Athabasca University, Nursing 400 Final Exam combined study guides questions with Complete, Exams of Nursing

Download Athabasca University, Nursing 400 Final Exam combined study guides questions with Complete and more Exams Nursing in PDF only on Docsity! Athabasca University, Nursing 400 Final Exam combined study guides questions with Complete Solutions Dysphagia - Correct answer-inability to swallow or difficulty in swallowing 2 key points about Dysphagia - Correct answer-1. 30 mins prior to meal time, the pt needs to be sitting at 90 degree unless its contraindicated 2. Monitor for possibility of aspiration -s/s of aspiration -Coughing -Wheezing -Redness of face -Decrease O2 sat 2 key points about Nasogastric Tube - Correct answer-Used for pt who suffers from dysphagia (difficulty swallowing) Residual volume must always be checked q4h d/t risk for aspiration *** if there is a large amount of residual volume, that means pt is not digesting the food - inform MD** Nasogastric Tube Supplies - Correct answer-Nasogastric tube Irrigation tray - 60 ml syringe A bottle of sterile water lubricant NGT insertion - Correct answer-1. Measure the tube from the nose to the back of the ear and down a little pass the bottom of the xiphoid process 2. Mark the tube (sharpie) 3. Have the patient swallow while inserting the tube (with or without ice chips) NGT placement - Correct answer-1. Once the NGT is inserted, aspirate 30 mL of air 2. Place the stethoscope over the stomach and listen to the "wooooosh" sound as you inject the air 3. If necessary, get an order for x ray for proper placement. NGT medication administration - Correct answer-1. Check if pt is on any fluid restrictions 2. Check gastric residual and put it back after. 3. Make sure to kink the tube so that air won't go in the tube (air causes bloating) Intravenous guages - Correct answer-Neonate and Infants: 24-26 G Child and Older Adults: 22 G Adults: 18, 20, and 22 G Intravenous angle - Correct answer-*** Angle depends upon where the IV insertion site is. (8) Rights of administration - Correct answer-1. Right Patient 2. Right Medication 3. Right Dose 4. Right Route 5. Right Time 6. Right Reason 7. Right Response 8. Right Documentation (Parenteral routes of medication administration) Intradermal - Correct answer-1. Medication is injected in the dermis (just below the epidermis) 2. Must form a "wheal" 3. Longest absorption time for parenteral routes 4. Dosage is usually less than 0.5mL (Parenteral routes of medication administration) Subcutaneuos - Correct answer-1. Injected in the adipose tissue 2. Absorption is slow to the capillaries 3. Dosage is usually no more than 1mL 4. Inject slowly so medication can disperse (10 sec/ 1 mL) (Parenteral routes of medication administration) Intramuscular - Correct answer-Injected in the muscle Faster onset than intradermal and subQ (Parenteral routes of medication administration) Intravenous - Correct answer-Injected in the vein Fastest absorption which also means fastest reaction to medication (Parenteral routes of medication administration) (7) Transdermal - Correct answer-1. Applied topically on the skin using a patch that contains medication 2. Remove old patch and wipe of remnants of medication 3. Clean and dry the area 4. Apply patch on different location (sites must be rotated to avoid skin irritation) 5. If the pt is hairy, trim the hair 6. Label the patch with date, time, and you initials 7. Most common patch used: Nitroglycerin - a vasodilator used to prevent angina (chest pain) for pts with CAD (Coronary Artery Disease) Urinary catheterization preparation - Correct answer-Doctor's order is needed for all catheterizations Ask for latex and iodine allergies Gather appropriate PPE supplies Clean the genital area prior to the procedure Assess the genitalia for any lesions, swelling, and skin breakdown Adjust the bed to appropriate height Vital signs - Correct answer-are indicators of physiological functioning person's temperature, pulse, respiration and blood pressure T, P, R and Blood Pressure taken every 4 hours in hospitalized patients Vital sign facts: - Correct answer-Changes in vital signs may indicate, or in some cases precede, fluid, electrolyte, and acid-base imbalances. Elevated body temp: may be the result of dehydration or a cause of increased body fluid losses. Tachycardia is an early sign of hypovolemia (abnormal decrease in the volume of blood plasma). Pulse volume will decrease in FVD and increase in FVE. Irregular pulse rhythms may occur with electrolyte imbalances. Changes