final exam health dev

What acid base imbalance can be caused by vomiting?

metabolic alkalosis

What acid base imbalance can be caused by myasthenia gravis (weakeness in the upper extremities, including chest muscles)?

respiratory acidosis

What acid base imbalance can be caused by COPD?

respiratory acidosis

What acid base imbalance can be caused by pneumonia?

respiratory acidosis due to excessive mucus that causes a decrease in respirations

What education should be provided an obese client before a surgical procedure?

* healthy diet
* increase activity levels

What education should be provided to an individual after a gastrectomy?

* maintain a semi-fowlers position
* report any new or unusual bleeding from surgical site
* do not manipulate NG tube, care for it
* start on clear liquid diet, advance as tolerated

What are the s/s of a duodenal ulcer?

Pain 1.5 hours after meals

Pain @ night when food is digesting

Relieved by food consumption

Well-nourished because they are still able to eat foods

What are the s/s of a gastric ulcer?

Pain 30-60 mins or immediately after eating

Pain during daylight hours (eating hours)

Relieved by exacerbating food (vomittiing)

Malnourished/thin due to not being able to keep food in

What are the s/s of GERD?

* dyspepsia
* jaw, chest, and throat pain
* pyrosis (burning in throat)
* odynophagia (pain by swallowing)
* dental cares due to acid rubbing on teeth

What education should be provided to an individual post op gastric bypass?

* educate about s/s of infection & hemorrhage
* strict I&Os
* follow clear liquid diet with 6 small meals a day
* educate about exercise

What complication can be caused by a duodenal ulcer?

* bleeding/hemorrhage
* pernicious anemia
* dumping syndrome
* pyloric obstruction

What is the method of action for GI medications?

reduce gastric acid

How do we diagnose a gastric ulcer?

esophagogastroduodenscopy (EGD)

What are the common problems associated with chronic gastritis?

* gastric bleeding
* gastric obstruction
* dehydration
* dumping syndrome
* pernicious anemia
* h. pylori

Describe post-op care for a client after a Billroth II (gastrojejunostomy) procedure?

eat small 6 meals a day

sit upright while eating

increase fluids before or after meals but not during

___ is the severing of the vagus nerve to reduce gastric acid by diminishing cholinergic stimulation or reduce gastric acid secretion. It is specifically used as a therapeutic procedure in treating gastritis.

vagotomy

What is the treatment plan for a tension headache?

apply heat or ice to forehead

What are some migraine triggers caused by food a patient with a history of migraines need to avoid?

foods high in tyramine such as aged cheese, beer, and chocolate

What education should be provided to an individual prescribed cardidopa- levodopa?

“You should not be concerned if you excrete dark or orange fluids because this is a side effect from the medication.'“

What nursing interventions should be provided for an individual with a hemorrhagic stroke?

* eat small but frequent meals, chew thoroughly
* eat with chin tucked in
* eat in a high-fowlers position
* remove all rugs/wires at home to avoid injury

What is a TIA?

a neurological deficit that completely resolves in 24 hours that serves as a warning sign before a real stroke

What are the signs and symptoms of a stroke?

numbness or weakness in the face, arm, or leg (does not have to be bilateral)

sudden confusion or headache

aphasia (cannot understand speech receptive or expressive)

difficulty walking, dizziness, or loss of balance

What education should be provided for an individual with a diagnosis of multiple sclerosis?

Encourage the patient to do moderate exercises

Educate on a healthy diet to patient and caretakers

Manage fatigue by sleeping 8 hours and frequent rest periods

Educate on schedule bathroom times to encourage bowel/bladder program

\

What are the s/s of multiple sclerosis?

