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153 Cards in this Set
- Front
- Back
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What are the three phases of the perioperative experience? |
* Preoperative Phase * Intraoperative Phase * Postoperative Phase |
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What are the 5 surgical classifications? |
* Diagnostic (biopsy, exploratory laparotomy) * Curative (excision of tumor or appendectomy) * Reparative (multiple wound repair) * Reconstructive (mammoplasty, facelift) * Palliative (insertion of gastrostomy tube for dysphagia in end of life care) |
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What does the surgical suffix "ectomy" mean? |
Excision or removal of, such as an appendectomy |
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What does the surgical suffix "lysis" mean? |
Destruction of (such as scar tissue), such as electrolysis |
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What does the surgical suffix "orrhaphy" mean? |
Repair of suture of |
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What does the surgical suffix "oscopy" mean? |
Looking into, such as a colonoscopy. |
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What does the surgical suffix "ostomy" mean? |
Creation of an opening into, such as a colostomy. |
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What does the surgical suffix "otomy" mean? |
Cutting into or incision of, such as a craniotomy. |
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What does the surgical suffix "plasty" mean? |
Repair or reconstruction of, such as a rhinoplasty. |
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What is the nursing role in the preoperative phase? |
* Obtain a health history * Physical assessment * Assure diagnostic testing is performed and monitor results * Determine patient's understanding of the disease and treatment plan * Teach appropriate to patient needs * Identify patient's emotional state and coping skills * Discuss and review advanced directives (DNR) * Begin to develop discharge plan |
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What are the 8 systems that are assessed into the preoperative phase? |
* Cardiovascular * Respiratory * Renal * Gastrointestinal * Liver * Endocrine * Cognitive & Neurological * Skin Assessment |
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Why is it important to perform an assessment of the endocrine system before an operation? |
If the patient is a diabetic, operative stress will case the glucose level to rise. If the patient has COPD or Addison's Disease and is often on steroids, a higher level of steroids will be needed if administered peri or postoperatively. |
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What is also assessed, besides the 8 systems, that could affect surgery outcomes? |
* Age * Congenital Disorders (malignant hyperthermia) * Nutritional Status (how the wound will heal) * Infection and Immunity (diverticulitis) * Hematological conditions (DVTs, anemias) * Lifestyle habits/meds (smoke, drink, depressed) * Use of herbal remedies (could cause bleeding) * Previous surgical experiences * Spiritual and cultural attitudes and coping skills |
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What is important regarding allergies and surgery? |
* Allergies must be known prior to surgery * Be sure to know the actual reaction to know the difference between an actual allergy and an adverse side effect * Be sure to address medications, latex, food and contrast dyes |
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What are the two fluid compartments in the body? |
Intracellular (ICF) and extracellular fluid (ECF) |
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Where is intercellular fluid? |
Located within the cells. |
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Where is extracellular fluid? |
* Interstitial fluid * Plasma * Transcellular fluid |
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What makes up transcellular fluid? |
* Cerebrospinal fluid * Fluid in the GI tract * Pleural * Synovial * peritoneal * intraocular * pericardial fluid |
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How much extracellular fluid is in the plasma? How much in the interstitial space? |
About 20%. About 70% in the interstitial space. |
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What are some positively charged ions that are electrolytes? |
* Sodium (Na+) * Potassium (K+) * Calcium (Ca+) * Magnesium (Mg2+) |
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What are some negatively charged ions that are electrolytes? |
* Bicarbonate (HCO3-) * Chloride (CI-) * Phosphate (PO43-)
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What is the major ion and the major anion in extracellular fluid? |
Major ion: Sodium (Na+) Major anion: Chloride (CI-) (Think of normal saline .9%NaCl) |
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What is the major ion and the major anion in intracellular fluid? |
Major ion: Potassium (K+) Major anion: Phosphate (PO43-) (Both start with P) |
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What is diffusion? |
The movement of molecules from an area of high concentration to an area of low concentration. |
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What is facilitated diffusion? |
Also known as passive transport, a molecule requires a protein carrier to aid in crossing the cell membrane. |
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What is active transport? |
