Green
Normal values for pH, PaCO2, Pao2, HCO3, & Sp02?
pH: 7.35-7.45
PaCO2: 35-45
HCO3: 22-26
Sp02: 95-100
Signs and symptoms of opioid use disorder
Psychomotor retardation
drowsiness
slurred speech
altered mood and mental status
impaired memory and attention
pinpoint pupils
decreased bowel sounds
decreased R.R and HR
hypotension
may have visible track marks
What medications would you expect a patient with heart failure to be taking?
ACE Inhibitors, ARBs, Beta blockers, Digoxin, diuretics
Signs and symptoms of right sided heart failure? (at least 4)
Systemic congestion, JVD, anorexia/nausea, distended abdomen, weight gain, peripheral edema
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings would alert the nurse to the potential for alcohol withdrawal delirium?
A. Hypotension, ataxia, hunger
B. Stupor, lethargy, muscular rigidity
C. Hypotension, coarse hand tremors, lethargy
D. Hypertension, changes in LOC, hallucinations
What causes substance use disorder?
genes
other mental health conditions
developmental factors
environmental influences
What area of the body does left sided heart failure effect and which area of the body does right sided heart failure effect?
Right: REST OF BODY
Signs and symptoms of left sided heart failure? (At least 4)
Restlessness, confusion, tachycardia, fatigue, exertional dyspnea, cyanosis, cough, crackles, blood tinted sputum, tachypnea, decreased O2 levels, SOB, oliguria during day, weak pulses, angina, cool extremities
What are the complications of alcohol withdrawal?
Alcohol related liver disease
-cirrhosis and scarring of liver can lead to liver disease and failure
Alcoholic cardiomyopathy
- heart failure caused by drooping and stretching of heart muscle
Alcoholic neuropathy
- nerve damage
Wernicke-Korsakoff syndrome
- vitamin B1 deficiency leading to permanent damage in certain areas of brain, especially hypothalamus and thalamus
Other health related issues: stroke, cancer, mental health issues, digestive problems, weakening of immune system
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the PCP and prepares to implement which priority interventions? Select all that apply.
A. Administer oxygen
B. Insert foley catheter
C. Administer furosemide
D. Administer morphine sulfate IV
E. Transport client to coronary care unit
F. Place client in a low-Fowler's side-lying postion
What populations are most at risk for iron-deficiency anemia?
infants
children up to 3
woman
older adults
people with poor diets
family history
What is Sickle Cell Anemia?
Autosomal recessive disorder in which RBCs become elongated in size. RBCs are more rigid, fragile, and are rapidly destroyed.
Apply oxygen, administer pain meds, normal saline IV, remove constrictive clothing, keep extremities extended, elevate HOB no more than 30 degrees, do NOT raise knee position of bed, keep room temp at 72 degrees or above, check circulation in extremities every hour, avoid taking BP with automatic or standard cuff
What are the risk factors for older adult abuse?
Poor mental health or physical health
Older person's dependency level predisposes them to abuse
Caregiver fatigue and burnout
Parents who abuse their children are more likely to end up as targets of abuse by their children
The nurse is caring for a client with an NG tube attached to low suction. The nurse monitors the client for which manifestations of which disorder that the client is at risk for?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
What is arteriovenous malformation?
Abnormality in a group of blood vessels that occurs during embryonic development
What are the signs and symptoms of a stroke?
Loss of balance, uneven face, slurred speech, headache, dizziness, sudden loss of vision (one or both eyes), arm weakness
Genetics
DM
Smoking
Obesity
HTN
Substance use
Elevated cholesterol
Oral contraceptives
Explain how you, as a nurse, would deescalate a situation in which a patient has become angry and aggressive.
remove them from area if other people are present
remove items that could be used as weapons
use therapeutic communication skills
be aware of YOUR personal space and safety
The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully?
A. Gets angry with family if they interrupt a task
B. Experiences bouts of depression and irritability
C. Has difficulty using modified feeding utensils
D. Consistently uses adaptive equipment in dressing self
What the signs and symptoms of pulmonary edema?
cough with pink, frothy sputum, crackles in bases of lungs, disorientation, orthopenia
Explain systolic heart failure and diastolic heart failure.
Systolic heart failure: heart cannot contract forcefully enough
Diastolic heart failure: Left ventricle cannot relax adequately enough during diastole
Name the types of strokes and explain them
Ischemic: Caused by occlusion of a cerebral or carotid artery by thrombus or embolus.
Hemorrhagic: Bleeding in brain tissue or in subarachnoid space, HTN, aneurysm, or ateriovenous malformation
Transient Ischemic Attack (TIA): Temporary blockage from a brief interruption of cerebral perfusion.
1st Line- buffers
2nd Line- lungs
3rd Line- kidneys
The nurse reviews blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which results validates the nurse's findings?
A. pH: 7.35 PaCO2: 50
B. pH: 7.35 PaCO2: 40
C. pH: 7.50 PaCO2: 52
D. pH: 7.52 PaCO2: 28