Acid Base
Professor LaPointe may hyperventilate if you tell her you have not yet begun to study for your final exam. As an excellent nursing student, you realize that hyperventilation can cause this type of acid base imbalance.
What is respiratory alkalosis?
Hyperventilation causes respiratory alkalosis, an acid-base imbalance that occurs when you breathe out too much carbon dioxide.
The nurse would be most concerned that a pt with a thrombophlebitis has now developed a PE if the pt complains of these two symptoms
___________ and _____________
A pt is newly prescribed 1L continuous oxygen at home, and the nurse is educated the pt and family why they cannot smoke while there is oxygen in the home which includes which of the following:
a. oxygen is an explosive
b. oxygen is combustible
c. oxygen supports combustion
What is
C. oxygen SUPPORTS combustion
The nurse should avoid this route of administration of medication to a pt with hemophilia.
What is injections (both SQ and IM) d/t their high risk of bleeding?
A nurse is interpreting a patients EKG and there their heart rate is 92 bpm, are no identifiable p waves present, their rhythm is irregular, and a QRS duration as 0.10 seconds. The nurse interprets the client's rhythm as what:
__________ _____________
What is atrial fibrillation?
atrial fibrillation is irregular, no p waves present
aflutter is regular, no p waves present
Which of the following is an ABG result that indicates hypoxemia.
a. PaO2 58mm Hg
b. PaO2 70mm Hg
c. PaO2 65mm Hg
What is A. PaO2 58mm Hg
hypoxemia is defined as a PcO2 of <60mm Hg
True or False
If a pt has PVD (peripheral vascular disease) the nurse should educate the patient to avoid wearing constrictive clothing such as socks with elastic tops.
What is true?
constrictive clothing can impaired circulation and a pt with PVD already has impaired circulation so this will worsen their condition.
If a pt is immobile this can lead to what respiratory complication.
What is stasis pneumonia?
stasis pneumonia is a lung infection that results from fluid pooling in the lungs due to poor circulation, especially in people who are bedridden for long periods
IN DIC (disseminated intravascular coagulation) the nurse would expect the patients PT lab value to be within the normal range or above the expected range?
What is above the expected range?
"PT" refers to the Prothrombin Time lab test, which is a measurement of how long it takes for blood to clot. A prolonged PT is a common laboratory finding in DIC because the condition consumes clotting factors
Your pt states they take warfarin on a daily basis for their afib as prescribed by their cardiologist, and upon lab findings their pt/inr is critically supratherapeutic. You anticipate administering this reversal agent for warfarin.
What is Vitamin K?
The ABG values of pH 7.21, PaCO2 64mm Hg, HCO3 of 24mm Hg reflects what acid base imbalance.
What is respiratory acidosis?
When caring for a pt with a hx of rheumatic carditis. Which nursing intervention is considered a priority consideration
a. frequent vital signs
b use of sterile or clean technique for any invasive procedure (whichever is applicable)
c. encourage 1500ml of fluid daily
What is B, use of sterile and/or clean technique for invasive procedures?
Rheumatic carditis is inflammation of the heart caused by rheumatic fever and preventing infection is a priority nursing consideration.
You are working as an infection prevention nurse and notice an increase of HAP (hospital acquired pneumonia). You educate the staff that administering this to vulnerable individuals is an important measure for the PREVENTION of HAP.
What is the pneumococcal vaccine?
The nurse is caring for a client with DIC (disseminated intravascular coagulation) and would anticipate which 3 of the following findings
excessive thrombosis
increased clotting factors
excessive bleeding
decreased clotting factors
What is:
excessive thrombosis
excessive bleeding
decreased clotting factors (this is do to excessive clot formation)
Oh no, you are an L&D nurse the and the unit is alerted of a delivery in room 2 with noted shoulder dystocia. What members of the interdisciplinary team will you need to care for this newborn: (choose 3)
social worker, anesthesia, surgeon, rapid response team, pediatrician
What is anesthesia, surgeon, and pediatrician?
You will not need a social worker or rapid response team (who on the rapid response team would be helpful if you already have the surgeon, anesthesiologist and pediatrician at the bedside).
The pediatrician is for immediate infant resuscitation if needed, the anesthesiologist is to manage the mother's pain or to provide anesthesia for an emergency C-section if initial maneuvers fail, and a surgeon (or experienced obstetrician) is to perform the maneuvers required to free the baby and manage any maternal injuries
The nurse may be concerned the patient is at risk for this type of acid base imbalance if they have had an NG tube on suction for 3 days and their lab value shows they are hypokalemic.
What is metabolic alkalosis?
The nurse suspects this health problem if an otherwise healthy pt presents with c/o sharp, mid-chest pain (worse with movement) and all diagnostics reveal pt is negative for an MI.
What is pericarditis.
negative MI testing would r/o angina and unstable angina.
dilated cardiomyopathy is gradual and involves fatigue and not pain
remember the P's are painful!
The pulmonologist has performed a thoracentesis on your patient and reports the fluid as serous. this could indicate what
a. trauma
b. infection
c. inflammation
What is C, inflammation?
serous fluid (which is clear) may be associated with inflammation, cancer or heart failure
bloody (or sanguineous)fluid is suggestive of trauma
purulent fluid is indicative of infection
What is platelets?
When tissue is injured, first the platelets break down and cause the release of a chemical thromboplastin which then interacts with protein factors and calcium ions to form prothrombin activator. This is the first step when the formation of a blood clot forms.
The nurse knows this body system is most vulnerable to infection during the postpartum period
a. urinary
b. respiratory
c. gastrointestinal
b. breasts
What is A urinary system?
it must handle an increased workload in the early postpartum period which can result in urinary stasis and lead to urinary tract infections.
breasts are not a body system (they are part of the reproductive system)
Your kidneys excrete this to try to maintain a normal pH when a patient is in respiratory alkalosis.
What is bicarb (HCO3) to lower the pH?
This valvular disorder can contribute to RIGHT VENTRICULAR failure
_________ _____________ _____________
What is mitral valve stenosis?
the increased pressure in the left side of the heart is transmitted backward into the lungs, causing pulmonary hypertension. The right ventricle, which pumps blood to the lungs, must then work much harder against this high pressure eventually becoming strained, weakened, and failing.
The nurse explains to the pt who has been ordered to have a diagnostic Mantoux test how the test will be administered as this route.
What is intradermal injection on the lower forearm?
a Mantoux (PPD) test is administered by intradermal injection in the inner aspect of the lower forearm.
The lymphatic system (which consists of the thymus gland, spleen, and a network of lymphatic vessels, lymph nodes, and lymph) circulates how:
a. intravascular fluid and carries it to the arteries
b. interstitial fluid and carries it to the veins
c. extracellular fluid and carries it to the arteries
What is B?
interstitial fluid and carries it to the veins
A pt arrives to the ED via ems with a massive hemorrhage as a result of multiple gun shot wounds. There is no time to wait for a blood type and cross match from the lab. The nurse anticipates administering this blood type (include + or -) with type.
What is O, Rh negative?
this is the universal as you cannot transfuse Rh+ blood to anyone who is Rh- and O is the universal donor.