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A comprehensive set of questions and answers covering various topics related to nursing care, including acute kidney injury, chronic kidney disease, trauma assessment, surgical procedures, blood transfusions, burns, and the raas system. It offers insights into nursing interventions, assessment techniques, and key concepts in these areas, making it a valuable resource for nursing students and professionals.
Typology: Exams
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Acute Kidney Injury - Answer -rapid-onset disease of the kidneys resulting in a failure to produce urine -most common cause: sepsis -will see: hyperkalemia, dialysis daily, possibly reversible oliguric phase - Answer <400ml/day, U/A= casts, RBCs, WBCs, sp gr 1.010, metabolic acidosis, increase potassium, BUN, Cr, decreased sodium , fatigue and malaise diuretic phase - Answer gradual increase in u/o, 1-3L/day, hypovolemia, dehydration, hypotension, BUN and Cr normalize recovery phase - Answer begins when the GFR increases, allowing the bun and serum creatinine levels to plateau then decrease. Improvements occur generally in the first 1 to 2 weeks of this phase but may take up to 12 months to stabilize. Chronic Kidney Disease - Answer -progressive, irreversible deterioration in renal function d/t HTN, DM, glomerulopathy, nephritis, polycystic disease, congenital. -decrease 15ml/min GFR -weak, fatigue, HA, increase BP, edema, heart failure, ammonia breath, metallic taste, GI bleeding, behavior changes, anorexia, N/V, muscle cramps -increase potassium, metabolic acidosis trauma assessment - Answer 1. ABCD: airway patency, breathing effectiveness, circulation, disability
-cost effective -pericardiac, perihepatic, perisplenic, peripelvic -eliminates unnecessary CT scans Surgery: preop - Answer education, NPO, consent, V/S, iv site, IVF/ABX on call, review MAR for meds that would put pt at risk, check labs (glucose on call), call report surgery post op - Answer -v/s, color, ECG, emoboli, assess activity level, check IV fluid and rate, electrolyte levels, GI drainage, renal function, -assess o2 needs, encourage cough and deep breathing and incentive spirometer use, -bowel sounds, flatus, bowel movement, -analgesics, antiemetics, positioning, rest, hygiene, turn q2hrs chest tube anatomy - Answer A: wet or dry suction B: water seal chamber C: air leak chamber D: collection chamber E: suction monitor assessing the tube - Answer -avoid dependent loop, coil the tube on bed to prevent backup of drainage -mark level of draining q8hr -dressing should be clean dry and intact -palpate for crepitus (subq emphysema) -if disconnected: reconnect with new sterile setup and document, can place end of tube into sterile saline container -if dislodged: place vaseline gauze on puncture, place sterile gauze, taper 3-4 sides w/ silk tape and contact HCP before admin blood - Answer -consent, type and crossmatch, order, v/s, normal saline and y tubing, two nurse check off.
-18g needle Nx consideration for blood products - Answer -FFP: 50ml can be given over an hour, allow 30min to thaw in blood bank -PLT: 50ml given in 1hr -PRBC: 300ml or more should be given w/in 4 hours. -1prbc will increase hbg by 1 -initiate 20 minutes after recieving, v/s first 15 min then every hour, monitor for s/s reaction and fluid overload (wt gain, increase BP, edema, ascities, SOB) blood reactions - Answer -febrile: chills fever HA flushing increase HR and anxiety -allergic: hives, pruritis, flushing in face, SOB, bronchospasms -hemolytic: low back pain, decreased BP, chest pain, increase RR, hemoglobinuria, fever, chills, increased HR nursing implication for bld reactions - Answer -stop transfusion and notify HCP -change IV tubing, treat symptoms: o2 fluids epi, recheck cross match Burns - Answer -chemical: wash w/ water, remove clothing, call poision controll -electrical: assess CNS (increase risk for cardiac arrest) -thermal: 1st= sunburn, 2nd= blisters 3rd= muscle/bone exposed and no pain -inhalation Nx interventions for burns - Answer -ABC's, fluids, prevent infection, pain management, glucose, DVT/PUD, increase calories and protein, -hemografts (human cadaver) xenografts (animal) autografts (self) palmar method for burns - Answer Arms= 9% each Head= 9% neck= 1%
Legs=18% each anterior trunk= 18% posterior trunk= 18% RAAS system - Answer -liver>angiotensinogen>renin>angio I> ACE> angio II> Na and fluid retention, muscle hypertrophy, vasoconstriction of blood vessels -Aliskiren: blocks renin, ACE inhibitors blocks ACE, ARBS block angio II -kidneys secret renin when: decrease in arterial pressure in kidneys, decrease in Na in blood, increase in sympathetic tone blood types - Answer O-= universal donor AB+= universal recipient all + can give to every but only receive other + all - can give to only other - but receive - and + extra notes: - Answer -air bubbling in water seal chamber and fluctuation (tiddling)= good indicator that system is in tact -Trauma patient we need to start feeding within 24-48hrs. due to higher metabolism needs. Ng tube feeding. Enteral is the best if not parental -Mean arterial pressure tells me perfusion tells me fluid needs. If my map is less than 65 then my systolic is low. -Purpose of loop of Henle- pulls more water from the blood stream