118 Questions
an elderly woman was at the eye clinic and stated she is having trouble sewing, seeing her grandchildren, etc .the nurse noted this as a loss of central vision but her peripheral vision is fine.
macular degeneration
normally a thrill will come with a murmur but is a palpable vibration. but a murmur can exist without a thrill so don't correlate them having to be together. a thrill is a palpable vibration.
True
Crackle sounds are HIGH pitched; fine sounds heard at the end of an inspiration
True
wheezing sounds like musical squeaks
True
ASEPTIC TECHNIQUE IS THE SAME AS STERILE TECHNIQUE- WILL BE ON TEST
True
Polycystic kidney disease (an inherited disorder in which clusters of cysts develop primarily within your kidneys, causing your kidneys to enlarge and lose function over time.)
True
Urinary calculi (masses/stones that form in the urinary tract and may cause pain, bleeding, or an infection or block of the flow of urine)
True
a complicated UTI fancy word is Pyelonephritis
True
gout is crystals - imagine there being crystals to where you cant pee..
True
dysuria is painful urination
True
match
Diuretics: = prevent reabsorption of water and certain electrolytes in tubules Cholinergic medications: = stimulate contraction of detrusor muscle, producing urination Analgesics and tranquilizers: = suppress CNS, diminish effectiveness of neural reflex What are you going to monitor for with these? = input and output ALWAYS in mL's
The more you leave urine in the bladder, the higher risk for infection because its just sitting there because you're giving the bacteria time to grow. this is why peeing is so important and why we have to make sure our patients, especially after they have had several medications that kind of put their bladder to sleep.
True
a patient presented in the clinic with incontinence, as a result the physician ordered the nurse to measure the patients PVR (postvoid residual volume) with a ultrasound bladder scanner. The nurse notes a PVR of 130mL. What is a normal PVR?
100 mL or less
an indwelling catheter is for long term and a straight catheter is to collect rn one time-in the moment.
True
a client comes in is ordered a urine sample but she is on her period. The nurse knows to:
use a straight catheter
The nurse is caring for a new mother. The nurse recognizes that part of the patient education should be to do Kegels as this is an exercise to help strengthen the pelvic floor. How many Kegels should the nurse recommend as a good amount of Kegels per day?
30-80 per day
match the types of urinary incontinence
Transient = appears suddenly and lasts 6 months or less Mixed = urine loss with features of two or more types of incontinence Overflow = overdistention and overflow of bladder Functional = caused by factors outside the urinary tract. like when ur taking medication and u cant go to restroom, the keyword is OUTSIDE the urinary tract
match the types of urinary continence
Reflex: = emptying of the bladder without sensation of need to void; like when Jiovonne was washing dishes after she had her baby and the pee just came out. Total = continuous, unpredictable loss of urine Stressed = involuntary loss of urine related to an increase in intra-abdominal pressure Mixed = has 2 or more types of urinary continence
A patient presents with a pressure ulcer on the sacrum. The nurse knows to apply an indwelling catheter. What is the nurses reasoning for said catheter?
to keep the urine from going into the pressure ulcer. If pee gets into the wound, it would not only burn but increase the chance of creating a new one, making the situation worse.
the client presents with trouble peeing due to an obstruction in the urethra from a bladder neck mass, what kind of catheter is best for this patient?
A suprapubic catheter
a patients lab values came back and their sodium level was reading at 165mEq/L. The nurse recognizes this as:
high
A patient comes in with an irregular heartbeat, The physician ordered bloodwork to further assess. Potassium level of 6.0 mEq/L. While waiting for the physician to come back with more information, its now dinner time and the nurse is to give the patient some baked chicken, with peas, carrots and a banana. What is the nurses next course of action?
stop as the nurse knows the patient's potassium levels are too high and too much potassium in the blood affects the way the heart muscles work; which causes beat irregularity and can lead to a heart attack. This meal is packed with foods that deliver more potassium.
The nurse is ordered to give a patient their daily calcium vitamin, on the way to the clients room, the nurse gets a call saying that the patients bloodwork came back and their total calcium level is at 15 mg/dL. What will the nurse do next?
Stop the vitamins as this is an elevated level
A clients blood work for magnesium comes back and is showing 1.5 mEq/L. The nurse recognizes this as:
normal
A clients blood work comes back and shows a Chloride level of 115mEq/L. The nurse knows that a normal chloride level is 97-107mEq/L.
contact the physician and let them know about the levels and that the patient has the symptoms of toxicity by displaying muscle weakness.
