Ch. 35
Positive Trousseau and Chvostek signs commonly indicate which electrolyte imbalance and what is that the normal range of that electrolyte.
Hypocalcemia and 8.5-10.5.
Calculate the calories per gram for the following: Protein 15g, Carb 7g, Fat 5g
Protein 60 calories, Carb. 28 calories, Fat 45 calories
A normal healthy stoma should look?
Moist, red or pink.
A patient who has a skin injury should be encourage to maintain/increase intake of?
Proteins
During a wound assessment you note formation of granulation tissue, that easily bleeds when performing wound care. What phase of wound healing would this be considered?
Proliferative phase
A patient receives an ABG and the following values are documented PH: 7.28 PCo2: 49 HCO3: 24, the nurse would interpret these values and say the patient is in a state of?
Respiratory Acidosis
What lab values would we assess to evaluate nutritional status?
Prealbumin
Ways to promote regular defecation would include?
Privacy, seated upright, timing (after meals, may need assistance), fluid intake, proper diet, exercise.
A urine specimen is obtained by a client cleaning the exterior meatus, then beginning to void, then collecting the urine sample midstream. Which type of specimen does this describe?
Clean-catch specimen
When performing a skin assessment you note full thickness skin loss extending down to fascia, what level pressure injury would this be considered?
Stage III
The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called?
Diffusion
Name food sources for vitamin B6
Meats, beans, nuts, seeds, dairy products
What is the difference between colostomy irrigation and lleostomy irrigation?
lleostomies should never be irrigated by a nurse and have liquid stool. Colostomy has formed stool that may need to be irrigated.
A specific gravity of 1.040 would indicate?
Patient has massive fluid loss, from diarrhea, vomiting, dehydration.
Normal Specific Gravity 1.002 to 1.030.
A patient after surgery falls and has a total separation at the incision site with viscera protruding out, what is the term used for this complication?
Evisceration
What are some s/s of a patient experiencing hyponatremia?
Lethargy, confusion, muscle cramp ->seizure weakness
Name food sources for calcium
Dairy products, sardines, green leafy vegetables, fortified products
What is your main priority when caring for a patient with a new colostomy?
Have patient care for colostomy
What is one of the most important steps when emptying a JP Drain
Re-compressing drain and closing it to reestablish suction and prevent contamination.
You receive report that an older adult patient who is mobility impaired has been in a supine position all day. You would assess which areas for pressure injuries?
Back of head (Occipital bone), Scapulae, Elbow (Olecranon process), Sacrum, Heels (Calcaneus)
What are some causes of hypokalemia and s/s?
Causes: Diuretics, GI fluid loss through vomiting, gastric suction, or diarrhea, Steroid administration, Hyperaldosteronism, Anorexia or bulimia
s/s: Fatigue, Anorexia, nausea, and vomiting, Muscle weakness, Decreased GI motility, Dysrhythmias, Paresthesia, Flat T wave on ECG, Increased sensitivity to digitalis
What are complications of parenteral nutrition?
Infection or septic shock, Blood clots, liver dysfunction, gallbladder disease
When performing a fecal occult blood test which medications may cause a false negative?
Vitamin C
What is Transient incontinence and common causes?
Short term loss or lack of voluntary control of urination expected to resolve spontaneously. May be caused by UTI or medications such as diuretics.
Your patient has a chronic wound around the inner ankle with reddend/brown surround skin, irregular margins, shallow, and pain with leg dependence. What type of wound would this be considered?
Venous stasis ulcer