GB exam 1 / M exam 4
What is Acute Kidney Injury?
Acute kidney injury (AKI) is characterized by a rapid loss of kidney function.
This loss is accompanied by a rise in serum creatinine and/or a reduction in urine output.
AKI can develop over hours or days with progressive elevations of blood urea nitrogen (BUN), creatinine, and potassium with or without a reduction in urine output.
The severity of dysfunction can range from a small increase in serum creatinine or reduction in urine output to the development of azotemia, an accumulation of nitrogenous waste products (urea nitrogen, creatinine) in the blood.
Phases of AKI: oliguric, diuretic, recovery
Will see metabolic acidosis (HCO3 issue), variable serum Na, increased serum K, elevated BUN & Cr (Cr more reliable indicator of AKI vs BUN), elevated wbc, neuro changes
While caring for a client in shock, the nurse knows how to monitor which parameter to determine the client’s response to treatment?
a. Cardiac output
b. Respiratory rate
c. Peripheral pulse rate
d. Central venous pressure
a. Cardiac output
The cardiac output is the best indicator for response to treatment for shock because it reflects left ventricular function.
Peripheral pulse rate and respiratory rate are part of the compensatory mechanism systems and may remain within normal limits due to hormonal and sympathetic nervous system response.
Which male population has a higher incidence of testicular cancer?
m/c type of cancer in young men between 15 and 44 years of age. The median age at diagnosis is 33 years old.
Testicular tumors are more common in males who have had undescended testes (cryptorchidism) or a family history of testicular cancer or anomalies.
Other predisposing factors include orchitis, human immunodeficiency virus (HIV) infection, maternal exposure to exogenous estrogen, and testicular cancer in the other testis.
Which of the following is a priority when suctioning a client with increased intracranial pressure?
a. Limit the suction passes to 10 seconds
b. Suction the client as needed
c. Suction the client at least every hour
d. Schedule the suctioning with other nursing tasks
a. Limit the suction passes to 10 seconds
Suctioning (and coughing) can cause an increase in intracranial pressure and should be used cautiously.
The client must be closely assessed during suctioning, and suction passes should be kept to a minimum and limited to 10 second (or less) suction passes.
The client should be allowed to rest for several minutes between suction passes, manually hyperventilated, and pre-oxygenated with 100% oxygen prior to suctioning
To avoid cumulative increases in the ICP with suctioning, limit suctioning to 2 passes per suction procedure, if possible.
After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?
a. A patient whose cranial x-ray shows a linear skull fracture
b. A patient who has an initial Glasgow Coma Scale score of 13
c. A patient who lost consciousness for a few seconds after a fall
d. A patient whose right pupil is 10 mm and unresponsive to light
d. A patient whose right pupil is 10 mm and unresponsive to light
The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure.
The other patients are not at immediate risk for complications such as herniation.
The nurse is teaching the patient and family that peptic ulcers are
a. caused by a stressful lifestyle and other acid-producing factors, such as H. pylori.
b. inherited within families and reinforced by bacterial spread of Staphylococcus aureus in childhood.
c. promoted by factors that cause oversecretion of acid, such as excess dietary fats, smoking, and alcohol use.
d. promoted by a combination of factors that cause erosion of the gastric mucosa, including certain drugs and H. pylori.
d. promoted by a combination of factors that cause erosion of the gastric mucosa, including certain drugs and H. pylori.
fig. 41.9 or fig. 46.9
Peptic Ulcer Disease (PUD) is a condition characterized by erosion of the GI mucosa from the digestive action of HCl acid and pepsin.
Peptic ulcers develop only in an acid environment. However, an excess of HCl acid is not necessary for ulcer development.
The major risk factor for PUD is infection with Helicobacter pylori. 80% of gastric and 90% of duodenal ulcers are related to H. pylori.
High alcohol intake is associated with acute mucosal lesions. Alcohol and smoking stimulate acid secretion. Coffee (caffeinated and decaffeinated) is a strong stimulant of gastric acid secretion. Smoking and psychologic distress, including stress and depression, can delay the healing of ulcers once they have developed.
NSAID use is responsible for most non–H. pylori peptic ulcers. NSAIDs inhibit prostaglandin synthesis, increase gastric acid secretion, and reduce the integrity of the mucosal barrier. Patients taking corticosteroids or anticoagulants with NSAIDs have a higher risk for PUD. Corticosteroids affect mucosal cell renewal and decrease its protective effects.