Molecules move against the concentration gradient. ATP is required for this process. An example is the sodium/ potassium pump. There are concentration differences inside and outside of the cell. |
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What is osmosis? |
The movement of water from a low solute concentration to a high solute concentration across a semipermeable membrane. |
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What is osmotic pressure? |
The strength of a solution's pull. It is determined by the concentration of the solution. The higher the concentration, the more osmotic pressure. It is measured in milliosmoles and may be expressed as 'fluid osmolarity' or 'fluid osmolality'. |
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What is osmolality? |
The concentration of molecules per weight of water. Is about the same intracellular and extracellular. |
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What is hydrostatic pressure? |
Blood pressure in the blood vessels. Gradually decreases until the capillary level of about 30 mm Hg. |
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What is oncotic pressure? |
When the plasma protein molecules attract water, pulling fluid from the interstitial space into the vascular space. |
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What is edema? |
An accumulation of fluid in the interstitial space. This can be caused by an elevation of venous hydrostatic pressure (pressure is too high in the vessels, not allowing the fluid to return to the capillaries) causing edema. |
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What is fluid spacing? |
Term to describe the distribution of body water. There is first, second and third spacing. |
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What is first spacing? |
Describes normal distribution of of fluid in ICF and ECF compartments. |
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What is second spacing? |
Refers to an abnormal accumulation of interstitial fluid (edema). |
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What is third spacing? |
Fluid trapped and unavailable for functional use, such as in a boil, ascites or peritonitis. |
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What primary organ regulates fluid and electrolyte balance? |
The kidneys. |
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What is insensible water loss? How much does it account for in the body? |
Water lost in vaporization through the lungs and skin. Normal is 600 - 900 mL/ day. |
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What are the clinical manifestations of ECF volume deficit? |
* restlessness, drowsiness, lethargy, confusion * thirst, dry mucous membranes * decreased skin turgor, longer capillary refill * postural hypotension, faster pulse, lower BP * lower urine output, concentrated urine * Increased respiratory rate * weakness, dizziness * weight loss * seizures, coma |
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What are the clinical manifestations of ECF volume excess? |
* Headache, confusion, lethargy * peripheral edema * jugular venous distention * Bounding pulse, increased BP * polyuria (with normal renal function) * dyspnea, crackles * muscle spasms * weight gain * seizures, coma
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What are the clinical manifestations of hypernatremia? |
With decreased ECF volume * intense thirst, dry swollen, tongue * agitation * decreased alertness (sleepiness to coma) * postural hypertension, increased pulse * weakness, lethargy With normal ECF volume (with those above) * flushed skin * weight gain, peripheral & pulmonary edema * increased BP
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What are the clinical manifestations of hyponatremia? |
With decreased ECF volume * irritability, apprehension, confusion, dizziness, personality changes, tremors, seizures, coma * dry mucous membranes * postural hypotension * decrease in jugular venous filling, fast, thready pulse * cold, clammy skin With normal ECF volume * headache, apathy, confusion, muscle spasms, seizures, coma * N/V, diarrhea, cramps * weight gain, increased BP |
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What is the most common cause of hyperkalemia? |
Renal failure. |
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What are the clinical manifestations of hyperkalemia? |
* irritability * anxiety * abdominal cramping, diarrhea * weakness of lower extremities * paresthesias * irregular pulse * cardiac arrest if it is sudden or severe * EKG changes |
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What EKG changes happen in hyperkalemia? |
* Tall, peaked T-wave * prolonged PR interval * ST segment depression * Loss of P-wave * Widening QRS * V-fib * Ventricular standstill |
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What clinical manifestations occur with hypokalemia? |
* fatigue * muscle weakness, leg cramps * N/V, paralytic ileus * soft, flabby muscles * paresthesias, decreased reflexes * weak, irregular pulse * polyuria * hyperglycemia * EKG changes |
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What EKG changes happen in hypokalemia? |
* Flattened T-wave * ST segment depression * Presence of a U-wave * Prolonged QRS * Ventricular dysrhythmias * Bradycardia |
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What are some common causes of hyperkalemia? |
* acidosis * fever, sepsis, burns * renal disease * ACE inhibitors * crush injury * tumor lysis syndrome |