The normal levels for Bicarbonate is 25-29 mEq/L
True
The normal level for phosphate is 2.5-4.5 mg/dL
True
Match the normal levels
sodium = 135-145 mEq/L Potassium = 3.5-5.0 mEq/L Calcium total = 8.6-10.2 mg/dL Ionized Calcium (not binded to proteins) = 4.5-5.1 mg/dL
Match the values
Magnesium = 1.2-2.3 mEq/L Chloride = 97-107 mEq/L Bicarbonate = 25-29 mEq/L Phosphate = 2.5-4.5mg/dL
We worry about carbon dioxide in patients with COPD, patients need to stay at 88-92%. KNOW who is affected by carbon dioxide for the test.
True
Match the respiratory functions
Hypoxia = inadequate amount of oxygen available to the cells Dysnea = difficulty breathing Hypoventilation = decreased rate or depth of air movement into the lungs NA = NA
Match the symptoms
Hypoxia = Patient will exhibit Tachycardia, Cyanosis, Anxiety, Panic Dyspnea = the patient presents with difficulty breathing Hypoventilation = known as respiratory depression. Fatigue, drowsiness, cyanosis, swelling of the ankle Hyperventilation = In patients with COPD because of the carbon dioxide being increased; the body has a hard time getting the carbon dioxide out.
Respiratory functioning in older adults
kyphosis = hunch back; the appearance of leaning forward barrel chest = deformity you see alot with COPD patients older adults have = an increased risk for pneumonia older adults tissues = and airways become more rigid and the diaphragm moves less efficiently
When we are assessing a patient we want to know all of this nursing history including :
Usual patterns of respiration Medications Health history Recent changes- if you were 100 lbs and now your 150 lbs, there is gonna naturally be a change in respirations/breathing patterns Lifestyle and environment Cough or sputum - sputum tells us if there is an infection Pain or dyspnea Fever or fatigue
True
a structural abnormality.. example, if a patient is laying down and breathing and only one side is rising.. it could be a collapsed lung. its asymmetrical. its not normal
True
temperature.. if we touch a patient and they are ice cold - this indicates perfusion issues
too hot- infection
True
Normal breath sounds NORMAL
Vesicular = low-pitched, soft sound during expiration heard over most of the lungs Bronchial = high-pitched and longer, heard primarily over the trachea Bronchovesicular = medium pitch and sound during expiration, heard over the upper anterior chest and intercostal area These are all = NORMAL breath sounds, this is what we want to hear
The nurse is auscultating breath sounds on a patient who presents with intermittent sounds occurring when air moves through airways that contain fluid. the nurse knows this to be called...
Crackles
The nurses is assessing a patient with her stethoscope and hears continuous sounds heard on expiration and sometimes on inspiration as air passes through airways that are constricted by swelling, secretions or possible tumors.. this is either classified as sibilant (high pitched, whistle like sounds) or sonorous (a deep, low-pitched rumbling or coarse sound, as air moves through tracheal/bronchial passages in the presence of mucus or respiratory secretions). This is known as:
Wheezes
Coarse crackles - tend to occur around the beginning of inspiration but can extend into expiration. they tend to be longer than fine crackles, their pitch is low and they are discontinuous, they also tend to be located in larger airways such as the bronchi. They tend to have a bubbling/gurgling sound that is not cleared with coughing.
True
wheezes- you will more than likely hear them on expiration, where they will be the loudest. They will be high pitched and continuous throughout the respiratory system. They will have a defining characteristic like a squeaky, whistling, musical noise with them. especially if your patient is having an active asthma attack.
True
As the nurse is doing rounds, she notices that one of her clients is having difficulty breathing. What is one of the first things the nurse can do to help this patient?
Place the patient in a high fowlers position
Pursed lip breathing is a technique that helps you when you feel short of breath. it works by moving fresh air into your lungs and stale air out of your lungs by keeping your airways open longer
True
Your Bronchodilators are always taken before the steroids. your bronchodilators open narrowed airways. YOU HAVE TO KNOW THIS!
True
the nurse is assisting a client in acute care and has administered albuterol. The client is asking the nurse about how the albuterol works. The nurse knows albuterol is a short-acting beta agonist and is a bronchodilator that does what?
open narrowed airways
Precautions for OXYGEN ADMINISTRATION:
Avoid open flames in the patient’s room. Place “no smoking” signs in conspicuous places. Check to see that electrical equipment in the room is in good working order. Avoid wearing and using synthetic fabrics (builds up static electricity). Avoid using oils in the area (oils ignite spontaneously in oxygen).
