GB exam 1 / M exam 2
An older woman is admitted to the medical unit with GI bleeding. Assessment findings that indicate fluid volume deficit include... (select all that apply)
a. weight loss
b. dry oral mucosa
c. full bounding pulse
d. engorged neck veins
e. decreased central venous pressure
a. weight loss
b. dry oral mucosa
e. decreased central venous pressure
choice c & d are associated with fluid volume excess
(table 16.3 or table 17.3)
Nursing diagnoses for the patient with anemia include (name 1/3):
Fatigue
Impaired nutritional intake
Ineffective tissue perfusion
92 yo female admitted to the ED with severe shortness of breath. Being aware of the patient's condition, what approach should the nurse use to assess the patient's lungs? (select all that apply)
a. apex to base
b. base to apex
c. lateral sequence
d. anterior then posterior
e. posterior then anterior
b. base to apex
e. posterior then anterior
Auscultate posteriorly first to avoid breast tissue and start at bases because of her respiratory difficulty and the chance that she may tire easily.
Important sounds may be missed if the other strategies are used first.
A pt on the cardiac tele unit goes into vfib and is unresponsive. Following initiation of the emergency call system (Code Blue), what is the next priority for the nurse in caring for this pt?
a. Get the crash cart
b. Begin CPR
c. Administer Amiodarone IV
d. Defibrillate with 360 joules
b. Begin CPR
Until the defibrillator is available, the pt needs high quality CPR.
Defibrillation is needed as soon as possible, so someone (other than the pt nurse) should bring the crash cart to the room.
Amiodarone is an antidysrhythmic med that is part of the ACLS protocol for vfib arrest.
Defibrillation would be with 360 joules for monophasic defibrillators and 120 - 200 joules for biphasic defibrillators.
The nurse reviews the following vital signs recorded by the unlicensed assistive personnel: HR 102 bpm, RR 24, T 98.2 F (36.7 C), SpO2 84% on 2 Lpm via nasal cannula
a. Which of these findings is of HIGHEST priority?
b. What should the nurse do next?
a. SpO2 84% on 2 Lpm via nasal cannula indicates impaired oxygen saturation. ABC priority
b. ASSESS the pt: assess mental status/LOC and talk about their breathing status with the pt; reposition the pt into high fowlers; recheck SpO2; auscultate lung sounds; check the oxygen connection and rate setting and adjust per prn order
A patient has the following arterial blood gas results: pH: 7.52, PaCO2: 30 mmHg, HCO3: 24 mEq/L. The nurse determines that these results indicate
a. metabolic acidosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. respiratory alkalosis.
d. respiratory alkalosis (uncompensated)
compensated: pH is b/w 7.35 - 7.45
partially compensated: pH, CO2, & HCO3 are all out of range
uncompensated: pH & one other value is out of range, one value is within normal limits
A pt is receiving a continuous infusion of morphine via an epidural catheter after major abdominal surgery. What actions should the nurse include in the plan of care? (select all that apply)
a. Label the catheter as an epidural access
b. Assess the pts pain relief frequently
c. Use sterile technique when caring for the catheter
d. Monitor the pts level of consciousness
e. Monitor pt vital signs
f. Assess the motor and sensory function of the pts lower extremities
a. Label the catheter as an epidural access
b. Assess the pts pain relief frequently
c. Use sterile technique when caring for the catheter
d. Monitor the pts level of consciousness
e. Monitor pt vital signs
f. Assess the motor and sensory function of the pts lower extremities
The major complication of epidural analgesia are catheter displacement and migration accidental infusions of neurotoxic agents, and infection. These actions will help reduce those risks.
MD order: IV regular insulin gtt = 5 units/hr
Pharmacy delivers IV regular insulin bag= 150 units in 500 ml 0.9% NS
Calculate infusion rate in ml/hr (round to the nearest whole number)
x ml/hr= 500 ml / 150 units x 5 units / 1 hr
x= 2500 / 150
x= 16.67 or 17 ml/hr
The nurse is encouraging a sedentary patient with major risk factors for CAD to perform physical exercise on a regular basis. In addition to decreasing the risk factor of physical inactivity, the nurse tells the patient that exercise will directly contribute to reducing which risk factors?
a. DM and hypertension
b. Hyperlipidemia and obesity
c. Increased serum lipids and stressful lifestyle
d. Hypertension and increased serum homocysteine
b. Hyperlipidemia and obesity
Increased exercise withOUT an increase in caloric intake will result in weight loss, reducing the risk associated with obesity.