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What are some common causes of hypokalemia? |
* stress * starvation * diet low in potassium * insulin therapy (with diabetic ketoacidosis) * diarrhea or laxative abuse * vomiting |
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What are some common causes of hypercalcemia? |
* multiple myeloma * malignancies with bone metastasis * prolonged immobilization * hyperparathyroidism * Vitamin D overdose * Thiazide diuretics * Milk-alkali syndrome * acidosis |
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What are the manifestations of hypercalcemia? |
* lethargy, weakness * depressed reflexes * decreased memory * confusion, personality changes, psychosis * anorexia, N/V * Bone pain fractures * polyuria, dehydration * nephrolithiasis * stupor, coma |
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What saying can help remember manifestations of hypercalcemia? |
Moans, stones, bones and groans Mental - reflex slowing (depression) Stones - kidney and other stones Bones - bone pain Groans - constipation |
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What is a good way to remember the symptoms of hypokalemia? |
The 6 L's - Lethargy |
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What are the 5 W's for postoperative fever? |
* Wind - pneumonia, atelectasis - within the first 24 - 48 hours. * Water -UTI at anytime after postoperative day 3 * Wound - wound infections anytime after day 5 * Wonderdrugs - especially anesthesia - can occur anytime * Walking - can help reduce risk of DVTs or PE's which usually occurs PODs 7 - 10 |
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How do you treat a fever less than 101 post surgery? |
With pulmonary exercises, ambulation and increased fluid intake. A slight fever is common after surgery. |
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What elevation of temperature should be reported after surgery? |
Above 101.5. Less than that is common after surgery. |
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What are the most common respiratory complications from surgery? |
* Atelectasis * pneumonia * pulmonary emboli |
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What is atelectasis? |
Partial or total collapse of the alveoli. Symptoms are fever, tachycardia, tachypnea, crackles and decreased breath sounds. Develops in 1 - 2 days post op. |
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What is the most serious postoperative complication? |
Shock * Hypovolemic * Neurogenic * Cardiogenic * Septic |
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What are the clinical manifestations of shock? |
* Anxiety, restlessness * Pallor; cool, moist skin * Rapid breathing, cyanosis * Rapid, weak, thready pulse * Hypotension * Low, concentrated urine |
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When should a patient void after surgery? |
Within 8 hours of surgery. |
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How much should a patient void after surgery? |
When a patient finally voids after surgery, they should have urinary output of .5mL/kg/hour or 30CC/hr. |
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If a patient postoperatively is retaining urine, what amount requires a 'straight cath'? |
Over 100mL of urine retained. |
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An example of an IV solution that would be appropriate to treat hypovolemia (ECF volume deficit) is: A. D5NS B. 3% saline C. 0.45% saline D. Lactated Ringers (LR) |
Answer is D. Lactated Ringers A. is a hypertonic solution B. is a hypertonic solution C. is a hypotonic solution D. is an isotonic solution which does not affect osmolality of the ICF or ECF and does not cause fluid shifts between the ICF or ECF. |
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To Provide free water and ICF hydration for a patient with acute gastroenteritis and is NPO, the nurse would expect administration of; A. Lactated ringers solution B. D5W (5% dextrose in water) C. 10% dextrose in water D. 5% dextrose in normal saline (D5NS) |
Answer is B. Need a hypotonic solution A. is an isotonic solution C and D are hypertonic solutions (D5W is isotonic, but once the dextrose is metabolized, it leaves free water to shift into the cells). |
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What is the easiest way to determine fluid loss or gain? |
Daily weight measurement. 1kg = 1L of fluid |
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What is the normal level of sodium for the human body? |
135 - 145 mEq/L |
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What is the normal level of potassium for the human body? |
3.5 - 5.0 mEq/L |
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What is the normal level of magnesium for the human body? |
1.5 - 2.5 mEq/L |
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What is the normal level of chloride for the human body? |
96 - 106 mEq/L |
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What is the normal level of calcium for the human body? |
8.6 - 10.2 mg/dL |
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What is the normal level of phosphate for the human body? |
2.4 - 4.4 mg/dL |
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What causes hypernatremia? |
* Diabetes Insipidous * Uncontrolled Diabetes Mellitus * Cushing's Syndrom * Excessive sweating with high fever * Patient given enteral tube feedings * Patient with hypertonic solution * drinking seawater * hyperaldosteronism (tumor on adrenal gland) |
