion | Transudate (clear fluid from CHF or renal and liver failure), Exudate (from TB or pneumonia) or Empyema (pus) in pleural space. |
| Tension Pneumothorax | EMERGENCY. Causes rapid cardiovascular collapse from pressure on the heart. |
| S/S of Tension Pneumothorax | Decreased BP, Increased Pulse, JVD, Deviated trachea |
| S/S of Pneumothorax | Shallow respirations, decreased breath sounds, anxiety, SOB, Decreased O2 sats. |
| Tx for Tension Pneumothorax | Needle Decompression using a large bore IV catheter. After decompression it will be a sucking wound and will need a chest tube. |
| Thoracostomy Procedure | Insertion of chest tube and drainage system. Drainage system does not need to be sterile but the chest tube does. |
| Always keep the chest tube ....the level of the pt. | Below the pt. Drainage system works on gravity. |
| Chest tubes need to be.... after placement. | verified with CXR |
| What should you do if a chest tube gets pulled out on accident. | Immediately apply a Vaseline gauze. It should be taped to the bed. |
| CDI | Clean, dry, intact. |
| Order to obtain blood samples | Blood cultures are always first. Then Blue, Red, Green, Purple, Grey. |
| Diagnostic tests for Lavender Tube | CBC, Blood counts, blood sugar |
| Diagnostic tests for Light Blue | Coagulation studies (PT, PTT, INR) |
| Diagnostic tests for Green top | Ammonia, troponin, iSTAT |
| Diagnostic tests for Gray top | Alcohol levels |
| Diagnostic tests for Red top | CMP (chemistry) |
| Gray tops are drawn after what type of prep is used.. | Betadine (NOT Alcohol or Chloraprep. They contain alcohol which may interfere with alcohol levels in blood) |
| Gray top tubes are kept....after blood is drawn. | On the person that performed the phlebotomy (in their pocket) |
| Arterial blood gas (ABG) procedure. | Must immediately go on ice, hold manual pressure for at least 5 minutes, and should be hand delivered to the lab. |
| Lab specimens that go on ice | Ammonia (green), lactate or lactic acid (green), ionized calcium (green), ABG (syringe) |
| If patient has a vagal reaction when drawing blood.... | Stop draw, call for help, lower HOB, and Check airway. |
| Purpose of NGT | Lavage stomach, assess for GI bleed, Decompress stomach. |
| Check continuous tube feedings every... | 4-6 hours. |
| Prodrugs | Drugs that are designed so that their 1st metabolite is the active form of the drug. If this drug is given IM or IV it will take longer to get a therapeutic effect. |
| Drug half-life | Time in which half of original dose is removed. It takes about 5 half-lives to remove a drug. |
| Additive effect | Similar drugs and response |
| Antagonistic effect | Less effective than each alone |
| Synergistic effect | Greater effect than each alone |
| Teratogenic | Causes Fetal deformities |
| Mutagenic | Mutates DNA |
| Carcinogenic | Predisposes PT to cancer |
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