Adult Health I Finals Review

Adult Health I Finals Review 1. A nurse is preparing to administer diphenhydramine 30mg IM stat to a client who is having an allergic reaction. Available is diphenhydramine 50mg/ 1 ml. How many ml should the nurse administer? - 30mg/50mg x 1 ml = 0.6ml 2. A nurse is preparing to administer meperidine 75mg IM to a client who reports postoperative pain. Avaible is meperidine 100mg/1ml. How many ml do we give. (Round to the nearest tenth) - 75mg/100mg x 1ml = 0.8 ml 3. A client is prescribed 1g potassium phosphate to be infused continuously over 6 hr. Available is 1g Potassium Phosphate in 250ml dextrose 5% water (D5w) The nurse should set the IV pump to run at how many ml/hr. Round to nearest whole number. - 250ml/ 6hr = 42ml/ hrs 4. Rules of 9’s - Anterior ( Front) Head/ Neck 4.5% Arms R&L ea. 4.5 % Chest 18% Legs R&L 9% Perineal 1% Posterior ( Back ) Head/ neck 4.5% Arms R&L 4.5% Chest 18% Legs R&L 9% Total: 9% 18% 36% 36% 1% = 100 % 5. What is the highest priority for a patient with burns to the head the neck and the chest - Check their Airway 6. Burns to the face and lower extremities - Assess airway and look in the mouth to check for any kind of inflammation 7. How do we provide emotional support for a burn patient - Have family involved and carry out conversations 8. Patient with burns are at risk for what? - Infections 9. Patients that are at a higher risk for skin breakdown what interventions can we do? - TQ2hr - adequate protein intake - Don’t rub bony prominence, put foam dressing to the prominence - float the heal so the heals don’t touch the bed. - Make sure it is clean and dry if incontinent apply barrier cream. 10. Stages of pressure injuries: Stage 1 : Skin is intact with nonblanchable erythema Stage 2: Partial thickness skin loss * looks like a blister when the skin peels off* Stage 3: Full thickness skin loss adipose tissue Stage 4: Full thickness Bone and muscles is seen as well as neurotic tissue 11. What happens to the body with pressure injuries - Not enough circulation, tissues are dying 12. Who is at a higher risk for developing a pressure injury - Unresponsive patient who changes position occasionally 13. What lab value lets us know there is an infection. - WBC * if it's low you're at a higher risk for infection * if it is high you have a potential infection. 14. Besides WBC, what lets us know the presence of a infection? - you will see an increase in basophil also known as a left shift/bandemia (when there is more immature cells than mature cells) - The differential that is ordered with cbc breaks down all the agranulocytes and granulocytes - Absolute is the mature neutrophil - Basophil count is the immature neutrophil 15. Psoriasis how does it look on the skin? - white scaly, Stress worsens psoriasis. * If they have psoriasis, include stress management in their teaching. 16. When you have client that has dark skin and you're assessing for cyanosis where do you assess? - Conjunctival sac - Mucus membrane - oral mucosa - Palms of the hand (palmar) - Sole of your feet(Plantar) 17. What devices do we use to prevent shear and friction - Sliding sheet and a Hoyer lift 18. When a patient comes in with a burn what is the preferred iv fluid - Lactated ringer (LR) 19 . What is the difference between modifiable and unmodifiable - Modifiable( can change) - Smoking - Alcohol - Exercise - Diet - Weight - Non modifiable ( genetics) - Gender - Age - Ethnicity - Family History 20. The nursing process Has 5 steps ADPIE 1. Assessment - subjective and objective data, why they hear, allergies,vital signs 2. Diagnosis/analyze- what we have found to determine plan of care 3. Planning- Goal planning, what we are aiming for patient to obtain in x amount of time, S.M.A.R.T goals 4. Implementation- Interventions, what we are actually doing to help them reach their goal, collobartiong with providers, therapy, adminstering medication 5. Evaluation- seeing if the goals have been met, if what we did helped them reach their goal or not if it didn’t that’s where we modify our care plan. 21. Nonmalficence: to do no harm (withholding the narcotic) if we give them the narcotic and they have respitory depression it would cause