Order: Infuse heparin at 2,000 units/hr IV from a solution containing 20,000 units of heparin in 500 mL D5W.
How many milliliters will infuse per hour? _____ mL
x ml/hr =
20,000 units/500 ml = 2,000 units/x ml
cross multiply, solve for x
= 50 ml/hr
or
500 ml/20,000 units x 2000 units/1 hour
= 50 ml/hr
or
desired/have x carrier (ml) = 2000/20,000 x 500
What is a TURP?
TransUrethral Resection of the Prostate - gold standard for surgical tx bph
Removes excessive prostate tissue, decreases size, obstruction
Increased bloody clots, inpatient w/ CBI
figure 54.4 or fig. 59.4
A neonate delivered at 37 weeks gestation has been admitted to the neonatal intensive care unit for respiratory distress. The physician has ordered an IV for fluid support. To increase safety prior to hanging the new IV fluids for a neonate, the nurse should:
a. Check the neonate’s weight
b. Determine if the neonate has adequate urine output
c. Determine the neonate’s glucose level
d. Double check the fluids and physician order
d. Double check the fluids and physician order
Safe practice and error reduction can be increased by double checking orders and medication before administration - safety.
Knowing the neonates weight, urinary output and glucose level is an important part of understanding the potential needs of the neonate;
However double checking orders and interventions is the most important step to increase SAFETY
Clinical manifestations/differences between Rheumatoid Arthritis vs Osteoarthritis
RA- autoimmune disease?; Specific joint involvement is marked by pain, stiffness, limited motion, and signs of inflammation (e.g., heat, swelling, tenderness). Joint symptoms occur symmetrically and often affect the small joints of the hands (PIP and MCP) and feet (MTP); morning stiffness; fig 64.4 or fig. 69.3
OA- OA involves the gradual loss of articular cartilage with formation of bony outgrowths (spurs or osteophytes) at the joint margins; Joint pain is the main symptom and the typical reason the patient seeks medical attention. Pain generally gets worse with joint use
fig 64.1 or fig. 69.1
Which characteristics are most commonly associated with cholelithiasis? (select all that apply)
a. obesity
b. age > 40
c. multiparous female
d. hx of excessive alcohol intake
e. family hx of gall bladder disease
f. use of estrogen or oral contraceptives
a. obesity
b. age > 40
c. multiparous female
e. family hx of gall bladder disease
f. use of estrogen or oral contraceptives
Incidence of cholelithasis (stones in the gall bladder) is higher in women, multiparous women, age > 40, and those with family hx and obesity.
Post menopausal women taking estrogen replacement therapy and younger women on oral contraceptives have a higher incidence.
Alcohol intake and diet do not increase the incidence of cholelithiasis.
The cause of gallstones is unknown. They develop when the balance that keeps cholesterol, bile salts, and calcium in solution is changed so that these substances precipitate. Conditions that upset this balance include infection and changes in cholesterol metabolism.
In patients with gallstones, the bile secreted by the liver is supersaturated with cholesterol (lithogenic bile). The bile in the gallbladder then becomes supersaturated with cholesterol and precipitation of cholesterol occurs in the gallbladder.
Changes in the composition of bile are significant in gallstone formation. Bile stasis leads to progression of the supersaturation and changes in the chemical composition of the bile (biliary sludge). Immobility, pregnancy, and inflammatory or obstructive lesions in the biliary system decrease bile flow. Hormonal factors during pregnancy may cause delayed emptying of the gallbladder, resulting in bile stasis.
The nurse understands that the initial therapy for ARDS focuses on:
a. Preventing multiple organ dysfunction syndrome
b. Decreasing the P/F ratio
c. Increasing preload
d. Maintaining adequate oxygenation and tissue perfusion
d. Maintaining adequate oxygenation and tissue perfusion.
Acute Respiratory Distress Syndrome (ARDS) is a sudden and progressive form of Acute Respiratory Failure in which the alveolar-capillary membrane becomes damaged and more permeable to intravascular fluid.
ARDS problem is poor oxygenation and perfusion. The goal of therapy is aimed at increasing these back to normal or baseline.
The P/F ratio is (pulmonary shunt fraction- used to calculate the severity of ARDS): PaO2 value from ABG divided by FiO2; assesses lung function in intubated pts; <300 indicates respiratory failure
What do we teach women with dysmenorrhea about medications and lifestyle management to decrease symptoms?
