ABGS
The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 32 mm Hg (32 mm Hg). What condition is the patient experiencing?
What is Respiratory alkalosis
recurring episodes of dyspnea, constriction of the bronchi, high-pitched musical sounds, use other chest muscles, retractions at the sternum and ribs.
What is s/s of Asthma
jaw/arm pain, SOB, indigestion, N, dizziness, and sweats, relieved with rest, ischemia
What is Angina
A form of acquired immunity in which the body produces its own antibodies against disease-causing antigens.
What is Active immunity
cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.
What is findings associated with fluid volume excess
Lethargic, shortness of breath
Weird food cravings (ice, dirt, clay),
Pallor
Increased Heart rate
Reduced Hemoglobin level
What is iron deficiency anemia
Wear gloves and gown while in the room caring for the client.
Use soap and water, not alcohol-based hand rub, for hand hygiene.
What is interventions for patients with C diff
A prominent U wave on the EKG indicates
What is Hypokalemia
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid–base disorder that is most likely to occur in this situation?
What is Metabolic alkalosis
When auscultating a patient's lungs, your hear crackles. These are caused by:
What is fluid in the alveolar space.
therapeutic INR for a client with a mechanical heart valve
What is 3-4.5
An individual does not produce his or her own antibodies, but rather receives them directly from another source, such as mother to infant through breast milk
What is Passive immunity
The nurse notes that the IV site is cool, pale, and swollen
What is Infiltration
Hydration, oxygen, pain meds, Hydroxyurea
What is tx for sickle cell crisis
warmth, redness, swelling, and tenderness of skin, fever and chills, purulent drainage
What is S/S of infection
What should the nurse look for on the cardiac monitor as a result of Hyperkalemia
What is Narrow, peaked T waves
Additional findings: a wide, flat P wave; a prolonged PR interval; a widened QRS complex
The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid–base disorder?
What is Metabolic acidosis
Frequently results from shallow breathing
fever, productive cough, painful breathing, and an increased respiratory effort and rate
Fine crackles in lungs
What is Pneumonia
narrowed pulse pressure, hypotension, jugular venous distention, muffled or distant heart sounds, dyspnea, tachypnea, and tachycardia
What is Cardiac Tamponade
a disease in which the immune system attacks the organism's own cells as they are seen as non self
What is autoimmune
The nurse notes the IV site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter
What is phlebitis of the vein
In a client with idiopathic thrombocytopenic purpura (ITP) there is problem with
What is destruction of the platelets
High fever, headache, nuchal rigidity
stiffness and soreness in the neck area; positive Brudzinski's sign pain in the vertebral column and passively flexes the hip and knee in response to neck flexion; positive Kernig's sign flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.
What is signs of meningitis
renal failure, intestinal obstruction, Addison's disease, and metabolic acidosis
What is patients at risk for hyperkalemia
The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (30 mm Hg), and the nurse is told that the client is experiencing
What is respiratory alkalosis
50 mL of drainage in chamber
system is maintained below the chest
occlusive dressing is in place over insertion site.
Fluctuation of water in the water-seal chamber
What is normal finding for chest tube system
decreased BP, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, loss of potassium
What is findings associated with long term use of diuretics
A protein made by plasma B lymphocytes that binds to a specific antigen. Labels specific cells for destruction.
What is antibody
cool, clammy, and pale skin; feelings of anxiety and restlessness; and thirst
What is signs/symptoms of hypovolemia
A client has a bone marrow biopsy done. Which nursing intervention is the priority post-procedure?
What is apply pressure to the biopsy site
(The initial action should be to stop bleeding by applying pressure to the site)
Wearing gloves when emptying the client's bedpan
Keeping all linens in the room until the implant is removed
Wearing a film (dosimeter) badge when in the client's room
Wearing a lead apron when providing direct care to the client
What is interventions for patients with internal radiation implants
Fluid overload (weight gain), Low sodium (euvolemic hyponatremia…sodium is watered down), Confusion (due to brain swelling with extra fluid), Anorexia (full of water…doesn’t want to eat), low urine output, concentrated urine
What is SIADH
Fruity breath odor and decreasing level of consciousness, increased respirations, dehydration, hypotension
What is DKA
Changes in the vital signs
What is pulmonary embolism
indication: pulmonary embolism, cardiac dysrhythmias, artificial heart valves
- nursing interventions: monitor PT and INR
- antidote: vit K
- avoid aspirin, NSAIDS, and alcohol
What is warfarin
sympathomimetic, will cause vasoconstriction (this will increase the blood pressure and decrease swelling) and bronchodilation (this will dilate the airways).
What is epinepherine
A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which sign?
What is an Air embolism
white blood cell (WBC) count of 6000 mm3 (6 × 109/L) and a platelet count of 20,000 mm3 (20 × 109/L), low RBC count of < 4 million cells/mcL
What is Aplastic anemia
Increased BP
Decreased heart rate
Decline in visual acuity
Decline in short-term memory
Increased susceptibility to urinary tract infections
Increased incidence of awakening after sleep onset
What is physiologic changes associated with aging
a rapid, thready pulse; postural blood pressure changes, seizures & Stupor, abdominal cramping, neuro changes (confusion), lethargic, tendon reflexes diminished
What is s/s hyponatremia
The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to assist in administering to the client?