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What are the nursing interventions for hypernatremia? |
For fluid loss, free fluid such as D5W. For excess sodium, sodium free fluid and diuretics to encourage excretion of the excess sodium. |
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While witnessing a preoperative consent, the nurse learns that the client does not understand the risks of the surgery. The nurse's best action is to: A. Notify the anesthesiologit B. Notify the surgical unit C. Notify the client's family D. Notify the surgeon |
D. Notify the surgeon |
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Which of the following is the most dangerous complication during induction of spinal anesthesia? A. Respiratory paralysis B. Cardiac Arrest C. Hypotension D. Hyperthermia |
A. Respiratory paralysis |
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The nurse is caring for a patient who had undergone exploratory laparotomy. Which of the following postop findings should the nurse report to the physician? A. The patient's wound drainage B. The patient's urine output is 20ml/hr for the past 2 hours C. The patient pushes out the oral airway with his tongue D. The patient's vital signs are as follows: BP 100/70; HR is 95; RR is 9; Temp is 98.2 |
D. The vital signs |
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The nurse is transferring the patient from the PACU to the surgical unit. Which of the following is the primary reason for gradual change of position of the patient? A. To prevent muscle injury B. To prevent respiratory distress C. To promote comfort D. To prevent sudden drop in BP |
D. prevent sudden drop in BP |
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Which of the following items on the client's pre-surgery lab results would indicate a need to contact the surgeon? A. Platelet count of 250,000/mm3 B. Hemoglobin 9.5 mg/dL C. Total cholesterol of 325 mg/dL D. Blood urea nitrogen of 17 mg/dL |
B. Hemoglobin 9.5 mg/dL. It should be between 13.8 and 17.2 for a man or 12.1 to 15.1 for a woman. |
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Upon admission of a patient to the PACU, the nurse's PRIORITY assessment is the patient's A. surgical site B. level of consciousness C. vital signs D. respiratory adequacy/ airway |
D. respiratory adequacy/ airway |
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To promote coughing, deep breathing, and ambulation of the post-operative patient, it is MOST important for the nurse to; A. Explain the rationale for these activities B. Use an incentive spirometer to motivate the patient C. Teach the patient controlled breathing D. Provide adequate and regular pain medication |
D. pain medication |
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A 250 lb. male patient recovering from general anesthesia has the following assessment findings: pulse =150, BP 90/50, RR = 28, tympanic temp = 99.8, and rigid muscles. The nurse determines that the client is; A. In the early stages of malignant hyperthermia B. Exhibiting the effects of excessive blood loss experienced in the operating room and increases the rate of his IV C. Recovering as expected from the anesthesia and continues monitoring him D. In pain and offers him pain medication |
A. In the early stages of malignant hyperthermia. |
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On the day of surgery, a client with diabetes who takes Insulin on a sliding scale is ordered to have nothing by mouth NPO and all medications withheld. The patient's 6am glucose level is 300 mg/dL. The nurse should: A. Administer the insulin as dictated by the sliding scale B. Call the physician for specific orders based on the glucose level C. Withhold all medications as ordered D. Notify the surgery department |
B. Call the physician for specific orders. |
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36 hours postoperatively, a patient has a temperature of 100F. The nurse finds that this is most likely of; A Dehydration B. Wound infection C. The normal surgical stress response D. Lung congestion and atelectasis |
C. Normal surgical stress response |
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What is the parkland formula and how is it calculated? |
It is the formula to determine how much IV fluids to give a burn victim in the first 24 hours. The formula is determined as: 4mL/kg/TBSA 1/2 is given in the first 8 hours and a quarter over the following 8 hours and another quarter for the last 8 hours. |
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Using the rule of nines, what is the TBSA of a patient who was burned on the right side of her face and neck, right side of the anterior trunk, 2/3 of lower right thigh and all of the right arm? |
Right side of face and neck = 4.5% (half of 9) Right side of the anterior trunk = 9% (half of 18) 2/3 of lower right thigh = 3% (2/3 of 4.5) Right arm = 9% 4.5+9+3+9 = 25.5% TBSA |
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What are the normal pH values? |
7.35 - 7.45 |
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What are the normal values for partial pressure of carbon dioxide? |
PCO2 or PaCO2 ranges from 35-45 mm Hg |
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What are the normal values for partial pressure of Oxygen? |
PO2 or PaO2 ranges from 80-100 mm Hg |
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What are the normal values for bicarbonate? |
HCO3 ranges from 22 - 26 mEq/L |
