Nursing Arts and Science Exam #3

What is the normal range for sodium levels?

135-145 mEq/L

What is the function of sodium in the body?

- regulates extracellular fluid volume
- affects serum osmolality
- role in irritability and conduction of nerve muscle tissue
- regulation of acid-base balance as sodium bicarb

What causes hypernatremia?

- increased sodium intake: excess oral sodium ingestion, excess administration of IV fluids with sodium, and hypertonic IV fluids
- loss of fluids: diarrhea, fever, diabetes insipidus, excessive diaphoresis, and infection
- decreased sodium excretion: kidney problems

What causes hyponatremia?

- increased sodium excretion: diaphoresis, diarrhea, vomiting, drains (NGT suction), and diuretics
- SIADH (syndrome of inappropriate antidiuretic hormone secretion)
- adrenal insufficiency
- inadequate sodium intake
- kidney disease
- HF

What are signs and symptoms of hyponatremia?

SALT LOSS: Stupor/coma, Anorexia, Lethargy, Tachycardia, Limp muscles, Orthostatic hypotension, Seizures/headache, Stomach cramping (hyperactive bowels)
also edema, and increased ICP

What are signs and symptoms of hypernatremia?

FRIED SALT: Flushed skin, Restless, irritable, confusion, anxious, Increased BP and fluid retention, Edema, Decreased urine output, Skin flushed and dry, Agitation, Low-grade fever, and Thirst (dry mucous membranes)

What is the normal range for potassium levels?

3.5-5 mEq/L

What is the normal range for calcium levels?

8.6-10.2 mg/dL

What is the normal range for chloride levels?

97-107 mEq/L

What is the normal range for magnesium levels?

1.3-2.3 mEq/L

What is the normal range for phosphate levels?

2.5-4.5 mg/dL

What are the functions of potassium?

- controls intracellular osmolality
- regulator of cellular enzyme activity
- role in the transmission of electrical impulses in nerve, heart, skeletal, intestinal, and lung tissue
- regulation of acid-base balance by cellular exchange with H+

What are causes of hyperkalemia?

- medications: potassium-sparing diuretics, ACE inhibitors, and NSAIDs
- excessive potassium intake
- kidney disease or those on dialysis
- adrenal insufficiency
- tissue damage
- acidosis
- hyperuricemia
- hypercatabolism

What are signs and symptoms of hyperkalemia?

- muscles contract for too long!
MURDER: Muscle cramps and weakness, Urine abnormalities, Respiratory distress, Decreased cardiac contractility (decreased HR and BP), EKG changes, and Reflexes (increased DTR)

What are causes of hypokalemia?

- actual total bod potassium loss
- inadequate potassium intake
- movement of potassium from the extracellular fluid to the intracellular fluid: alkalosis and hyperinsulinism
- dilution of serum potassium: water intoxication, IV therapy with potassium-deficient solutions

What are signs and symptoms of hypokalemia?

- muscles don't contract enough!
- thready, weak, irregular pulse
- orthostatic hypotension
- shallow respirations
- anxiety, lethargy, confusion, coma
- paresthesias
- hyporeflexia
- hypoactive bowel sounds
- n/v, abdominal distention

What is the function of calcium?

- role in blood coagulation and in transmission of nerve impulses
- helps regulate muscle contraction and relaxation
- major component of bones and teeth

What are causes of hypercalcemia?

- increased calcium absorption
- decreased calcium excretion
- kidney disease
- thiazide diuretics
- increased bone resorption of calcium: hyperparathyroidism and cancer
- hemoconcentration

What are signs and symptoms of hypercalcemia?

BACKME: Bone pain, Arrhythmias, Cardiac arrest, Kidney stones, Muscle weakness (decreased DTR), Excessive urination

What are causes of hypocalcemia?

- inhibition of calcium absorption from the GI tract
- increased calcium excretion: kidney disease, diuretic phase, diarrhea and steatorrhea, and wound drainage
- conditions that impair calcium absorption

What are signs and symptoms of hypocalcemia?

CATS GO NUMB: Convulsions, Arrhythmias, Tetany, Spasms and stridor, Numbness in fingers, face, and limbs

What are functions of magnesium?