Exercise increases lipid metabolism and increases HDL, thus reducing CAD risk.
Exercise may indirectly reduce the risk of CAD by controlling htn, promoting glucose metabolism in DM, and reducing stress.
While high blood levels of homocysteine are linked to an increased risk for CAD, reducing these levels has NOT been shown to reduce the risk of heart disease.
Delegation is a process used by the RN to provide safe and effective care in an efficient manner. Which nursing interventions should NOT be delegated to unlicensed assistive personnel but should be performed by the RN? (select all that apply)
a. Administering pt medications
b. Ambulating stable pts
c. Performing pt assessment
d. Evaluating the effectiveness of pt care
e. Feeding pts at mealtimes
f. Performing sterile procedures
g. Providing pt teaching
h. Obtaining vital signs on a stable pt
i. Helping with pt bathing
a. Administering pt medications
c. Performing pt assessment
d. Evaluating the effectiveness of pt care
f. Performing sterile procedures
g. Providing pt teaching
The RN must EAT-UM (Evaluate Assess Teach Unstable pt IVP Med). These actions or interventions require critical thinking & clinical judgment/decision making: therefore they should be performed by a RN.
The nurse expects the long-term treatment of a patient with hyperphosphatemia from renal failure will include
a. fluid restriction.
b. calcium supplements.
c. magnesium supplements.
d. increased intake of dairy products.
b. calcium supplements.
Ca & Phos have an inverse relationship.
Activated vitamin D is necessary to optimize absorption of calcium from the GI tract. As kidney function deteriorates, less vitamin D is converted to its active form, resulting in decreased serum levels. Low levels of active vitamin D result in decreased serum calcium levels.
A pt with chronic CA related pain has started using MS Contin for pain control and has developed common side effects of the drug. The nurse reassures the pt that tolerance will develop to most of these side effects but that continued tx will most likely be required for what?
a. pruritus
b. dizziness
c. constipation
d. nausea/vomiting
c. constipation
Tolerance to many of the side effects listed develops within days, however, there is no tolerance that develops to opioid induced constipation.
A bowel regimen that includes a gentle stimulant laxative and a stool softener should be started at the beginning of opioid therapy and should be continued for as long as the drug is taken.
Indicate whether the following manifestations are most characteristic of asthma (A), COPD (C), or both (B).
a. wheezing on expiration
b. wt loss
c. barrel chest
d. polycythemia
e. cor pulmonale
f. flattened diaphragm
g. decreased breath sounds
h. cough, particularly at night or early in the morning
a. asthma
b. COPD
c. COPD
d. COPD
e. COPD
f. COPD
g. Both
h. Asthma
Which characteristics describe Unstable Angina (USA)? (select all that apply)
a. usually precipitated by exertion
b. new onset angina with minimal exertion
c. only occurs when the person is recumbent
d. characterized by increased duration or severity
e. usually occurs in response to coronary artery spasm
b. new onset angina with minimal exertion
d. characterized by increased duration or severity
USA is new onset angina occurring at rest or with minimal exertion and increases in frequency, duration, or severity.
Chronic stable angina is usually precipitated by exertion.
Angina decubitus occurs when the person is recumbent.
Prinzmetal's angina is often caused by a coronary artery spasm.
After defibrillation, the advanced cardiac life support (ACLS) nurse says the pt has pulseless electrical activity (PEA). What is most important for the nurse to understand about this rhythm?
a. The HR is 40-60 bpm
b. Hypoxemia and hypervolemia are common with PEA
c. There is dissociated activity of the ventricle and atrium
d. There is electrical activity with no mechanical response.
d. There is electrical activity with no mechanical response.
PEA occurs when there is electrical activity on the ECG but no mechanical activity on assessment and therefore no pulse.