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What are the normal values for O2 saturation? |
95 - 100% |
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With arterial blood gases, what works faster and what packs more of a punch? |
The respiratory system can work faster, but the renal system is more powerful. |
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What can the respiratory system do to maintain homeostasis? |
* Blow off CO2 * Hold onto CO2 * Take in O2 |
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What can the renal system do to maintain homeostasis? |
* Reabsorb and conserve HCO3 * Generate HCO3 * Eliminate excess H+ ions |
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What are the 6 easy steps to ABG analysis? |
1. Is the pH normal? 2. is the CO2 normal? 3. Is the HCO3 normal? 4. Are the pO2 and O2 saturation normal? 5. Match the CO2 or the HCO3 with the pH 6. Does the CO2 or the HCO3 go in the opposite direction of the pH? |
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What are the symptoms of respiratory acidosis? |
* Hypoventilation (hypoxia) * Rapid shallow respirations * BP decreased * Pale or cyanotic * Headache * Hyperkalemia * Dysrhythmias (K+ goes down) * Drowsiness (disorientation, dizziness) * Muscle weakness, hyperreflexia |
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What can cause respiratory acidosis? |
* Anesthesia * Overdosing * Increased Intracranial pressure * Pneumonia * COPD |
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What is respiratory alkalosis characterized by and give an example. |
A decrease in the PaCO2 and an increase in pH. An example would be someone in pain and anxiety producing tachypnea and blowing off CO2. |
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What are the symptoms of respiratory alkalosis? |
* Hyperventilation (increased rate and depth) * tachycardia * Normal or low BP * Hypokalemia * numbness or tingling in the extremities * Hyperreflexes and muscle cramping * seizures * Increased anxiety (and /or irritability) |
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What causes respiratory alkalosis? |
Hyperventilation |
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Describe respiratory failure regarding ABGs. |
PaCO2 >45 pH is <7.35 *With evidence of the body's inability to compensate (no compensation) * The pH is at a level where further decrease may lead to severe acid-base imbalance |
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What might cause metabolic acidosis? |
* Diarrhea (loss of intestinal bicarbonate) * liver failure (making less bicarb) * Diabetic ketoacidosis (increased H+ production) * renal failure (lowered elimination of H+) |
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What are some symptoms of metabolic acidosis and how does a nurse respond? |
* Hypotension * weak irregular pulse * fatigue * muscle weakness * hyperkalemia * headache * N/V * Low muscle tone, low reflexes Nurse would monitor LOC, VS and lethargy |
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What are some symptoms of metabolic alkalosis? |
* confusion * dysrhythmias (tachycardia from low K+) * Dizzy, irritable * N/V, diarrhea * Increased anxiety, seizures * tremors, muscle cramps, tingling of fingers & toes (from low serum Ca++) |
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what are the symptoms of malignant hyperthermia? |
* Rigid muscles * High temp * tachycardia * cyanosis * hypotension * low CO2 * oliguria * dark blood at the wound area * Usually occurs within 10-20 minutes of surgery, however, can occur during the first 24 hours |
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What foods have vitamin B12? |
*Red meat * liver * fish * dairy * eggs |
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What might cause metabolic alkalosis? |
* Antacids or baking soda * Prolonged vomiting * Loop and thiazide diuretics * hypokalemia |
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What is hypoxemia and when is it common? |
Inadequate concentration of oxygen in arterial blood. It is most common in postop day 2. |
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What are the symptoms of hypoxemia? |
* Restless * dyspnea * tachycardia * hypertension * cyanosis * diaphoresis |
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What are the ABGs for hypoxemia? |
* A normal level of arterial oxygen is 80 - 100 mm Hg but real concern is below 60 mm Hg. * The normal amount of oxygenated hemoglobin in arterial blood is 95 - 100% measured by pulse ox. |
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What is the nursing interventions for hypoxemia? |
* Respiratory exercise prevention * Respiratory treatments * Mechanical ventilation |
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What are the nursing interventions for hypernatremia? |
* Oral Fluids * Na+ free IV fluids (such as D5W or 4.5% NaCl) * Diuretics * Restriction of dietary intake of Na+ |
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What causes hyponatremia? |
Loss of Na+ containing fluids such as in * Diarrhea * Vomiting * NG suction * Diuretics * Burns * Wound drainage Water excess |
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What are the nursing interventions for hyponatremia? |
For abnormal fluid loss * replacement with Na+ containing solutions For water excess * Fluid restrictions * If severe, (i.e. seizures) -small amt of IV 3% NaCl Drugs that block ADH * increase diuresis * Vasopressin causes urine output without the loss of Na+ or K+ |