True
trach suctioning is a STERILE/ASEPTIC procedure
True
The nurse is teaching a patient about fluid content and the patient asks her what is the normal total of body water in a healthy person? The responds by saying...
a total body water is 50-60% of body weight
women and obese people have less body water than others
True
Your body wants to always MAINTAIN HOMEOSTASIS.. how does it do this?
by fluid balance with your Solvents: liquids that hold a substance in solution (water) and Solutes: substances dissolved in a solution (electrolytes and nonelectrolytes)
True
Match the fluid imbalances
Involve either = volume or distribution of water or electrolytes Hypovolemia = deficiency in amount of water and electrolytes in ECF with near-normal water/electrolyte proportions Dehydration = decreased volume of water and electrolyte change Third-space fluid shift (edema) = distributional shift of body fluids into potential body spaces
______________controls and regulates volume of body fluids; normal value is 135-145mEq/L
sodium
_____________is the chief regulator of cellular enzyme activity and water content; normal value is 3.5-5.0mEq/L
potassium
_____________controls nerve impulse, blood clotting, muscle contraction, B12 absorption; normal value is TOTAL 8.6-10.2mEq/L or Ionized 4.5-5.1mEq/L
calcium
______________is responsible for the metabolism of carbohydrates and proteins, vital actions involving enzymes; normal value is 1.3-2.3mEq/L
Magesium
maintains osmotic pressure in blood, produces hydrochloric acid; normal value is 97-107mEq/L
Chloride
________________is the body’s primary buffer system; normal value is 25-29mEq/L
bicarbonate
__________is involved in important chemical reactions in the body, cell division, and hereditary traits; normal value is 2.5-4.5mg/dL
Phosphate
Acid-Base balance
Acid = substance containing hydrogen ions that can be liberated or released Base = substance that can trap hydrogen ions Acidosis = excess hydrogen ions Alkalosis = loss of hydrogen ions
fluid volume excess- definitions to know
Hypervolemia: = excessive retention of water and sodium in ECF Overhydration = above-normal amounts of water in extracellular spaces Edema = excessive ECF accumulates in tissue spaces Interstitial-to-plasma shift: = movement of fluid from space surrounding cells to blood
burns, trauma and surgery are HUGE risk factors for imbalances.
True
When you see therapies, think medications.. some therapies can cause fluid retention or fluid elimination
True
the lab studies to test for imbalances are:
Complete blood count (CBC) Serum electrolytes, blood urea nitrogen (B.U.N.), and creatinine levels Urine pH and specific gravity Arterial blood gases (ABG)
MAKE SURE YOU KNOW THE LAB VALUES FOR THIS EXAM!
True
Urge incontinence (the involuntary loss of urine that occurs soon after feeling an urgent need to void)
True
Sedatives and tranquilizers may diminish awareness of the need to void.
True
People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine.
True
match the pathologic conditions
Acute kidney injury (AKI) = is a sudden decline in kidney function (over hours or within a day [Norris, 2020]), and may be caused by conditions such as severe dehydration, anaphylactic shock, sepsis, and ureteral obstruction. Renal failure = is a condition in which the kidneys fail to remove metabolic end products from the blood and are unable to regulate fluid, electrolyte, and pH balance Urinary Calculi = are kidney stones Chronic kidney disease (CKD) = is the slow loss of kidney function over months or years as a result of irreparable damage to the kidneys. This is caused by conditions such as diabetes, hypertension, and glomerulonephritis.This will eventually lead to the final stage of CKD, known as kidney (renal) failure or end-stage renal disease (ESRD)
In kidney failure, kidney function drops below 15%
True
Anticoagulants may cause Hematuria (blood in the urine), leading to a pink or red color.
True
After surgery, the biggest concern is pneumonia, an incentive spirometer can help in expanding those lungs.
True
match the IV gauges
green = 18 gauge pink = 20 gauge blue = 22 gauge yellow = 24 gauge
Sputum is mucus or phlegm coughed up from your lungs (not spit, saliva, or nasopharyngeal discharge). Sputum samples are used to diagnose active tuberculosis (TB) and to monitor the effectiveness of TB treatment.
Step 1
• Drink plenty of water the night before collection. Best time of day to collect sputum is when you first wake.
• Do not eat, drink or smoke before coughing up sputum from the lungs.
• Rinse (do not swallow) the mouth with water before sputum is collected to minimize residual food particles, mouthwash, or oral drugs that might contaminate the specimen.
Step 2
• Go away from other people either outside or beside an open window before collecting the specimen. This helps protect other people from TB germs when you cough.
• Take the plastic tube with you. The collection tube is very clean. Do not open it until you are ready to use it.
Carefully open the plastic tube.
Step 3
• Take several deep breaths.
• Cough hard from deep inside the chest three times to bring sputum up from your lungs.