PEA is the most common dysrhythmia seen after defibrillation and may be caused by hypovolemia, hypoxia, metabolic acidosis, altered potassium level, hypoglycemia, hypothermia, toxins, cardiac tamponade, thrombosis, tension pneumothorax, and trauma.
Dissociated atria and ventricles is a 3rd degree heart block.
The nurse is admitting a pt to the clinical unit from surgery. Being alert to potential fluid volume alterations, what assessment data will be important for the nurse to monitor to identify changes in the pts post op fluid volume? (select all that apply)
a. Intake & Output
b. Skin turgor
c. Lung sounds
d. Respiratory rate
e. Level of consciousness
a. Intake & Output
b. Skin turgor
c. Lung sounds
d. Respiratory rate
e. Level of consciousness
All of the above are important in assessing fluid balance in a post op pt. Daily weights along with these assessments will provide data about potential fluid volume abnormalities.
Nursing diagnoses for the patient with DIC may include the following (name 2/4):
Risk for bleeding
Ineffective tissue perfusion
Acute pain
Impaired cardiac output
Disseminated intravascular coagulation (DIC) is a serious bleeding and thrombotic disorder that results from abnormally initiated and accelerated clotting. Subsequent decreases in clotting factors and platelets ensue, which may lead to uncontrollable hemorrhage.
The term DIC can be misleading because it suggests that blood is only clotting. However, there is profuse bleeding that results from the aggregation of platelets and clotting factors.
DIC is always caused by an underlying disease or condition. That underlying problem must be treated for the DIC to resolve.
What assessment findings occur with diabetic ketoacidosis (DKA)? (Select all that apply)
a. Thirst
b. Ketonuria
c. Dehydration
d. Metabolic acidosis
e. Kussmaul respirations
f. Sweet, fruity breath odor
a. Thirst
b. Ketonuria
c. Dehydration
d. Metabolic acidosis
e. Kussmaul respirations
f. Sweet, fruity breath odor
In DKA, thirst occurs to replace fluid used to eliminate ketones in the urine in trying to decrease the blood glucose and ketonemia.
The metabolic acidosis leads to the Kussmaul respirations trying to decrease the acid in the system.
The sweet, fruity breath odor is from acetone.
Thirst and dehydration are found with both DKA and hyperosmolar hyperglycemic syndrome (HHS).
Which statements accurately describe heart failure (HF)? (select all that apply)
a. A common cause of HF with preserved ejection fraction (HFpEF) is left ventricular dysfunction.
b. A primary risk factor for HF is coronary artery disease (CAD).
c. Systolic failure results in a normal left ventricular ejection fraction.
d. HF with reduced ejection fraction (HFrEF) is characterized by abnormal resistance to ventricular filling.
e. Hypervolemia precipitates HF by decreasing cardiac output and increasing oxygen consumption.
a. A common cause of HF with preserved ejection fraction (HFpEF) is left ventricular dysfunction.
b. A primary risk factor for HF is coronary artery disease (CAD).
Heart failure with preserved ejection fraction (HFpEF) (diastolic failure) is characterized by abnormal resistance to ventricular filling.
Hypertension, coronary artery disease (CAD), advanced age, and diabetes are all risk factors for heart failure (HF).
Ejection Fraction (EF- the percentage of end-diastolic blood volume that is ejected during systole) is decreased in systolic HF.
Decreased Cardiac Output (CO= HR x SV) and increased workload and oxygen requirements of the myocardium precipitate HF because of left ventricle dysfunction.
Name 2 possible complications of sickle cell anemia.
Pain
Infection
Acute chest syndrome is a term used to describe acute pulmonary complications that include pneumonia, tissue infarction, and fat embolism
End organ damage from lack of oxygen delivery
(fig. 30.4 or fig. 34.4)
The nursing care for a patient with hyponatremia and fluid volume excess includes
a. placement of an indwelling urinary catheter.
b. administration of hypotonic IV fluids.
c. administration of a cation-exchange resin.
d. fluid restriction.
d. fluid restriction.
In mild hyponatremia caused by water excess, fluid restriction may be the only treatment.