- metabolism of carbs and proteins
- role in neuromuscular function
- acts on cardiovascular system, producing vasodilation

What are causes of hypermagnesemia?

- increased magnesium intake: magnesium-containing antacids, laxatives, and excessive administration of magnesium IV
- renal insufficiency: decreased renal excretion of magnesium increases magnesium in the blood
- diabetic ketoacidosis

What are signs and symptoms of hypermagnesemia?

- LOW everything, aka SEDATED
- decreased energy, HR, BP, RR, bowel sounds, DTR, and shallow respirations

What are causes of hypomagnesemia?

- insufficient magnesium intake: malnutrition, n/v, malabsorption syndrome, and celiac and crohn's
- increased magnesium excretion: diuretics and chronic alcoholism
- intracellular movement of magnesium: hyperglycemia and insulin administration, and sepsis

What are signs and symptoms of hypomagnesemia?

- HIGH everything, aka NOT SEDATED
- increased HR, BP, RR, DTR
- twitches, paresthesias, tetany, seizures, irritability and confusion

What are functions of chloride?

- major component of interstitial and lymph fluid, gastric and pancreatic juices, sweat, bile, and saliva
- acts with sodium to maintain osmotic pressure
- combines with hydrogen ions to produce hydrochloric acid

What are causes of hyperchloremia?

metabolic acidosis, head trauma, increased perspiration, excess adrenocortical hormone production, and decreased glomerular filtration

What are causes of hypochloremia?

severe vomiting and diarrhea, drainage of gastric fluid, metabolic alkalosis, diuretic therapy and burns

What are signs and symptoms of hyperchloremia?

tachypnea, weakness, lethargy, diminished cognitive ability, hypertension, decreased cardiac output, dysrhythmias, and coma

What are signs and symptoms of hypochloremia?

hyperexcitability of muscles, tetany, hyperactive DTR, weakness, and muscle cramps

What are the functions of phosphate?

- role in acid-base balance as a hydrogen buffer
- promotes energy storage, carbs, protein and fat metabolism
- bone and teeth formation
- role in muscle and red blood cell function

What are causes of hyperphosphatemia?

impaired kidney excretion and hypoparathyroidism

What are causes of hypophosphatemia?

administration of calories to malnourished patients, alcohol withdrawal, diabetic ketoacidosis, hyperventilation, insulin release, absorption problems, and diuretic use

What are signs and symptoms of hypophosphatemia?

confusion, appetite loss, muscle weakness, fatigue, bone pain, slow growth in children

What are signs and symptoms of hyperphosphatemia?

tetany, anorexia, nausea, muscle weakness, and tachycardia

What are ways fluid is lost through sensible losses?

urination, defecation, vomit, and wounds

What are ways fluid is lost through insensible losses?

evaporation through the skin and water vapor from the lungs during respiration

What is a hypotonic solution?

a solution that contains more water than salt. the vessel will become less concentrated than the cell and the water will travel into the cells.
TIP: go Out of the vessel and into the cells

What is a hypertonic solution?

a solution that contains more salt than water. the vessel becomes more concentrated than the cell which will cause water to leaves the cells
TIP: Enter the vessel from the cells

What is an isotonic solution?

a solution that has an equal water to salt ratio
TIP: stays where I put it

What are examples of hypotonic solutions?

0.45% NS (1/2 NS), 0.33% NS (1/3 NS), 0.225% NS (1/4 NS), 5% dextrose in water (D5W)

What are examples of isotonic solutions?

0.9% sodium chloride (NS), 5% dextrose in water (D5W), and lactated ringers (LR)

What is something important to remember with D5W?

it starts out as isotonic and then changes to hypotonic once the dextrose is metabolized

What are examples of hypertonic solutions?

5% NS, 3% NS, 5% dextrose in 0.9% NS (D5NS), 5% dextrose in 0.45% NS (D5 1/2 NS), 5% dextrose in LR (D5LR), and 10% dextrose in water (D10W)

What are signs and symptoms of excess fluid volume (hypervolemia)?

- JVD
- increased HR (bounding) , BP, and weight
- crackles in lungs
- edema
- polyuria

What are signs and symptoms of deficient fluid volume (hypovolemia)?