in resp rate and depth may cause respiratory acid-base imbalances or indicate a compensatory mechanism in metabolic acidosis or alkalosis. BP: sensitive measure for detecting blood volume changes may fall significantly with FVD and hypovolemia or increase with FVE. Postural or orthostatic hypotension may also occur with FVD and hypovolemia. Pull the pinna up and back to straighten the ear canal in an adult. If a patient has an earache, do not use the affected ear to take a tympanic temperature. The movement of the tragus may cause severe discomfort. Assess the patient for significant ear drainage or a scarred tympanic membrane (not good) An ear infection or the presence of earwax in the canal will not significantly affect a tympanic thermometer reading. If the patient has been sleeping with the head turned to one side, take a tympanic temperature in the other ear. Heat may be increased on the side that was against the pillow, especially if it is a plastic- covered pillow. (Temperature) Axillary - Correct answer-Place the probe in the center of the axilla; hold the patient's arm by the patient's side until the measurement is complete The axillary site may be used when both oral and rectal sites are contraindicated or when these sites are inaccessible, but should not be used where accurate temperature measurement is required. Axillary readings are affected by ambient temperature, local blood flow, appropriate placement of the probe, and closure of the axillary cavity. Do not take after shower (Temperature) Rectal - Correct answer-Assist patient to side lying position Cleanse the area Lubricate about 1 inch of the the covered probe with water-soluble lubricant Reassure patient and separate the buttocks until the anal sphincter is clearly visible Insert the thermometer probe about 1.5 inches for adults and no more than 1 inch for a child Hold the probe in place until you hear a beep. Dispose the probe and document the temperature Do not use if contraindicated by neutropenic patient Respiration measurement - Correct answer-Do not tell patient your measuring his/her breathing Using a watch with a second hand, count the respiration for 30 seconds and multiply by 2. If respiration is abnormal, count it for a full minute. Note the depth and rhythm Common Respiratory sounds - Correct answer-Rhonchi: resemble snoring. Large airway blocked Stridor: Wheeze-like sounds, Trachea/wind pipe blocked Wheezing: high pitched, small airways Common Breathing rates - Correct answer-Eupnea: normal 12-18 breathes Bradypnea: slow less than 10 Tachypnea: fast more than 24 Apnea: stop breathing Pulse arteries (8) - Correct answer-Temporal Carotid Brachial Radial Femoral Popliteal Posterior Tibialis Dorsalis Pedis Characteristics of peripheral pulse - Correct answer-Rate- Normal pulse rates for adolescent to adults is 60-100 BPM Rhythm- the pattern of pulsations and the pauses between them Amplitude (quality; strong or weak, bounding, thready) 0: Absent, unable to palpate 1+: Diminished, weaker than expected, 2+: Brisk, expected (normal) 3+: Strong pulse 4+: Bounding Most common pulse sites - Correct answer-Adults, Adolescent, and Older child Radial pulse B line is usually your IVPB MUST ALWAYS MAKE SURE THAT WHEN YOU ARE PRIMING TO LOCK THE TUBING BEFORE YOU START PRIMING Want to make sure that when you start an IV you want to prime the tubing, which means that the I.V fluid will go all the way to the end of the tubing. Needleless is what stays in the patient while the fluid is running Basic therapy for IVPB - Correct answer-If you have a gravity pump you must hang your primary bag must hang lower than your IVPB. You must backprime when starting an IVPB in order to start the fluid from the IVPB In order to keep the I.V from leaking, you must use a luer lock Nursing Process - Correct answer-ADPIE Assessment Diagnosis Planning Implementation Evaluation Assessment - Correct answer-is the collection, organization, and documentation of data. When documenting data stick to the facts, no opinions. Make sure to validate data before documenting. Can use the facility database to collect data on patients. Data sources: Patient, Family members, Facility Database What are the 4 goals of the Assessment? - Correct answer-1. Established during admission 2. Identifies the client's strengths and health problems that can be prevented or resolved 3. Develop a list for nursing and collaborative problems. 