* ataxia
* paresthesia
* nystagmus
* Uhtoff’s sign

LEFT CVA clinical manifestations:

ataxia

aphasia (expressive, receptive, global)

slow cautious behavior,

right visual deficits and weakness

altered intellectual ability

What is the plan of care for an individual receiving tPA?

monitor for bleeding:

vitals such an low BP and cardiac arrhythmias

IV site

NG tube

stool/emesis

catheters

What acid base imbalance can be caused by an NG tube?

metabolic alkalosis due to the risk of excessive suctioning of acidic secretions

What acid base imbalance can be caused by an opiod overdose?

respiratory acidosis due to the low respiratory drive

What acid base imbalance can be caused by diarrhea?

metabolic acidosis due to the base leaving the ass

What is the treatment plan for an individual experiencing respiratory alkalosis?

paper bag form hyperventilation

monitor calcium and potassium levels

oxygen therapy, reduce anxiety

What acid base imbalance can be caused by hyperventilation?

respiratory alkalosis due to blowing off too much CO2

A patient with Fluid Volume Excess should report what to the physician?

2 pounds weight gain in 24 hours or 5 lbs in a week

What electrolyte imbalance is the patient most at risk for when taking Furosemide/Lasix?

hypokalemia

What electrolyte imbalances cause a positive Chvostek sign and positive Trousseau’s Sign?

hypocalcemia

What are the two major causes of hyperkalemia?

potassium sparing diuretics (Aldactone)

excess K+ intake

kidney failure bc it starts to retain everything

adrenal insufficiency

cellular movement of K+ (burns)

Tall, peaked T-waves are indicative of what electrolyte imbalance?

hyperkalemia

What are some examples of isotonic IV solutions? Remembered the

sodium chloride 0.9% (NS)

lactated ringers

Dextrose 5% Water (D5W)

What are some examples of hypertonic IV solutions? \*more than 0.9% is hypertonic.

3% NaCL

5% dextrose in LR

5% dextrose in NS

What are some examples of hypotonic IV solutions? \*remember anything that is less than 0.9% is hypotonic.

0\.45% NaCl

0\.225% NaCl

A safe administration routes for potassium chloride is:

Potassium has to be administered slowly over at a IV rate of 10-20 meq/L but is to not excess 20 meq/L.

What should a nurse monitor for when administering K+ chloride safely?

phlebitis- look for any swelling, tenderness, warmness and redness

infiltration

When a patient is receiving Potassium Chloride, administering ____ can be dangerous since hypokalemia increases the sensitivity to digitalis, predisposing one to digitalis toxicity at lower digoxin level. (therapeutic level of digi is 0.8-2.0 ng/mL).

digoxin

A person with a magnesium level greater than 2.6 mg/dL is at risk for what?

\

respiratory depression due to magnesium affecting the cardiovascular system by regulating BP

What is the most common cause of symptomatic hypomagnesemia?

excessive alcohol

What should be encouraged for a patient with Hypernatremia?

PO fluids

decreased sodium intake

anticipate hypotonic or isotonic IV solutions

What should be restricted for a patient with Hyponatremia?

fluids bc they ordinally already have excess fluids

COPD is composed of what two diseases?

chronic bronchitis & emphysema

Which oxygen delivery system delivers the most precise amount of oxygen and which one delivers the most concentrated?

venturi mask & non-rebreather

What are your safety education points for a patient who is on oxygen at home?

* no smoking signs or smoking at all
* ensure all electric devices are secured and wired down
* know where the clothes fire extinguisher is
* cotton instead of synthetic material
* avoid use of acetone or alcohol containing products

What is the most effective way to assess oxygen therapy?