- flat neck veins
- increased HR (weak and thready), and respirations
- decreased weight, BP, skin turgor, and urine output
- dry mucous membranes
- thirst

What are nursing diagnoses related to fluid and electrolyte imbalances?

risk for electrolyte imbalance, risk for imbalanced fluid volume, deficient fluid volume, risk for deficient fluid volume, excess fluid volume

impaired urinary elimination, impaired gas exchange, risk for unstable blood pressure, impaired physical mobility, acute confusion, risk for acute confusion, autonomic dysreflexia, risk for autonomic dysreflexia, risk for dry mouth, impaired oral mucous membrane integrity, risk for vascular trauma, risk for oral mucous membrane integrity, impaired skin integrity, risk for impaired skin integrity, risk for falls

What are nursing interventions for patients with hypovolemia?

- fluid replacement (PO or IV)
- safety precautions (risk for fall due to orthostatic hypotension)
- daily I&O and weights

What are nursing interventions for patients with hypervolemia?

- low sodium diet
- daily I&O and weights
- diuretics
- high-fowlers or semi-fowlers to assist with breathing

What are nursing interventions for patients with hypermagnesemia?

- diuretics
- IV administration of calcium chloride or calcium gluconate
- restrict dietary intake of magnesium
- avoid the use of laxative and antacids containing magnesium
- hemodialysis

What are nursing interventions for patients with hypomagnesemia?

- magnesium sulfate PO or IV
- seizure precautions
- instruct the pt to increase magnesium containing foods

What are nursing interventions for patients with hypercalemia?

- discontinue IV or PO calcium
- discontinue thiazide diuretics
- administer phosphorus, calcitonin, biphosphonates, and prostaglandin synthesis inhibitors (as calcium increases, phosphate decreases)
- avoid foods high in calcium

What are nursing interventions for patients with hypocalcemia?

- administer calcium PO or IV (for IV, warm before and administer slowly)
- administer aluminum hydroxide and vitamin D
- initiate seizure precautions
- consume foods high in calcium

What are nursing interventions for patients with hyperkalemia?

- monitor EKG
- discontinue IV and PO potassium
- initiate a potassium restricted diet
- potassium-excreting diuretics
- prepare pt for dialysis
- prepare for administration of IV calcium gluconate and IV sodium bicarb
- avoid use of salt substitutes or other potassium containing substances

What are nursing interventions for patients with hypokalemia?

- oral potassium supplements
- liquid potassium chloride
- potassium retaining diuretic
- IV potassium (diluted)

What are nursing interventions for patients with hypernatremia?

- administer IV infusions if due to fluid loss
- give diuretics that promote sodium loss if due to inadequate renal excretion of sodium
- restrict sodium and fluid intake

What are nursing interventions for patients with hyponatremia?

*ADD SALT*
- Administer IV sodium chloride infusion (only if due to hypovolemia)
- Diuretics (if due to hypovolemia
- Daily weights
- Safety (risk for falls due to orthostatic hypotension)
- Airway protection: NPO, dont give food to a lethargic, confused pt due to risk for aspiration
- Limit water intake due to hypervolemia hyponatremia
- Teach about foods high in sodium

What nursing care should be performed with vascular access devices?

- checking the site for any complications
- checking for kinks in the tubing
- checking to make sure the flow rate is correct
- flush IV with 10 mL of NS twice a shift and every time you administer meds
- determine if the device is needed, esp. with peripheral venous catheters

How does the nurse ensure safe and effective IV fluid and medication administration?

- flush IV before and after meds are administered
- do not run two IVs at the same time if they are not compatible
- ask pt about allergies

What is an air embolism?

when air enters the vein through the IV tubing

How do you manage an air embolism?

- clamp the tubing
- turn pt on left side and place in trendelenburg
- notify provider

What is infiltration?

- when IV fluids leak into surrounding tissue

How do you manage infiltration?

- remove IV
- elevate extremity
- apply warm or cool compress
- don't rub the area

What is infection of an IV?

entry of microorganism into the body via IVH

How do you manage infection of an IV?