• Spit the sputum into the tube carefully. Try not to touch the rim of the container.
• Repeat until you have 1 - 2 tablespoons of sputum in the tube.
• Replace the cap tightly on the plastic tube.
• Wash and dry the outside of the tube.
• Write date of collection in the proper box on the lab slip.
Step 4
• Place the primary specimen container (usually a conical centrifuge tube) in the clear plastic baggie that has the biohazard symbol imprint.
• Place the white absorbent sheet in the plastic baggie.
• Expel or "push" excess air from the plastic baggie and then seal it. Refer to the printed instructions on the baggie for detailed guidance on sealing the baggie properly.
•Place the plastic baggie inside the white Tyvek envelope.
• Expel or "push" excess air from the Tyvek envelope and then seal the Tyvek envelope securely.
Place the Tyvek envelope inside the fiberboard canister.
• Place the specimen submission form inside the fiberboard canister.
• Screw the canister lid onto the canister. Secure the lid closed with sealing/mailing tape.
True
What is the correct method for measuring a patient's urine output?
Discarding urine in the toilet regardless of specimen needs
Which action promotes urinary elimination in patients according to the text?
Encouraging regular voiding habits
What should a nurse do to assist a patient experiencing fluid imbalances?
Ensure fluid and electrolyte balance is maintained
Why is it important for a patient to maintain fluid balance according to the text?
To maintain homeostasis
What does a patient producing urine output equal to fluid intake indicate?
Normal fluid balance
How does promoting fluid intake help in urinary elimination?
Aids in frequent urination
What is a common side effect of bronchodilators?
Increased inflammation of the airways
Which precaution is essential for nurses to follow when administering supplemental oxygen?
Check that electrical equipment in the room is in good working order
What is the primary function of nebulizers in respiratory treatment?
Deliver a controlled dose of medication with each compression of the canister
Which symptom indicates potential fluid and electrolyte imbalances in a patient?
Rapid weight gain or loss
What is a common effect of corticosteroids administered in respiratory care?
Decreased inflammation in the airways
What is a vital aspect to consider when developing a dietary plan for a patient with respiratory issues?
Ensuring proper nutrition to support overall health
What is the expected outcome in terms of fluid intake and output balance over a 3-day period?
2,500-mL intake and output
Which action should a patient take if they experience recurrence of fluid and electrolyte imbalance symptoms?
Report relief of symptoms after treatment
What should be done to identify signs and symptoms of restored balance in a patient with fluid and electrolyte imbalance?
Practice self-care behaviors to promote balance
In developing a dietary plan for a patient with fluid and electrolyte imbalance, what should be the primary focus?
Balancing electrolytes through food choices
When preventing fluid and electrolyte imbalances, what intervention should be prioritized for short-term venous access?
Placing a PICC line
Which intervention is crucial for managing patients with impaired fluid intake due to vomiting or diarrhea?
Maintaining approximate fluid intake and output balance
Which condition is likely to result from fluid overload?
Hypertension and peripheral edema
What is a common cause of fluid imbalance?
Hypovolemia from dehydration
Which electrolyte is primarily responsible for controlling nerve impulses and muscle contractions?
Calcium
What is a symptom commonly associated with hypovolemia?
Bradycardia and cool skin
Why is maintaining fluid balance important for the body?
To regulate blood pressure
Which organ is primarily responsible for maintaining electrolyte balance in the body?
Kidneys
What is the primary characteristic of hypovolemia?
Deficiency in amount of water and electrolytes with near-normal proportions
Which electrolyte is primarily responsible for controlling and regulating the volume of body fluids?
Sodium
What is the main consequence of dehydration in the body?
Decreased volume of water and electrolyte change
In cases of fluid imbalance, which organ primarily filters plasma and excretes urine to help maintain homeostasis?
Kidneys
What is the principal function of bicarbonate in the body's physiology?
Act as the primary buffer system
Which condition is characterized by a distributional shift of body fluids into potential body spaces, also known as edema?
Third-space fluid shift
Which gland stores and releases ADH, a hormone that helps regulate water balance in the body?
Pituitary gland
In which type of solution do cells swell due to a lower concentration of particles compared to plasma?
Hypotonic
What effect does hypertonic solution have on cells?
Causes cells to shrink
Which organ is responsible for increasing blood flow in the body and renal circulation?
Thyroid gland
What is the normal range for calcium level in the extracellular fluid (ECF)?
135-145mEq/L
A patient is found to have a significantly low level of potassium in their blood. What is the medical term for this condition?
Hypokalemia
What is the primary electrolyte responsible for controlling nerve impulses, blood clotting, muscle contraction, and B12 absorption?
