Fundamentals
Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain?
1) Assess the patient's incision.
2) Clarify the order with the prescriber.
3) Assess the patient's respiratory status.
4) Monitor the patient's heart rate
3) Assess the patient's respiratory status.
Rationale:
Before administering an opioid analgesic, such as morphine, the nurse should assess the patient's respiratory status because opioid analgesics can cause respiratory depression.
Signs and Symptoms of Hyponatremia
Anorexia, nausea, vomiting, weakness, lethargy, confusion, muscle cramping or twitching, seizures
Normal blood pH?
Normal C02?
Normal HC03?
7.35-7.45
35-45
22-28
Weak thready pulse, poor skin turgor, dry cracked lips and tounge, increased pulse rate, thirst are s/s of
Dehydration
(clinical dehydration is associated with fluid deficit AND hypernatremia)
Disorder which involves lability in mood from depression to hypo-mania or mania.
What is bipolar disorder
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis?
1) Ibuprofen (Motrin)
2) Celecoxib (Celebrex)
3) Aspirin (Ecotrin)
4) Indomethacin (Indocin)
3) Aspirin (Ecotrin)
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation.
A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following?
1. hyperkalemia
2. hypokalemia
3. hypercalcemia
4. hypocalcemia
Answer: 1
Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes.
pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L.
Respiratory alkalosis
What interventions would you implement for a patient with deficient fluid volume?
Monitor daily weight (most accurate way to evaluate fluid balance)
Monitor I & O
Increase fluid intake (PO and IV if severe)
Treat underlying cause
Motor inner driven restless (tapping foot incessantly, rocking in chair)
What is akathisia?
The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the:
1) Pulse deficit
2) Blood pressure
3) Apical pulse
4) Pulse pressure
2) Blood pressure
Rationale:
If the leg pulses are weak, the nurse should assess the blood pressure in order to further explore the reason for the low pulse volume. If the blood pressure is low, then a low pulse volume would be expected.
A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented?
1. seizure
2. infection
3. neutropenic
4. high-risk fall
Answer: 1
Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment raised side rails, & having an oral airway at the bedside would be included.
Remember: any type of sodium imbalance will effect the brain :) Think AMS, confusion, and in severe cases seizures
A student is nervous for a big exam and is breathing rapidly. What do you expect to see in this patients acid-base balance?
A) Metabolic Acidosis
B) Respiratory Alkalosis
C) Metabolic Alkalosis
D) Respiratory Acidosis
Respiratory Alkalosis
Your body releases carbon dioxide when you exhale. When you breathe faster, the lower carbon dioxide level in your blood can lead to respiratory alkalosis. Respiratory alkalosis is usually caused by over-breathing (called hyperventilation) that occurs when you breathe very deeply or rapidly.
A postoperative pt is diagnosed with fluid volume overload. Which of the following should the nurse assess in this pt?
1. poor skin turgor
2. decreased urine output
3. distended neck veins
4. concentrated hemoglobin & hematocrit levels
3: distended neck veins
Circulatory overload causes manifestations such as a full, bounding pulse; distended neck & peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema
A client is taking Isocarboxazid (Marplan) . The visiting nurse is monitoring for client safety. What should the nurse reinforce as a priority regarding client teaching?
1. Limiting daily intake of salt
2. Encourage a fluid intake of at least 2000 mL
3. Encourage the client to have a scheduled blood test time
4. Eliminating foods containing tyramine
4. Eliminating foods containing tyramine
With an MAOI, such as phenelzine, the client must eliminate foods that contain tyramine. Intake of tyramine-containing foods could lead to severe hypertension and other complications.\
Another common: Phenelzine (Nardil):
Which factor(s) in the patient's past medical history place(s) him at risk for falling? Select all that apply.
1) Orthostatic hypotension
2) Appendectomy
3) Dizziness
4) Hyperthyroidism
Answer:
1) Orthostatic hypotension
3) Dizziness
Rationale:
Orthostatic hypotension, cognitive impairment, difficulty with walking or balance, weakness, dizziness, and drowsiness from certain medications place the patient at risk for falling.
The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?
A. Client behavior that changes from anxious to lethargic
B. Deep furrows on the surface of the tongue
C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched
D. Urine output of 950 mL for the past 24 hours
A. Client behavior that changes from anxious to lethargic
This change in mental status suggests poor cerebral blood flow and fluid shifts within the brain cells. Immediate intervention is needed to prevent further cerebral dysfunction. Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.
pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, and HCO3 12 mmol/
Metabolic Acidosis, Partially, Compensated
The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority?
A. Monitoring urine output
B. Encouraging sodium rich fluids and foods throughout the day
C. Instructing the client not to ambulate without assistance
D. Assessing deep tendon reflexes
Safety is the priority in this instance. Instructing the client not to ambulate without assistance is the priority for a client with a sodium level of 118 mEq/L (118 mmol/L). This sodium level denotes severe hyponatremia which makes depolarization slower and cell membranes less excitable. This is manifested as general muscle weakness which is worse in the legs and arms. Additionally, this client may have developed confusion from cerebral edema.
A client admits to drinking heavily for many years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. The nurse realizes that these symptoms probably result from:
A. Acetate accumulation
B. Thiamine deficiency
C. Triglyceride buildup
D. A below-normal serum potassium level
B. Thiamine deficiency
Rationale: Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of Vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake
Which action demonstrates a break in sterile technique?
1) Remaining 1 foot away from nonsterile areas
2) Placing sterile items on the sterile field
3) Avoiding the border of the sterile drape
4) Reaching 1 foot over the sterile field
4) Reaching 1 foot over the sterile field
Rationale:
Reaching over the sterile field while wearing sterile garb breaks sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from nonsterile areas while wearing sterile garb, place sterile items needed for the procedure on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape.
The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription?
A. Insulin
B. atropine
C. Sodium polystyrene sulfonate (Kayexalate)
D. potassium phosphate
The rapid response nurse expects to administer a combination of 20 units of regular insulin in 100 mL of 20% dextrose in water. This may be prescribed to promote movement of potassium from the blood into the intracellular fluid.While atropine will treat bradycardia, it does not address the underlying cause of bradycardia which is likely hyperkalemia.
pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg.
Respiratory Acidosis, Partially Compensated
The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make?
A. Heart rate and rhythm
B. Blood pressure (BP)
C. Increases in edema
D. Sodium level
The nurse must assess the heart rate for bradycardia related to digoxin and irritability or irregularity related to hypokalemia. Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range
The risk of experiencing serotonin syndrome when SSRI's are given with monoamine oxidase inhibitors such as phenelzine (Nardil). Serotonin syndrome is best characterized in which of the following?
-Hypotension and urinary retention.
-Muscle rigidity and high fever.
-A productive cough and vomiting.
-Tea-colored urine and constipation.
-Muscle rigidity and high fever.