ABGs

What should the nurse do first if a chest tube is accidentally removed from the patient’s chest wall?

apply petroleum gauze with dry sterile gauze and tape over to secure

What should the nurse do first if a chest tube is accidently removed from the chest tube drainage system?

immerse the end of the tube in sterile water to provide temporary water seal

Which medications should be withheld prior to a PFT?

bronchodilators should be withheld 4-6 hours before to prevent a false reading

What education should you give a patient prescribed Guaifenesin, a mucolytic that helps clear the airway and clearing chest congestion thus making it breath easier?

educate patient to increase fluids to help thin secretions

What are complications of a bronchoscopy?

pneumothorax, infection, aspiration

What assessment findings indicate a pneumothorax?

absent or restricted movement of affected side

pleuritic pain

dyspnea

Bubbling in the water-seal chamber of a chest tube system indicates what?

an air leak, bubbling should only be present in the 3rd chamber

A patient with pneumonia who is sent home on a prescription of antibiotics should be educated to call the physician if what happens?

if there is a change in secretions and change in color sputum

What symptoms of indicative of Pneumonia?

* crackles
* pleuritic chest pain
* yellow-tinged sputum
* dull chest percussion
* decreased O2 sat

\*accompanied by fever, chills, SOB

A patient brought up to the PACU after undergoing a vagotomy. What complications does the nurse need to monitor for?

* dumping syndrome
* diarrhea
* gastritis

The PACU nurse is preparing to insert a NG tube to a post-op patient that has underwent a Billroth II procedure. What does the nurse need to make sure to do if the NG needs to be manipulated in any way?

has to call HCP before doing so

The patient complains of a sore throat and states “I cough up some blood earlier this morning.” The nurse knows the patient has just underwent an EGD. What is the best response from the nurse?

“Minor bleeding accompanied by a sore throat is common after an EGD since a tube was inserted down your esophagus.”

A patient who is 1 hour post op from an EGD complains of a “sharp, retrosternal pain.” What is the nurse’s next action?

call HCP to request a CT scan

The nurse knows that the most important nursing intervention after an EGD is to monitor the patients ____ due to the possibility of puncturing a lung during the procedure or the stomach.

respiratory status

A nurse must assess the ___ before the patient can resume a tolerable diet after an EGD.

gag reflex

A nurse is assessing a post-op patients vital signs after an EGD procedure. The patients vitals are the following: BP of 96/70; HR of 110; 101 degrees temp. What is the nurse’s priority action?

contact HCP because esophageal perspiration is suspected

What patient education is essential pre-op of an EGD procedure?

NPO 6-8 hours before & remove objects such as dentures

GERDs medications include the following:

* PPIs (“azoles”)
* antacids
* histamine receptor antagonist (rantidine)
* prokinetics (metoclopramide)

___ is the GERD medications that controls nausea and vomiting by blocking dopamine & serotonin receptors increasing GI motility (increasing the tone of lower esophageal sphincter)?

metoclopramide (in the prokinetics drug class)

What GERD medication suppresses gastric acid and lowers hydrogen ions?

ranitidine

Antacids reduce gastric acid and protect the mucosal lining. What if the patient is taking magnesium hydroxide or calcium carbonate?

The nurse must educate that long term use of magnesium antacids causes diarrhea and long term use of calcium causes constipation.

What complication due to chronic gastritis can cause or lead to the other complications that can occur with the diease?

pyloric stenosis

The normal pH is __.

7\.4

The normal CO2 level is ___.

35-45

The normal CO3 (bicarb) is ___.

22-28

Anything less than ___ is considered acidic. Anything more than 7.45 is __.

acidic; alkalotic

The first line of maintenance of acid-base balance is the chemical and protein buffers. What is the last?

kidney buffers because they either excrete or retain electrolytes

The biggest indicator of respiratory acidosis upon assessment is ___.

diminished lung sounds

When the patient cannot fully expand the lungs, they are retaining acid, causing respiratory acidosis. What are common causes of this acid-base imbalance?

Drugs (anasethesia)

Edema in the lungs

Pneumonia due to excess mucus (chronic)

Respiratory center of the brain is damaged (stroke)

Sac elasticity of alveoli is impaired (COPD, Emphysema, bronchitis)

A patient experiencing respiratory acidosis will have a lack of O2, more CO2 (acidic). What clinical manifestations occur with acid base imbalance?