their RR to drop therefore hurting them. 22. What is the most reliable indicator of pain - Patient self-report 23. If the patient is not able to verbalize pain what do, we do? - Look at the procedure or disease process to determine patients' pain when nonverbal such as surgery. - We also look at their behaviors such as guarding, grimacing, restlessness, agitation - Also, physiological indicators such as elevated HR, RR, BP, dilated pupils 24. What is acute pain - sudden onset - signs of acute pain : dilated pupils, restlessness, elevated BP, overall distress and difficulty concentrating 25. What is chronic main - Longer than 6 months - Signs of chronic pain, we normally see lower vital signs (their body has gotten use to the pain) 26. Acid base imbalances: Normal Values Ph: 7.35-7.45 Paco2: 35-45 Hco3: 22-26 *27. Respiratory acidosis (lungs effected ) PH: <7.35 PaCO2: >45 Hco3-: 22-26 ( stays the same) *respirations can be variable but ineffective * Skin pale to cyanotic and dry *28. Metabolic acidosis( Renal System) PH: <7.35 PaCO2: 35-45 ( stays the same) HCo3- : <22 *Kussmauls respirations (rapid and shllow breathing), hot, flushed skin * For both we will see anything from bradycardia to heart block, we can see in the ekg they will have tall t-waves, a widen QRS complex, and prolong PR interval, hypotension, thready perphial pulses, possible lethargy, confusion, if really bad coma. May also see flacid paralysis, and skeletal muscle weakness. 29. If you have someone with kussmaul and hypertension what would they have. - Metabolic acidosis *30. Respiratory alkalosis PH: >7.45 Paco2: <35 HCo3- 22-26 ( stays the same) * hyperventilation * 31.Metabolic alkalosis PH: >7.45 Paco2: 35-45 HCo3- >26 *Decreased resiratory effort (due to decrease muscle contraction) *For both we are going to see anxiety, irritability, tetany, seizures, +chevosnik sign, + trousseau sign, parathesis (tingling and burning) hyperreflexia (overactive reflex ,muscle cramping/ twitching, skeletal muscle weakness, normal or low BP, increased HR 32.We have an ABG that shows PH: 7.22 Paco2: 68 Pao2: 78 Base excess of –2 Hco3: 26 - Respiratory acidosis 33. We have an ABG of: PH: 7.30 PaCO2: 28 HCO3: 18 * (for this question pay attention to the co2 because it needs to be high to be acidosis) - Metabolic acidosis 34. Common causes for dehydration - Vomiting Diarrhea Fluid without placement Sweating Impaired thirst (older population) burn victims On diuretic therapy Hemorrhaging Ileostomy Continous suctioning NPO Unconscious Dysphagia Impaired motor function Fistula 35. S&S of dehydration: - Dry crack lips - Dry mucus membrane - Decreased urine output (Dark and odorous) - Increased HR - Decreased BP - Flat veins due to lack of fluid - Skin turgor ( tenting ) - Furrows on tongue - Low grade fever 36. Electrolyte Imbalance: Normal sodium: 135-145 High sodium (hypernatremia) > 145 Low sodium ( hyponatremia) < 135 - Hyponatremia:<135 - decrease loc - Increase of thirst - general muscle weakness(leg & arm) - diminished deep tendon reflexes - increased Gi motility (nausea vomiting abdominal cramping) low values can cause seizures, comas, or death - Hyponatermia with Hypovolemia: Rapid weak thready pulse, low BP, - Hypernatremia:> 145 - Agitation - Confusion - Twitching - Muscle weakness - Hypernatremia with Hypovolemia: Orthostatic Hypotension, Peripheral pulses difficult to palpate - Hypernatremia with Hypervolemia- distended neck veins, pulse will be slow or normal but will be bounding, elevated diastolic b/p 37. Hypernatremia is greater than 145. What will we see? - Twitching, muslce weakness 38. Potassium ( K+) Values: 3.5-5 Hypokalemia what do we expect to see:< 3.5 - Dysrrythmia - shallow respiration - muscle weakness - decrease in hand grip strength, - Decreased deep tendon reflexes * if severe we will see flaccid paralysis, pulse will be weak and thready, patient may be irritable, anxiety, decrease in peristalsis ( bowel sounds will be hypoactive) pt will complain of constipation, if really low develop paralytic illues. Ekg: ST segment depression, T waves will be flat or inverted, will see U waves Hyperkalemia: >5 - Chest pain - muscle twitching - numbness of hands feet or face - complaint of leg weakness - they may say they feel like heart is palpating or skipping a beat. - May have diarrhea. EKG: - tall peak, t waves, prolong PR interval, p wave will be flat or missing, QRS complex will be wave, may see a heart block. May go into v-fib and cause asystole. 