Dysmenorrhea: painful menstruation
Primary- unknown cause (thought to cause uterine contraction pain by release of excessive prostaglandin)
Secondary- due to underlying pathology
Encourage Non pharm: heat, exercise, distraction, acupuncture, TENS
NSAIDS: take 1-2 days prior to start of menses
Oral Contraceptive Therapy
Avoid chocolate, caffeine, etoh, salt (similar for PMS)
PMS
Similar to above
Increase B6 foods to help with possible depression: pork, milk, legumes, eggs
After the delivery of the neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying the neonate, what should the nurse do next?
a. Assign the first Apgar score
b. Place the head in a “sniff” position
c. Administer oxygen
d. Start cardiac compressions
b. Place the head in a “sniff” position
When resuscitating the neonate, the principle of airway breathing circulation (ABCs) must be followed.
Positioning the neonate on the back with the head slightly extended in the “sniffing” position will open the airway, allowing oxygen to get to the neonate’s lungs.
Apgar scores are an evaluation of the neonate’s status at 1 and 5 mins of life.
Waiting to open the airway until assigning an Apgar score would be a waste of valuable time.
If the airway is not patent, O2 cannot be delivered.
Cardiac compressions must be accompanied by adequate oxygenation.
Which female patient(s) are at risk for developing osteoporosis? (select all that apply)
a. 60 yo white aerobics instructor
b. 55 yo Asian American cigarette smoker
c. 62 yo black who takes estrogen therapy
d. 68 yo white who is underweight and inactive
e. 58 yo Native American who started menopause prematurely
b. 55 yo Asian American cigarette smoker
d. 68 yo white who is underweight and inactive
e. 58 yo Native American who started menopause prematurely
Risk factors for osteoporosis: age > 65 yo, white or asian ethnicity, smoker, low body weight, inactive lifestyle, estrogen deficiency, family hx, diet low in Ca, vit D def, excessive alcohol use, and long-term use of medications such as corticosteroids, thyroid replacement, heparin, long-acting sedatives, or anti-seizure drugs.
The nurse is caring for a client who is jaundiced. The nurse should implement which of the following in the plan for the client’s pruritus?
a. Monitor the client’s temperature and assess the client’s color
b. Instruct the client to scratch with knuckles instead of nails
c. Administer prescribed analgesic and assist the client to bathe frequently
d. Encourage the client to eat a high-protein, low-cholesterol diet
b. Instruct the client to scratch with knuckles instead of nails
Pruritus occurs as a result of an accumulation of bile salts under the skin. Scratching with the knuckles instead of the nails maintains the skin’s integrity and prevents tearing
The purpose of adding PEEP to positive pressure ventilation is to
a. increase functional residual capacity and improve oxygenation.
b. increase FIO2 to try to help wean the patient and avoid O2 toxicity.
c. determine if the patient can be weaned and avoid pneumomediastinum.
d. determine if the patient is in synchrony with the ventilator or needs to be paralyzed.
a. increase functional residual capacity and improve oxygenation.
Positive End-Expiratory Pressure (PEEP) is a ventilatory maneuver, or mechanical ventilator setting, in which positive pressure is applied to the airway during exhalation.
Normally during exhalation, airway pressure drops to near 0, and exhalation occurs passively. With PEEP, exhalation is passive but pressure falls to a preset level, often 3 to 20 cm H2O.
Lung volume during expiration and between breaths is greater than normal with PEEP. This increases Functional Residual Capacity (volume remaining in the lungs after a normal, passive exhalation) and often improves oxygenation by restoring the lung volume that normally remains at the end of passive exhalation.
The mechanisms by which PEEP increases Functional Residual Capacity and oxygenation include increased aeration of patent alveoli, aeration of previously collapsed alveoli, and prevention of alveolar collapse throughout the respiratory cycle.
What are the clinical manifestations of decreased estrogen?
Vaginal dryness
Vaginal tissue atrophy
pH changes, infection
Uterine prolapse
Breast atrophy
Increased weight
Emotional lability: mood swings
Hot flashes: vasomotor instability
Urine incontinence
Osteoporosis
How to decrease symptoms?: HRT = No uterus: estrogen only; uterus: estrogen and progesterone
The nurse is planning care for the patient who suffered a Cerebral Vascular Accident (CVA) with residual dysphagia would write on the care plan to avoid doing which of the following during meals?
a. Feed the client slowly
b. Give the client thin liquids
c. Give food with consistency of oatmeal
d. Place food on unaffected side of mouth
b. Give the client thin liquids
A client who experiences a CVA may have involvement of the cranial nerve responsible for swallowing (XII), and generally undergoes a swallowing evaluation to determine whether a diet can be taken.