4. Develop an individualized care plan that is client specific in order for pt to meet the desired goal, promote wellness, restore health, and facilitate coping with altered functioning Types of Health assessments - Correct answer-comprehensive ongoing partial focused emergency comprehensive assessment - Correct answer-Conducted upon admission to healthcare facility ongoing partial assessment - Correct answer-conducted at regular intervals focused assessment - Correct answer-gathers data about a specific problem that has already been identified. emergency assessment - Correct answer-identify life-threatening problems Diagnosis - Correct answer-Must use NANDA for nursing diagnosis. Match objective and subjective data with diagnosis from NANDA. Can use medical diagnosis to help with nursing diagnosis. EX: Patient has pneumonia and difficulty breathing, your diagnosis would be they have ineffective breathing.nses to levels of wellness in an individual, family, or community Syndrome Diagnosis Diagnosis that is associated with a cluster of other dx Types of Nursing Diagnosis' - Correct answer-Actual Nursing Dx Possible Nursing Dx Wellness Dx Syndrome Dx Actual Nursing Dx - Correct answer-Problem present during the initial nursing assessment Risk Nursing Dx - Correct answer-Using clinical judgement and considering the risk factors to develop a potential problem Possible Nursing Dx - Correct answer-Evidence about health problems is incomplete or unclear Additional data are used to confirm or rule out the suspected problem Wellness Dx - Correct answer-Describes human responses to levels of wellness in an individual, family, or community Syndrome Dx - Correct answer-Dx that is associated with a cluster of other dx (Laboratory) RBC: red blood count - Correct answer-M: 4.5-5.3 F: 4.1-5.1 (Laboratory) Hgb: hemoglobin - Correct answer-M: 13.8-18 F: 12-16 (Laboratory) Hct: hematocrit - Correct answer-M: 36-49 F: 36-46 (Laboratory) WBC: white blood count - Correct answer-4500-11,000 (Laboratory) Platelet - Correct answer-150,000-350,000 (Laboratory) Sodium - Correct answer-135-145 (Laboratory) Potassium - Correct answer-3.5-5.0 (Laboratory) Chloride - Correct answer-95-108 (Laboratory) Calcium - Correct answer-8.5-10.5 (Laboratory) Magnesium - Correct answer-1.5-2.5 (Laboratory) Phosphate - Correct answer-2.5-4.5 (Laboratory) Serum Osmolality - Correct answer-Normal = 280 - 350 Measures solute concentration of the blood, used to evaluate fluid balance Increase = fluid volume deficit Decrease = fluid volume excess (Patient teaching) METHOD - Correct answer-Medication Environment Treatment Health teaching Outpatient referral Diet Teaching - Correct answer-nurses help patients and families develop self-care abilities (Knowledge, attitude, skills) they need to maximize function and quality of life or a dignified death. EX: Diabetic needs to have knowledge about the disease and health resources, value their health to make positive lifestyle changes, and master skills such as medication administration. Patient learning - Correct answer-has many factors such as age and developmental levels. If a young girl has diabetes, explain consequences in terms she'll understand. Provide concrete facts to teenagers that are straightforward and not ambiguous. Try and teach adults immediate ways to improve heath and make them want to get better. Adults like to be independent Why do we teach patient Health Literacy? - Correct answer-so they understand the importance of the changes they make and why they need to make them. Have them be able to identify the problem, what they need to do, and why the need to do it TEACH - Correct answer-Tune into patient, Edit patient information, Act on every teaching moment, Clarify often, Honor the patient as a partner in education process Teach self care practices - Correct answer-promote recovery such as lifestyle counseling for someone with a colostomy or sexual counseling for someone who recently experienced an MI. Teach illness prevention - Correct answer-can be used to prevent illness such as teaching pregnant mothers ways for optimal fetal development. Teach patients at risk for heart disease the importance of BP checks. First aid, safety, immunizations, managing risk factors 3. Evidence based practice - Correct answer-Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. (QSEN) 4. Quality improvement - Correct answer-Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. (QSEN) 5. Safety - Correct answer-Minimizes risk of harm to patients and providers through both system effectiveness and individual performance (QSEN) 6. Informatics - Correct answer-Use information and technology to