39. What does cap refill tell you - Tells you if there is any arterial insuffiency 40. Atrial fibrillation What does the pulse look like? irregular we are worried about pulmonary embolism 41. What do cardiac enzymes tell us? - tell us how much of the heart has been damage (troponin) - female patients complain of heart burn and jaw pain 42. Peripheral Arterial Disease (PAD) complain of? - Cold Feet * give them socks, blankets, increase thermostat at home, with PAD we want them to have a warm enviorment. 43. Venous insuffincy what can we have them use - Compression socks 44. How is HIV transmitted - By direct contact with infected body fluids 45. Initial infection what are the symptoms - Flu like 46. What does cd4 tell us - Tells us about their immunity if theyre HIV positive it tells us they're not complying with treatment and will have a high viral load. 47. If low cd4 count what infection do we expect? - Candidas 48. If your HIV pt have phagocytic dysfunction, what does it mean? - They can get opportunistic infection 49. What do you do if someone with hiv comes in with frequent pneumonia ? - Get a sputum culture 50. When someone has an anaphylactic reaction what do we see - Rash, Swelling of mouth and throat? We will expect stridor as well 51. Someone comes in with a delayed hypersensitivity reaction what do we expect - May see a rash ( some type of tissue damage to the skin) 52. Where can bone marrow be done? - Pelvic bone ( iliac crest) - sternum * done on a flat bone 53. 7 warning signs and symptoms of cancer - C : change in bowel A: A sore that does not heal U: Unusual bleeding T: Thickening or lump I : Indigestion O:Obvius changes in wart or mole N: Nagging cough 54. What is Neutropenia? - Diminished numbers of WBC *Educate patient not to go into big crowds, no fresh fruit or vegetables 55. What is antibody mediated immunity - B lymphocytes are at play 56. Cell mediated immunity is - T cells 57. If someone is suspected of having cataracts what will they complain of - They will have difficulty seeing color 58. If someone has glacoma and don’t get treatment what happens - They will go blind 59. If patient starts comlaing of headeache after lumbar punture what do we do? - Increase fluids and ask them to lay flat for 2 hours 60. What is Kyphosis? - seen in osteoprosis , a “Humpback” 61. What medication increases risk for osteoporosis - Thyroid hormone 62. Modifiable risk factors for osteoprsosis - Sedentary lifestyle - Smoking - Caffeine - Alcohol - Carbonated beverages 63. Osteoarthritis is first treated with what first - acetaminophen 64. With rheumatoid arthritis pt is prescribed methotrexate what do we teach them - don’t get pregnant nor breast feed - they need to be off of it for at least 3-6months if trying - increase fluid intake 2L-3L (Methotraxate effects your kidney) 65. RA teach to follow self care: - Use non- dominant hand - Turn handles counterclockwise, - allow them to open their own shit to promote independence, no washing dishes. 66. How long does it take for halux valgus to heal - 6-8 weeks , they should rest the foot elevated 67. If your patient had a total hip aristoplasty do you want to place a hip wedge with them? - Yes * Don’t place hip aligned with spine 68. How do you asses CN 3 - With pen light to check for pupil contraction 69. Someone who had cataract surgery should they have eye pain after - No let dr know immediately 70. If someone has dementia and they are confabulating, what are they doing - They are making up Stories 71. If someone has an initial onset of Dementia what do we tell the family - Personality changes - Forgets recent memories - Short term memory effective *Takes time forgetfulness takes months to years 72. We have a nurse that is caring for a client for a pt with total hip arthroplasty a day ago and is getting PCA and reports nausea and vomiting what action should the nurse take? - We assess pt first for active bowel sounds