- remove the IV
- obtain cultures
- possible antibiotic administrationW

What is circulatory overload?

administration of fluids too rapidly

How do you manage circulatory overload?

- decrease flow rate
- elevate HOB
- keep pt warm
- notify provider

What is phlebitis?

inflammation of the vein

How do you manage phlebitis?

- remove IV
- notify provider
- restart IV on the opposite side

What is a hematoma?

collection of blood in the tissues

How do you manage a hematoma?

- elevate the extremity
- apply pressure and ice

What is the phlebitis scale?

- grade 0: no symptoms
- grade 1: erythema at access site with or without pain
- grade 2: pain at access site with erythema and/or edema
- grade 3: pain at access site with erythema and/or edema, streak formation, and palpable venous cord
- grade 4: pain at access site with erythema and/or edema, streak formation, palpable venous cord >1 inch in length, purulent drainage

What is the nurse practice act?

a law that regulates and protects the public from nurses who are a risk to the health, safety, and welfare of the citizens within its state board jurisdiction

What is altruism?

a concern for the welfare and well being of others

What is fidelity?

keeping promises and commitments made to others

What is veracity?

the quality of being true, honest, or accurate

What is the difference between ethics and morals?

ethics are the standards of good and bad and morals are what an individual believes is good and bad

What is the purpose of incident reports?

to draw attention to an incident in order to prevent future incidents or minimize the likelihood that future incidents will happen

What is the difference between licensure and certification?

licensure: state requires one to meet minimum requirements to practice in profession
certification: met criteria established by nongovernmental association in specific area

What are the five rights of delegation?

right task, circumstance, person, directions and communication and supervision and elevation

What is I-SBAR-R?

I: identification of patient and self
S: situation
B: background
A: assessment
R: recommendation
R: readback

What is CUS?

a way to provide effective communication r/t patient safety
C: i'm concerned
U: i'm uncomfortable
S: this is unsafe

What are verbal vs nonverbal communication techniques?

verbal: spoken/written words, intellectual development, education, and language
nonverbal: body language, eye contact, facial expressions, posture, gait, sounds, silence, physical appearance, grooming, and gestures

What are ways communication can be blocked?

failure to perceive pt has a human being, failure to listen, leading questions, giving advice, cliches, changing the subject, giving false assurances, gossiping, disruptive interpersonal behavior

What is motivational interviewing?

a counseling approach designed to help people find the motivation to make a positive behavior change
ex: How can I help you with ____?, Help me understand ___?

What is the teach back method?

a way of checking understanding by asking patients to state in their own words/actions what they need to know about their health

What are characteristics of pain to assess?

quality, severity, duration, cause, origin, when it started, what triggers it, what relieves it

How do you assess pain in nonverbal patients?

faces scale

What are the different causes of pain?

- nociceptive: initiated by nociceptors that are activated by actual or threatened damage to the peripheral tissue and represents normal pain response
- neuropathic pain: caused by lesion or disease, frequently chronic
- intractable pain: resistant to therapy, persists despite interventions

What are origins of pain?

physical and psychological/psychogenic

What are different types of quality of pain?

sharp, pulling, stabbing, shifting, diffuse, shooting, pinching, throbbing

What are different durations of pain?

continuous, intermittent, and brief or transient

What are factors that can influence a patient's pain?

personal experience, background, culture, age, medical conditions, gender, support systems

What are the different responses to pain?

behavioral (voluntary), physiologic/sympathetic (involuntary), and parasympathetic

What occurs during a behavioral pain response?

- moves away from painful stimuli
- grimacing, moaning, crying
- mild pain typically has no response
- intense pain causes acceptance for a short period of time

What occurs during a physiologic pain response?

- increased HR, RR, BP, BS
- muscle tension
- pallor due to peripheral vasoconstrictors
- increased adrenaline output
- pupil dilation

What occurs during a parasympathetic pain response?

- N/V
- fainting/unconsciousness
- decreased BP, HR
- rapid and irregular breathing
- weakness

What are barriers to effective pain management?

culture, gender, money issues, knowledge, age, family

What are nonpharmacological pain relief measures?

hot/cold compress, massage, acupuncture, meditation, repositioning, breathing techniques, hypnosis, guided imagery, biofeedback