What is Calcitonin
The nurse suspects that the client has a pulmonary embolism. What are the most important nursing actions?
What is oxygen administration, elevate head of the bed, monitor vital signs
-a cardiac glycoside that helps the heart pump efficiently; used in heart failure and chronic atrial fibrillation.
Increases force of contraction
-Slows the conduction velocity through the atrioventricular (AV) node
-Decreases heart rate
What is Digoxin
INCREASES capillary permeability by shifting the intravascular fluid to the interstitial space… causing swelling and low blood pressure, vasodilates vessels…causes red skin, increases heart rate, constricts the airway…causes difficulty breathing and wheezes, stimulates contraction of GI smooth muscles and stimulates production of gastric secretions…this leads to vomiting, nausea, and pain, and there is also itching.
What is massive release of Histamine in Anaphylaxis
What solutions cause cell dehydration and help increase fluid in the extracellular space.
What is Hypertonic
clotting abnormalities due to the hyperviscous blood with sluggish flow, increase in all blood cells, particularly red blood cells
What is Polycythemia vera
A chemical that kills bacteria or slows their growth without harming body cells.
What is an antibiotic
The nurse understands that the long-term effect of prolonged bed rest is
What is Hypocalcemia
A patient with Cushing’s Syndrome is most likely to have which condition?
What is Metabolic alkalosis
rhythmic respirations with periods of apnea, occur with disorders affecting the respiratory center of the pons in the central nervous system such as a metabolic dysfunction in the cerebral hemisphere or basal ganglia.
What is Cheyne-Stokes respirations
A client is being treated for hypokalemia. The client's current medications include Inderal, digoxin, and Coumadin. The client reports nausea, abdominal discomfort, and visual changes. Which problem would the nurse suspect?
What is Digitalis toxicity
chemicals released by mast cells that increase the blood flow and cause dilation of blood vessels in the effected area as part of the body's inflammatory response.
What is Histamines
When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called?
What is isotonic
an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin attacking them.
What is graft-versus-host disease
A positive Bence-Jones protein finding would correlate with this condition.
What is multiple myeloma
The nurse is caring for a client with a suspected diagnosis of hypercalcemia. The nurse understands that this condition causes
What is sedation and generalized muscle weakness
A client has the following laboratory values: a pH of 7.55, an HCO3– level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action should the nurse plan to take?
What is slow down breathing or breathe in paper bag
children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas such as long-term care facilities, prisons, and mental health facilities; older clients; malnourished individuals, those with an infection, or an immune dysfunction or human immunodeficiency virus infection, or individuals who are immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are IV drug users.
What is People at risk for TB
A young man who is a smoker presents with numbness and tingling in legs, he also complains of pain with both exercise and rest. This is caused by a mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male and suggests Thromboangiitis obliterans, otherwise known as
What is Buerger's disease
Hyperuricemia, elevated levels of uric acid, is especially common after treatment for leukemias and lymphomas because of
What is chemo therapy results in massive cell destruction and the release of uric acid.
These fluids remove water from the extracellular space into the intracellular space.
What is Hypotonic
The schillings test
What is a dx test for pernicious anemia
dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise
What is things that cause sickle cell crisis
Insomnia
Weight loss
Tachycardia
heat intolerance
What is s/s hyperthyroidism
The respiratory system compensates for changes in the pH level by responding to changes in the levels of:
What is CO2
Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of
What is INH
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Auscultation reveals crackles. The client is experiencing
What is pulmonary edema
enlarged lymph nodes, fatigue, weakness, weight loss, and night sweats
What is s/s of Hodgkin's disease (lymphoma)
A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?
What is Check urine output
The nurse is caring for a client with a suspected diagnosis of aplastic anemia. Which test should the nurse anticipate to be performed to confirm the diagnosis?
What is Bone marrow aspiration
A client with diabetes mellitus visits a healthcare clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 mg/dL to 200 mg/dL (10.2 mmol/L to 11.4 mmol/L). What medication used for inflammation, added to the client's regimen, may have contributed to the hyperglycemia?
What is Prednisone?
A client with a history of cardiac disease is due for a morning dose of furosemide. Which electrolyte serum level, if , should be evaluated before administering the dose of furosemide?
What is Potassium
The kidneys compensate for acid-base imbalances by excreting or retaining:
What is Sodium bicarbonate
A patient diagnosed with status asthmaticus who was previously wheezing suddenly stops wheezing and continues to show signs of respiratory distress. Your assessment findings would indicate that:
What is: indicates severe bronchial constriction with little air movement during inspiration and expiration. This is a dangerous event, requiring immediate interventional to prevent respiratory collapse
fluid retention, edema develops in the lower legs jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain are classic signs of
What is R sided HF
punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.
What is Dx test for Kaposi's Sarcoma
The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation?
What is Urine output
D-dimer
Hemoglobin
Prothrombin time
What is DX tests for DIC
A client is receiving standard oral anticoagulant therapy with warfarin. The result of a newly drawn international normalized ratio is 3.8 seconds. The client needs to have an invasive procedure done on the next day. Which medication will likely be ordered to reverse the anticoagulant effect?
What is Vitamin K1 or phytonadione
muscle irritability, tachycardia, hypotension, paresthesia, twitching, cramps, tetany, seizures, hyperactive bowel sounds, and a prolonged QT interval on the electrocardiogram rhythm
What is s/s hypocalcemia