communicate, manage knowledge, mitigate error, and support decision making. (Roles of the nurse) Communicator - Correct answer-Use effective interpersonal and therapeutic communication skills to establish and maintain helping relationships with patients of all ages in all healthcare settings (Roles of the nurse) Teacher - Correct answer-Use communication skills to assess, implement, and evaluate individualized teaching plans to meet learning needs of patients and families (Roles of the nurse) Counselor - Correct answer-Use of therapeutic interpersonal communication skills to provide information, make appropriate referrals, and facilitate the patient's problem-solving and decision- making skills (Roles of the nurse) Leader - Correct answer-Assertive, self-confident practice of nursing when providing care, effecting change, and functioning with groups (Roles of the nurse) Researcher - Correct answer-Participation in or conduct research to increase knowledge in nursing and patient care (Roles of the nurse) Advocate - Correct answer-Protection of human or legal rights and securing care for all patients based on belief that patients have the right to make informed decisions about their own health and lives (Roles of the nurse) Collaborator - Correct answer-Effective use of skills in organization, communication, and advocacy to facilitate functions of all members of the healthcare team as they provide patient care. (Roles of the nurse) Caregiver - Correct answer-Combines both the art and science of nursing to meet physical, emotional, intellectual, sociocultural, and spiritual needs of patients. Incorporates all roles to promote wellness by activities that prevent illness, restore health, and facilitate coping with disability or death. EHR is used to - Correct answer-1. Improve quality, safety, efficiency, and reduce health disparities 2. Engage patients and family 3. Improve care coordination in population and public health 4. Maintain privacy and security of patient health information 5. Improve nursing process, maximize effective use, reduce errors and cost, eliminate inefficiencies, improve clinical decision support, and improve end-user skills and satisfaction with the system Why are hospitals with fully implemented EHR's less likely to encounter unfavorable outcomes? - Correct answer--Less chance of medication errors, poor quality of care, poor confidence in patients ready for discharge. 14% decrease in problems with transferring patients. Consider patient safety a high priority -Better clinical outcomes, improved population health outcomes, increased transparency and efficiency, empowered individuals, more robust research data on health systems Documentation - Correct answer-Only document the assessment and interventions you perform -primary purpose is to communicate between departments -If unsure about the order or cannot read legibly, check the order. -DO NOT GUESS THE ORDERS Primary purpose of documentation - Correct answer-is to have communication with other departments of the healthcare team Verbal order - Correct answer-are not given outside of emergency situations 1. Read backs are to confirm the orders and make sure there is no confusion 2. RN or Pharmacy reviews, read backs, documents, executes order 3. Immediately after emergency, MD or NP must: --Review order to make sure it was correct --Sign with name, title and pager number --Date and note the time of order 4. Registered professional must see that the order is documented and transcribed according to procedure Assistance to perform ADL's Motivating the patient to learn and to implement health-promotion activities Facilitate the patient's ability to execute the nursing care plan Express feelings about health problems Nursing care Progress or setbacks Termination phase - Correct answer-Occurs when the conclusion of the initial agreement is acknowledged. Might happen at change-of-shift time, when patient is discharged, or when a nurse takes vacation or employment somewhere else. Arteries that are commonly used for assessing the pulse - Correct answer-temporal ** Carotid ** Brachial ** Radial ** Femoral ** Popliteal ** Posterior Tibialis ** Dorsalis Pedis How do Peripheral pulses work? - Correct answer-Peripheral pulses result from a wave of blood being pumped into the arterial circulation by the contraction of the left ventricle. Characteristics of peripheral pulse - Correct answer-Rate- Normal pulse rates for adolescent to adults is 60-100 BPM Rhythm- the pattern of pulsations and the pauses between them -Amplitude (quality; strong or weak, bounding, thready) 0: Absent, unable to palpate 1+: Diminished, weaker than expected, 2+: Brisk, expected (normal) 3+: Strong pulse 4+: Bounding Common pulse sites - Correct answer--Adults, adolescent, and older child - Radial pulse -Infants and children 2 and younger is (apical pulse) Bradycardia - Correct answer-slow heart rate (less than 60 bpm) Tachycardia - Correct answer-Abnormally rapid heartbeat Apnea - Correct answer-absence of breathing tachypena - Correct answer-very rapid respiration Bradypena - Correct answer-abnormally slow breathing Eupnea - Correct answer-normal respiration 12-18 hypoventilation - Correct answer-decreased rate or depth of air movement into the lungs Hyperventilation - Correct answer-the condition of taking abnormally fast, deep breaths Wheezing - Correct answer-Air passing through narrowed airway squeaking High-pitched, continuous sounds Auscultated during inspiration and expiration Stridor - Correct answer-(Larynx or Trachea), Narrowing of upper airway presence of foreign body in airway Harsh, loud, high-pitched Auscultated on Inspiration Crackles - Correct answer-Alveolar, fluid build up crackle sound COPD Friction Rub - Correct answer-Inflamed PLEURA rubbing against chest wall Rubbing or grating Loudest over lower lateral anterior surface Auscultated during inspiration and expiration GLASGOW COMA SCALE - Correct answer-A tool used to assess the depth and duration of impaired consciousness and coma. It evaluates three key categories of behavior that most closely reflect activity in the higher centers of the brain: eye opening, 4-1 verbal response, 5-1 Tuning Fork - Correct answer-a two-pronged, fork-like instrument that vibrates when struck; used to test hearing, especially bone conduction reflex hammer - Correct answer-a medical instrument used by practitioners to test deep tendon reflexes. Infectious agent - Correct answer-a pathogen, such as a bacterium or virus that can cause a disease Gram-positive bacteria - Correct answer-have thick walls that resist the loss of color. Will stain violet Gram-negative bacteria - Correct answer-complex cell walls that can be decolorized by alcohol. Will not stain Anaerobic bacteria - Correct answer-bacteria that do not require oxygen to survive Viruses - Correct answer-- Smallest of all microorganisms, only visible with electron microscope - Causes infections like; common cold, hepatitis B and C, and AIDS - Antibiotics have no effect Antivirals - Correct answer-are effective and when given during the prodromal stage of certain viruses they can shorten the full stage of illness (ex: Tamiflu) Parasites - Correct answer-- Can live on or in a host and rely on it for nourishment - Ex: Malaria from a disease infecting a certain type of mosquito that then feeds on humans Organisms Potential to Produce Disease - Correct answer-Number of organisms (the more the better) Virulence (ability to produce disease) Competence of person's immune system Length/intimacy of contact between person and organism (colonization=long contact) Reservoir - Correct answer-used for growth and multiplication of microorganisms and is the natural habitat of the organism - People - Animals - Soil - Food - Water - Milk - Inanimate objects Carriers - Correct answer-individuals that are a reservoir and show no sign and symptoms. They are asymptomatic and can transmit the disease. Examples of Reservoirs - Correct answer-Rabies virus- in animals (dogs, squirrels, bats, and raccoons) West Nile- in animals (birds). Mosquitos feed on infected birds, become infected and pass the infection on to people when feeding on their blood Water- Giardia, E.coli, Shigella Food- E.coli, Milk- Listeria (unless it is pasteurized) Portal of Exit - Correct answer-point of escape for the organism from the reservoir ex. sneeze Means of Transmission - Correct answer-direct contact indirect contact airborne route Some organisms can be transported in more than one way. Vehicles of transmission - Correct answer-blood, food, water, or inanimate objects Vectors - Correct answer-mosquitos, ticks, lice transmit organisms from one host to another by injecting salivary fluid when a human bite occurs Airbonrne - Correct answer-germs float through the air after a person talks, coughs, or sneezes. Germs can be inhaled even after the original person is no longer nearby. Direct contact with the infectious person is NOT needed for someone else to get sick. Chicken pox and TB are spread through the air. smaller that 5mcm Droplets - Correct answer-- fluids