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How much water is lost through insensible losses on a daily basis? |
About 500mL/ day |
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What is the percentage of our bodies that is made up of water in each stage of life? |
* Infants - 70-80% * adults - 50 - 60% * elderly - 45 - 55% |
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What percentage of our body fluid is intracellular fluid? |
The majority of it - about 70% |
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What percentage of ECF is in the vascular space? |
about 1/3 |
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What is transcellular fluid? |
* Cerebrospinal fluid * Fluid in the GI tract * Pleural * Synovial * Peritoneal * Intraocular * Pericardial |
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What are the nursing interventions for hyperkalemia? |
* No oral or IV potassium * Increase elimination of potassium with diuretics, dialysis, increase fluid intake * IV insulin, IV sodium bicarb to reverse acidosis |
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What are the nursing interventions for hypokalemia? |
* give potassium orally and intravenously * always dilute IV K+ * Never give an IV K+ push or in concentrated amounts * Maximum concentration is 80 mEq/L (may require an ICU bed with EKG monitoring) * Rate of infusion should not exceed 10-20 mEq/hr * It is irritating to the vein and should check for phlebitis. |
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What are the nursing interventions for hypercalcemia? |
* Loop diuretic (Lasix) - promotes excretion of calcium in the urine * Hydration with isotonic saline solution * Drink 3000-4000mL of fluid DAILY (promotes renal excretion of calcium and prevent stones) * Synthetic calcitonin - reduces blood calcium |
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What causes hypocalcemia? |
* Anything that causes a decrease in PTH * Surgical removal of the parathyroid * Acute pancreatitis * Chronic kidney disease |
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What are the nursing interventions for hypocalcemia? |
* Oral or IV calcium (never give IM) * Observe patients with thyroid or neck surgery |
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What is important when administering a hypertonic solution IV to a patient and why? |
It is important to monitor lung sounds, blood pressure and sodium level because there is a high potential for fluid overload. |
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What is different about IV administration of dextrose 10% hypertonic solution? |
It must be given through a central line for adequate dilution. |
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What are the clinical manifestations of hypocalcemia? |
* Trousseau's sign * Chvostek's sign (tetany) * EKG changes * seizures |
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What causes hyperphosphatemia? |
* Acute or chronic renal failure * chemotherapy * excessive ingestion of milk * Large intake of vitamin D |
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What are the nursing interventions for hyperphosphatemia? |
* Treat the underlying cause for the patient with renal failure (calcium supplements, phosphate binding agents, dietary phosphate restriction) |
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What causes hypophosphatemia? |
* malnourished or malabsorption syndrome * Alcohol withdrawal * use of phosphate binding antacids |
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What are the clinical manifestations of hypophosphatemia? |
* CNS depression * muscle weakness * pain * dysrhythmias |
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What are the nursing interventions for hypophosphatemia? |
* oral supplements * Foods high in phosphorous * IV sodium phosphate, or potassium phosphate |
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What are the causes of hypermagnesemia? |
Patient with chronic kidney disease takes maalox or Milk of Magnesia. |
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What are the clinical manifestations of hypermagnesemia? |
* Lethargy * drowsiness * N/V * loss of deep tendon reflexes * respiratory and cardiac arrest |
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What are the nursing interventions for hypermagnesemia? |
* Prevention (teach CKD patients not to take magnesium containing drugs - read OTC labels) * IV calcium chloride or calcium gluconate * dialysis for the CKD patient |
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What causes hypomagnesemia? |
* Startvation * Chronic alcoholism |
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What are the clinical manifestations of hypomagnesemia? |
* Confusion * hyperactive deep tendon reflexes * tremors * seizures * cardiac dysrhythmias |
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What are the nursing interventions for hypomagnesemia? |
* oral supplements * Dietary - green veggies, nuts, bananas, oranges, peanut butter, chocolate * IV magnesium sulfate |
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The nurse checks the lab results of a patient and sees that the potassium level is 2.8 mEq/L. After reporting to the physician, the nurse assesses the patient for; A. A weak irregular pulse B. increases peristalsis C. A bounding pulse D. Hypertension |
A. A weak irregular pulse. Low potassium levels can cause EKG changes The other three are not symptoms of hypokalemia |