We manage hyponatremia from fluid loss by replacing fluid using isotonic sodium-containing solutions, encouraging oral intake, and withholding all diuretics.
Avoid rapid correction or overcorrection of Na. The level should not increase by more than 10 to 12 mEq/L per hour in the first 24 hours and 18 mEq/L or less per hour within 48 hours. Quickly increasing sodium levels can cause osmotic demyelination syndrome with permanent damage to nerve cells in the brain.
An accurate urine output record is essential. The patient may need a urinary catheter placed if unable to help with monitoring output.
If the patient has an altered consciousness or is having seizures, initiate seizure precautions.
Cation exchange resins are used in medicine to remove an excess of a particular positively charged ion that has accumulated in the body. When the resin is administered to the patient the positively charged ions binds to the resin in an exchange for another positive ion. (from Drugs.com)
A 60-year-old male farmer is diagnosed with multiple myeloma. He has pain in his ribs with movement and his diagnostic studies show hypercalcemia. What nursing interventions would be included in the plan of care? (select all that apply)
a. Provide privacy
b. Complete bed rest
c. Adequate hydration
d. Prepare for dialysis
e. Assess for infection
f. Encourage ambulation
c. Adequate hydration
e. Assess for infection
f. Encourage ambulation
Multiple Myeloma is a condition in which cancerous plasma cells proliferate in the bone marrow and destroy bone.
Because he has hypercalcemia, adequate hydration and ambulation, not bed rest, are implemented to dilute calcium and prevent protein precipitates from causing renal tubular obstruction and help bones resorb some calcium with weight bearing.
Assessing for infection must be done because the excess plasma cells are monoclonal and ineffective against infection.
Privacy would be provided for all patients.
Although this patient may need dialysis in the late states of multiple myeloma, it is not needed at this time.
Analgesia for rib pain will be provided as prescribed by the HCP
Other clinical manifestations of hypercalcemia:
Lethargy, weakness, fatigue
Decreased memory
Depressed reflexes
↑ BP
Confusion, psychosis
Anorexia, nausea, vomiting
Bone pain, fractures
Polyuria, dehydration
Nephrolithiasis
Seizures, coma
The pt has had COPD for years, and his ABGs usually show hypoxia (PaO2<60 or SaO2<88%) and hypercapnia (PaCO2>45). Which ABG result shows movement toward respiratory acidosis and further hypoxia indicating respiratory failure?
a. pH 7.35, PaO2 62, PaCO2 45
b. pH 7.34, PaO2 45, PaCO2 65
c. pH 7.42, PaO2 90, PaCO2 43
d. pH 7.46, PaO2 92, PaCO2 32
b. pH 7.34, PaO2 45, PaCO2 65
These results show worsening respiratory function and failure with the pH at 7.34, the lower PaO2, and the higher PCO2.
The pH of 7.35 and 7.42 show potential normal results for the pt described.
The pH 7.46 shows alkalosis, respiratory with the low PaCO2, but the HCO3 results are needed to be sure.
Myocardial ischemia occurs because of increased oxygen demand & decreased oxygen supply. What factors and disorders result in increased oxygen demand? (select all that apply)
a. hypovolemia or anemia
b. increased cardiac workload with aortic valve stenosis
c. narrowed coronary arteries from atherosclerosis
d. angina in the patient with atherosclerotic coronary arteries
e. LEFT ventricular hypertrophy caused by chronic hypertension
f. SNS stimulation by drugs, emotions, or exertion
b. increased cardiac workload with aortic valve stenosis
d. angina in the patient with atherosclerotic coronary arteries
e. LEFT ventricular hypertrophy caused by chronic hypertension
f. SNS stimulation by drugs, emotions, or exertion
There is an increased oxygen demand in b, d, e, f.
Hypovolemia, anemia, and narrowed coronary arteries contribute to decreased oxygen supply.
Order: 50,000 units of heparin in 1 L D5 0.9%NS to infuse at 40 ml/hr
Calculate the hourly dosage of heparin (units/hr).
X units/hr = 50,000 units/1L x 40 ml/1 hr x 1 L/1000 ml
X units/hr = 2,000,000/1,000
X units/hr = 2,000 units/hr