* bradypnea (lungs cannot full expand)
* confused, drowsy, HA (no O2 to brain)
* hyperkalemia due to acidity
* EKG changes with a peaked T wave
* pale or cyanotic

A patient is being treated for respiratory acidosis when suddenly he experiences a respiratory rate of 10. What is the nurse’s next action?

prepare the pt for intubation

The most important nursing intervention when a patient is experiencing respiratory alkalosis is ___.

having the patient breath into a paper bag

Respiratory alkalosis can be caused by anything that makes the body works too hard, or hyperventilate, and makes the body expel too much CO2 (acidic). What are some causes?

Temp

Aspirin toxicity

Controlled intubation

Pain/pregnancy

Anxiety, asphyxia, asthma

A patient with respiratory will have low calcium & low potassium due to losing acidity in the body, leaving it alkalotic. What assessment finding does the nurse expect to find?

positive Chvostek’s sign

The hallmark sign of respiratory alkalosis is ____.

tetany with tingling and numbness

What vital signs will a patient experiencing respiratory alkalosis exhibit?

tachypnea, tachycardia

A patient comes into the ER with a flushed face and is throwing up. The nurse notices the patient is having Kussmaul respirations and notes a fruity/acetone breath. The nurse knows the patient is likely to develop what acid-base imbalance?

metabolic acidosis due to a DKA

Anything that causes the body to lose base out the ass results in metabolic acidosis. What are some specific causes?

Diarrhea

Ostomy drainage

Fistula

Alcoholism (liver cannot produce bicarb)

A patient experiencing metabolic acidosis. The nurse checks the ABGs results and the pH is 7.25. The nurse assess the patients vitals a notes Kassumal breathing with a decreased BP. The patient is confused and weak. What does the nurse prepare for?

intubation

metabolic acidosis s/s:

* tachypnea
* hyperkalemia
* cardiac dysthrymias
* nausea/vomitting to try to make the body alkalotic
* \

metabolic alkalosis s/s:

* hypoventilation, bradypnea
* hypotension
* hypokalemia with EKG changes
* tremors
* tetany

To obtain an ABG:

\*must perform Allen test first\*


1. use heparin needle
2. APPLY PRESSURE FOR 5-10 minutes!!!
3. roll sample after drawing
4. put it in ice
5. monitor site for phlebitis

Partially compensated is when the pH, CO2 & CO3 are ___.

all out of range

Fully compensated is when the pH is _. The CO2 & CO3 are _.

normal; both outside expected range

What can trigger a migraine?

* environmental allergies
* bright lights
* odors
* alcohol
* stress/anxiety/ sleep deprivation

A nurse knows that a patient diagnosed with Parkinson’s disease is due to the loss of dopamine. What clinical manifestations does the nurse expect to see in the patient?

Tremors at rest “pill-rolling”

Rigidity “cogwheel” movement

Akinesia/bradykinesia

Postural instability “shuffling gait”

A nurse is assessing her patient in the ER that came in due to a hemorrhagic stroke when all of a sudden the patient begins to seize. What does the nurse do?

roll the patient to their side and do not put anything in their mouth

The patients complains of “on-going, excruciating pain” and pressure on one side of the eye and that doesnt seem to go away even with analgesia. What question should the nurse ask during the focused assessment?

“Do other members in your family get headaches often?”

“What coping skills do you practice when undergoing stress?”

“How many hours at night do you sleep?”

“Do you have seasonal allergies?”

The patient shouts “I have this headache that feels like the worst headache of my life!” The nurse is concerned because she suspects a hemorrhagic stroke. What is the nurse’s priority action?

obtain a CT/MRI

Increased ICP decreases cerebral perfusion which can increase the risk for a hemorrhagic stroke. What are the late signs of increased ICP?

cushing’s triad:

increased BP with pupillary changes

low RR with slurring speech

low HR with slow bounding pulse