Calcium
A patient's blood work reveals a potassium level of 2.0 mEq/L. This condition is known as:
Hypokalemia
Which condition is characterized by a significantly low level of sodium in the blood?
Hyponatremia
What is the correct term for a primary deficit of bicarbonate in the extracellular fluid?
Metabolic acidosis
In which condition do cells tend to swell due to a lower concentration of particles compared to plasma?
Hypotonic solution
Which electrolyte imbalance is associated with symptoms like muscle weakness, cardiac arrhythmias, and constipation?
Hypokalemia
Excess of carbonic acid in the extracellular fluid is a characteristic feature of which acid-base imbalance?
Respiratory acidosis
Which electrolyte plays a vital role in maintaining heart rhythm and conducting nerve impulses?
Potassium
What does a significantly high level of chloride in the blood indicate?
Hyperchloremia
Complete this statement: Metabolic alkalosis results from a primary excess of bicarbonate in the extracellular fluid combined with...
Respiratory alkalosis
Study Notes
Promoting Optimal Function
- Healthy lifestyle choices and behaviors, such as vaccinations against influenza, pneumococcal disease, and COVID-19, teaching about a pollution-free environment, and maintaining good nutrition
- Reducing anxiety, promoting comfort, and controlling coughing
- Performing chest physiotherapy and meeting oxygen needs with medications
- Administering inhaled medications, including bronchodilators, mucolytic agents, corticosteroids, antihistamines, and leukotriene receptor antagonists
Oxygen Administration
- Providing supplemental oxygen through various delivery systems, including nasal cannula, simple mask, nonrebreather, and Venturi mask
- Precautions for oxygen administration, including avoiding open flames, synthetic fabrics, and oils
Fluid Balance
- Maintaining approximate fluid intake and output balance (2,500-mL intake and output over 3 days)
- Maintaining urine specific gravity within normal range (1,010–1,025)
- Practicing self-care behaviors to promote balance
Preventing Fluid and Electrolyte Imbalances
- Developing a dietary plan and modifying fluid intake
- Administering medications, including mineral–electrolyte preparations and diuretics
- Administering intravenous fluid therapy through PICCs, nontunneled percutaneous central venous catheters, and indwelling catheters
Urinary Elimination
- Maintaining regular voiding habits and promoting fluid intake
- Strengthening muscle tone with Kegel exercises
- Assisting with toileting and promoting urinary elimination
- Measuring urine output and maintaining skin integrity
Physical Assessment
- Assessing skin and tone turgor
- Evaluating moisture and oral cavity, tearing, and salivation
- Inspecting skin appearance and temperature
- Monitoring body temperature, pulse, respirations, and blood pressure
Lab Studies
- Complete blood count (CBC)
- Serum electrolytes, blood urea nitrogen (BUN), and creatinine levels
- Urine pH and specific gravity
- Arterial blood gases
Actual or Potential Health Problems
- Fluid overload (hypervolemia) caused by heart failure, cirrhosis, or kidney failure
- Fluid imbalance caused by dehydration or fluid overload
- Impaired fluid intake caused by deficient fluid volume or electrolyte imbalance
Electrolytes and Homeostasis
- Major electrolytes and their chief functions:
- Sodium: controls and regulates volume of body fluids (lab value: 135-145 mEq/L)
- Potassium: chief regulator of cellular enzyme activity and water content (lab value: 3.5-5.0 mEq/L)
- Calcium: nerve impulse, blood clotting, muscle contraction, and B12 absorption (lab value: 8.6-10.2mg/Dl and ionized 4.5-5.1mg/dL)
- Magnesium: metabolism of carbohydrates and proteins, vital actions involving enzymes (lab value: 1.3-2.3mEq/L)
- Chloride: maintains osmotic pressure in blood, produces hydrochloric acid (lab value: 97-107 mEq/L)
- Bicarbonate: body’s primary buffer system (lab value: 25-29 mEq/L)
- Phosphate: involved in important chemical reactions in the body, cell division, and hereditary traits (lab value: 2.5-4.5mg/dL)
- Primary organs of homeostasis:
- Kidneys
- Cardiovascular system
- Lungs
- Adrenal glands
- Pituitary gland
- Thyroid gland
- Parathyroid glands
- GI tract
- Osmolarity of a solution:
- Isotonic: same concentration of particles as plasma
- Hypertonic: greater concentration of particles than plasma
- Hypotonic: lesser concentration of particles than plasma
This quiz discusses a case of an elderly woman experiencing central vision loss but with intact peripheral vision, as noted by a nurse in an eye clinic. The symptoms are impacting her daily activities like sewing and seeing her grandchildren.
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