The client with some residual dysphagia may be started on a diet once the gag and swallow reflexes have returned. In this instance, liquids should be thickened to avoid aspiration.
The other options represent HELPFUL actions for the client with dysphagia.
The increased risk for falls in the older adult is likely due to (Select all that apply)
a. changes in balance.
b. decrease in bone mass.
c. loss of ligament elasticity.
d. erosion of articular cartilage.
e. decrease in muscle mass and strength.
a. changes in balance.
b. decrease in bone mass.
c. loss of ligament elasticity.
e. decrease in muscle mass and strength.
A patient is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by
a. progressive irreversible destruction of the kidneys.
b. a rapid decrease in urine output with an elevated BUN.
c. an increasing creatinine clearance with a decrease in urine output.
d. prostration, somnolence, and confusion with coma and imminent death.
a. progressive irreversible destruction of the kidneys.
CKD: lower than normal creatinine clearance # = kidney dysfunction (more Cr is left and is unable to be removed from body thru pee); leading cause is DM (50%) or HTN (25%)
Serum Cr clearance (also called calculated GFR) are considered more accurate indicators of kidney fxn than BUN or Cr in CKD
Creatinine = better indicator of renal fxn than BUN; high # worse kidney fxn (>1.4), especially useful in AKI
BUN = indicates kidney damage and fluid vol status; will see elevated BUN with fluid vol deficit; high BUN - worse kidney fxn (normal = 7-20)
GFR = the lower the #, worse the kidney fxn; higher the #, better kidney fxn (>90)
urine specific gravity = high # in dehydration, low # in fluid vol overload (normal = 1.005 - 1.030)
will see uremia - which alters plt, WBC, & RBC production; mild/moderate hyperglycemia & hyperinsulinemia; cvd; severe metabolic acidosis; CNS depression/lethargy/fatigue; skin pruritis; hyperphos & hypocalcemia (activated vit D deficiency)
BP 68/44, CVP = 2 (low) and SVR = 2400 (high) - 1st Treatment? _________________
a. Nitroprusside
b. Lactated Ringers bolus
c. Dobutamine
d. Bumetanide
e. Continue to monitor
b. Lactated Ringers bolus
Possible tx options for endometriosis?
Conservative tx option "watch & wait" is the first choice if not painful and no desire for pregnancy
Drugs: combined oral contraceptives important to take daily for 9 months without stopping to simulate preg state - endometriosis tissue responds to the hormones of the ovarian cycle and undergoes a “mini-menstrual cycle” similar to the uterine endometrium
mpa (ovulation suppressor), danazol (androgen causes wt gain, hirsutism, acne), GnRH agonist (results in amenorrhea)
Surgical removal of endometrial tissue is the only cure
Following a head injury, an unconscious 32-year-old patient is admitted to the ED. The patient’s spouse and children stay at the patient’s side and constantly ask about the treatment being given. What action is best for the nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is completed.
b. Allow the family to stay with the patient and briefly explain all procedures to them.
c. Call the family’s pastor or spiritual advisor to support them while initial care is given.
d. Refer the family members to the hospital counseling service to deal with their anxiety.
b. Allow the family to stay with the patient and briefly explain all procedures to them.
The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures.
A pastor or counseling service can offer some support, but research supports information as being more effective.
Asking the family to stay in the waiting room will increase their anxiety.
After 7 days of IV antibiotic therapy, a patient with acute osteomyelitis of the tibia is preparing for DC from the hospital. The nurse determines that additional instruction is needed when the patient makes which statement?
a. I will need to continue antibiotic therapy for 4-6 weeks.
b. I should notify the provider if the pain in my leg becomes worse.
c. I shouldn't bear any weight on my affected leg until healing is complete.
d. I do not need to do anything special while taking antibiotic therapy.
d. I do not need to do anything special while taking antibiotic therapy.
Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Although Staphylococcus aureus is the most common cause of infection, a variety of pathogens can cause osteomyelitis.
Monitoring for side effects and complications of antibiotic therapy must be done.
Activities such as exercises that increase circulation and serve as stimuli for the spread of infection should be avoided by patients with osteomyelitis.
Oral or IV antibiotic tx should be continued for 4-6 weeks; may be needed up to 6 months.
The provider should be notified if pain becomes worse.
Weight bearing is contraindicated to prevent pathological fractures.