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The physicians orders read "flush NG tube with 30 to 50ml saline solution Q2H PRN. The nurse knows that saline solution is used instead of water because; A. flushing with water can deplete electrolytes in the stomach B. water is irritating to the gastric mucosa C. the sterility of the stomach is maintained with saline solution D. saline is better at maintaining tube patency |
A. flushing with water can deplete electrolytes in the stomach. Water is not irritating The stomach is not sterile Saline is no better at maintaining tube patency |
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Mrs. Morris is given IV fluids of lactated ringers solution. Which of the following best describes the properties of lactated ringers solution? A. Lactated ringers contains electrolytes and is a hypertonic solution B. Lactated ringers is a hypotonic solution used for fluid volume replacement. C. lactated ringers provides fluids and does not contain electrolytes. D. Lactated ringers is an isotonic solution and provides electrolytes |
D. isotonic solution which provides electrolytes at about the same concentration as plasma |
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The nurse understands that patients who are hypovolemic can manifest a; A. low hematocrit level B. high hematocrit level C. normal hematocrit level D. hematocrit level that is unaffected by fluid volume |
B. A high hematocrit level is seen with low blood plasma |
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Sodium is found abundantly in the body. Which statement is correct regarding sodium? A. Sodium is found in the ICF and helps to maintain water balance B. Sodium is regulated by the amount of daily oral intake C. Sodium regulation is controlled only by the kidneys D. Sodium is found in the ECF and helps to maintain water balance |
D. Sodium is found primarily in the ECF and helps to maintain water balance |
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A client has experienced vomiting and diarrhea for several days. The nurse understands that the nursing interventions should include safety precautions because hypovolemia can lead to; A. shortness of breath and pedal edema B. decreased cerebral circulation and postural hypotension C. abdominal distention and rapid pulse D. twitching and weak muscles |
B. decreased cerebral circulation and postural hypotension
(a clue in the question which may help answer this question is "safety precautions") |
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On admission a patient was confused and weak and complained of fatigue. Lab tests showed hypokalemia and hyponatremia. After 2 days of IV therapy and electrolyte replacement, the patient tells the nurse that she feels much better. The most appropriate way to evaluate electrolyte balance in a patient is to; A. Assess the patient's level of orientation and her ability to respond appropriately to simple questions B. Compare the patient's vital signs, especially the pulse to those taken on admission C. monitor lab results from admission to the most recent values D. Review the nurse's document indicating improved skin turgor and mucous membranes |
C. This nursing intervention will provide the nurse with the appropriate data to evaluate electrolyte balance. |
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What are the nursing interventions for malignant hyperthermia? |
* Recognizing symptoms early and stopping anesthesia is paramount! * Decrease metabolism * Reverse respiratory and metabolic acidosis * correct dysrhythmias * decrease body temp * provide oxygen and nutrition to tissues * Correct electrolyte imbalances |
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Immediately after surgery, what does the nurse assess? |
An immediate assessment of * airway * breathing * circulation * VS * mental status * surgical incision * fluids. |
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Describe taking vital signs of a patient immediately upon entering the PACU. |
Vitals should be taken * Q15 min X 4 * Q30 min X 4 * Q1H X4 |
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A patient had a resection of the terminal ileum 3 years ago. While obtaining a health history and a physical assessment, the nurse finds that the patient has weakness, shortness of breath, and a sore tongue. Which additional information from the patient indicates a need for intervention and teaching? A. I have three to four loose stools a day B. I have been drinking plenty of fluids C. I have been gargling with warm salt water D. I take a vitamin B12 tablet every day. |
D. I take a vitamin B12 tablet every day |
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What are the caloric needs of a burn patient? |
About 5000 kcal/day |
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What are the nursing interventions for a burn victim? |
* Monitor vital signs * Monitor lab values * Thrombosis prevention * Monitor Urine output * Airway management (humidified air, 100% O2) |
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What serum lab values do we need to know for the test? |
* RBC 4.4 - 5.8 for men, 3.0 - 5.2 for women * WBC 3.8 -10.8 * Hemoglobin 13.8 - 17.2 men, 12-15.6 female * Platelets 150 - 450 * Hematocrit 41-50% for men, 35 - 46% women * BUN 7 - 21 * Creatinine 0.7 - 1.2 men, 0.5 - 1.0 * Serum protein 6.4 - 8.3 |
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What's important about administering IV potassium? |
It should always be diluted and it should never be pushed. It is highly irritating to vessels. |