in large droplets from a sick person splash the eyes, nose, or mouth of another person or through a cut in the skin. Droplets may cause short-term environmental contamination, like a soiled bathroom surface or handrails, from which another person can pick up the infectious material. MRSA sputum, Plague can be spread through large droplets. Ebola might be spread through large droplets but only when a person is very sick early vague and nonspecific signs and symptoms of the disease - Unaware of being contagious, infection spreads Full stage of illness - Correct answer-presence of specific signs and symptoms of disease - Symptoms that are limited or occur in only one body are area are calls localized symptoms Convalescent period - Correct answer-recovery from the infection signs and symptoms disappear, person returns to healthy state Laboratory data used in infection - Correct answer--Elevated white blood cell count— normal is 5,000 to 10,000/mm3 -Increase in specific types of white blood cells -Elevated erythrocyte sedimentation rate -Presence of pathogen in urine, blood, sputum, or draining cultures Standard Precautions - Correct answer-A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious. New additions are respiratory hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures Handwashing - Correct answer-Hand hygiene is paramount to prevent the spread of disease endemic - Correct answer-occurs with predictability in one specific region or population can appear in a different geographic location Tort - Correct answer-a wrong committed by a person against another person or that person's property; tried in civil court ◦ Intentional ◦ Unintentional ◦ immediate purpose - compensation of victim Tort: - Correct answer-only victim injured; private interest only category of responsibility --- liability standard of proof --- "by a preponderance of the evidence" general domain of law --- civil fate of convicted defendant --- pays compensatory damages, sometimes punitive damages; sometimes is enjoined Intentional tort - Correct answer-Assault and battery ◦Defamation of character ◦Invasion of privacy ◦False imprisonment ◦Fraud Unintentional Tort - Correct answer-◦Negligence - "conduct that falls below a standard of care, (prudent nurse) ◦Malpractice - professional negligence HIPPA patient rights - Correct answer-To see and copy their health record To update their health record To request correction of any mistakes To get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations To request a restriction on certain uses or disclosures To choose how to receive health information Four Elements of Liability - Correct answer-Duty Breach of duty Causation Damages Duty - Correct answer-an obligation to use due care (what a reasonably prudent nurse would do), defined by the standard or care appropriate for the nurse-patient relationship Breach of duty - Correct answer-failure to meet the standard or care Causation - Correct answer-most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury Damages - Correct answer-the actual harm of injury resulting to the patient Informed consent - Correct answer-Disclosure Comprehension Competence Voluntariness Fiduciary Responsibility - Correct answer-Nurse is obligated to provide services that require specialized knowledge, integrity and fidelity to the client Documentation Adequate staffing Whistle-blowing Professional liability insurance Risk management programs Incident, variance, or occurrence reports Sentinel events and Never events Patients' rights Good Samaritan Laws Safeguards to Competent Practice - Correct answer--Respect Legal boundaries of practice -Follow institution's policies & procedures -Owning personal strengths and weaknesses -Evaluating proposed assignments -Keep current in nursing knowledge and skills -Respect patient's rights -Careful documentation -work within management policies Standard of Care - Correct answer-Whether negligence has occurred depends on a standard of care, what a reasonably prudent person would or would not have done under similar circumstances Ex: L&D nurses must understand how standards for nursing practice differ from those for medical obstetric practice, be familiar with specific standards for obstetric nursing Living Will - Correct answer-allows you to approve or decline certain types of medical care, even if you will die as a result of that choice. In most states, living wills take effect only under certain circumstances, such as terminal injury or illness. Durable Power of Attorney for Health Care - Correct answer-which is also known as a health-care proxy in some states, allows you to appoint a representative to make medical decisions for you. You decide how much power your representative will or won't have. Do Not Resuscitate Order - Correct answer-is a doctor's order that tells medical personnel not to perform CPR if you go into cardiac arrest. There are two types of Do Not Resuscitate Orders. One is effective only while you are hospitalized. The other is used while you are outside the hospital. Organ Donation Form - Correct answer-In most states, the advance directive form should have a section for specifying whether or not you wish to donate your organs upon your death. Ethics - Correct answer-refer to specific rules and actions, or behaviors. consists of acceptable standards of behavior and maintaining integrity Ethical behavior - Correct answer-involves demonstrating respect for key moral principles that include honesty, fairness, equality, dignity, diversity and individual rights. Acting in ways consistent with what society and individuals typically think are good values. Health care ethics (a.k.a "medical ethics") - Correct answer-is the application of the core principles of bioethics (autonomy, beneficence, nonmaleficence, justice) to medical and health care decisions. Beneficence - Correct answer-is action that is done for the benefit of others. Nonmaleficence - Correct answer-means non-harming or inflicting the least harm possible to reach a beneficial outcome Justice - Correct answer-is a complex ethical principle, with meanings that range from the fair treatment of individuals to the equitable allocation of healthcare dollars and resources. Confidentiality - Correct answer-Must not reveal information without consent unless required by law Patients must feel comfortable revealing information Some incidents must be reported Patients electronic health records must be secure Medical malpractice - Correct answer-is defined as any act or omission by a health care provider during treatment of a patient that deviates from accepted norms of practice in the medical community and causes an injury to the patient. medical negligence - Correct answer-A breach of the health care provider's obligation to follow the appropriate standard of care, which results in harm to the patient. Cardiac output - Correct answer-amount of blood ejected from LV every minute avg 4-6 liters (150 lb man) Stroke volume - Correct answer-amount of blood ejected from LV every contraction Preload - Correct answer-basically amount of blood returning from venous circulation volume of blood in ventricles at end of diastole Normal level carbon dioxide - 35 - 45 mmHg Normal C02 Levels - Correct answer-35-45mmHg Normal bicarbonate level - Correct answer-22-26 mEq/L Respiratory Acidosis - Correct answer-pH below 7.35 means CO2 is high HYPOVENTILATION (Surgery, Pneumonia, Pneumothorax, CNC depression, Embolus Treatment - Increase ventilation Respiratory Alkadosis - Correct answer-pH above 7.45 means CO2 is low HYPERVENTILATION (Fever, Sepsis, Pregnancy, Pain, Anxiety, Meds - Stimulants Treatment - Decrease ventilation Metabolic Acidosis - Correct answer-LOW pH, LOW HCO3 RENAL FAILURE, KETOACIDOSIS, STARVATION, SALICYLATE INTOXICATION TREATMENT - RESTORE TISSUE PERFUSION TO HYPOXIC TSUES Metabolic Alkalosis - Correct answer-HIGH pH, HIGH HCO3 EXCESS ANTACID USE, HCO3, LACTATE IN DIALYSIS (EXCESS BASE), LOSS OF ACIDS, VOMITING, NG SUCTION treatment DIURETICS (MOST DIFFICULT TO TREAT) Factors affecting oxygenation - Correct answer-•Physiologic - anemia, bleeding, cardiac dysrhythmias, MI, infection, •Developmental •Lifestyle - smoking, weight, dietary •Environmental - pollution, second -hand smoke, smog, incidence of resp. condition Hypoventilation - Correct answer-decreased rate or depth of air movement into the lungs Nursing management of Respiratory - Correct answer-•Assessment •Nursing history --Current and past CV problems --Family history --Medical history - DM, kidney, respiratory --Exercise --Smoking history --Diet --Signs/symptoms - CP, SOB, fatigue, cough --Medications --Lifestyle Nursing management of Poor Oxygenation - Correct answer-•Nursing intervention Promoting circulation and oxygenation Deep breathing and coughing, IS, Oxygen Percussion/Vibration, Postural drainage Position, humidification, chest tubes Medications Prevent venous stasis - exercises, SCD Blood thinners CPR Nursing Interventions Promoting Adequate Respiratory Functioning - Correct answer-•Teaching about a pollution-free environment •Promoting optimal function •Promoting comfort •Promoting proper breathing •Managing chest tubes •Partial rebreather mask •Nonrebreather mask •Venturi mask •Tent Simple mask - Correct answer-is a basic disposable mask, made of clear plastic, to provide oxygen therapy for patients who need low volume of oxygen Oxygen tent - Correct answer-Equipment used in healthcare institutions to provide large amounts of extra oxygen for a patient Macronutrients - Correct answer-Nutrients that supply energy Carbohydrates Protein Fats (Lipids Micronutrients - Correct answer-Nutrients that regulate body processes Vitamins Minerals Water Carbohydrates - Correct answer-Sugars and starches Organic compounds composed of carbon, hydrogen, and oxygen Serve as the structural framework of plants; lactose is only animal source Most abundant and least expensive source of calories in the world Classified as simple or complex sugars 90% of carbohydrate intake is ingested Converted to glucose for transport through the blood Cells oxidize glucose to provide energy, carbon dioxide, and water. 50 to 100 g of carbohydrates are needed daily to prevent ketosis Easiest macro to digest - Correct answer-Carbohydrates Simple carbs - Correct answer-monosaccharides and disaccharides glucose, dextrose di: sucrose, lactose Complex carbs - Correct answer-polysaccharides (glycogen, starch, fiber) Carbs and Protein energy - Correct answer-1 g= 4 kcal Protein - Correct answer-Required for the formation of all body structures Labeled complete (high quality) or incomplete (low quality), based on amino acid composition Animal proteins are complete; plant proteins are incomplete. Protein tissues are in a constant state of flux. RDA for adults is 0.8 g/kg of body weight, 10% to 35% total calorie intake Fats - Correct answer-Insoluble in water and blood Composed of carbon, hydrogen, and oxygen 95% of lipids in diet are triglycerides Contain mixtures of saturated (raise cholesterol levels) and unsaturated (lower cholesterol levels) fatty acids Most animal fats are saturated. Most vegetable fats are unsaturated. Digestion occurs largely in the small intestine. Most concentrated source of energy in the diet RDA not established, should be no more than 20% to 35% total calorie intake Fat energy - Correct answer-1g= 9 kcal Vitamins - Correct answer-Organic compounds needed by the body in small amounts Providing oral nutrition Providing long-term nutritional support Consistent-Carbohydrate Diet - Correct answer-Total daily carbohydrate content is consistent; emphasizes general nutritional balance. Calories based on attaining and maintaining healthy weight. High-fiber and heart-healthy fats encouraged; sodium and saturated fats are limited. Type I and type 2 diabetes, gestational diabetes, impaired glucose tolerance Fat-Restricted Diet - Correct answer-Low-fat diets are intended to lower the patient's total intake of fat. Chronic cholecystitis (inflammation of the gallbladder) to decrease gallbladder stimulation; cardiovascular disease, to help prevent atherosclerosis. High-fiber - Correct answer-Emphasis on increased intake of foods high in fiber. Prevent or treat constipation; irritable bowel syndrome; diverticulosis Low-fiber: - Correct answer-Fiber limited to <10 g/day. Before surgery; ulcerative colitis; diverticulitis; Crohn's disease Sodium-restricted - Correct answer-Sodium limit may be set at 500-3000 mg/day Hypertension; heart failure; acute and chronic renal disease, liver disease Renal diet - Correct answer-Reduce workload on kidneys to delay or prevent further damage; control accumulation of uremic toxins. Protein restriction 0.6-1 g/kg/day; sodium restriction 1,000-3,000 mg/day; Potassium and fluid restrictions dependent on patient situation Nephrotic syndrome; chronic kidney disease; diabetic kidney disease Normal or House Diets - Correct answer-no foods are excluded, portion size is not limited Vegetarian Diets - Correct answer-Meats are replaced with legumes, grains, and vegetables Clear Liquid Diet - Correct answer-a diet that consists of foods that are liquid at room temperature and leave little residue in the intestine. Ex: Water, Sprite, Ginger Ale, all beverages without any residue, broth, Jello Preparation for bowel surgery and lower endoscopy; acute gastrointestinal disorders; initial postoperative diet Modified Consistency Diets - Correct answer--Clear liquid diet -Pureed diet -Mechanically altered diet Pureed Diet - Correct answer-foods have been blenderized to liquid form; consistency based on client's needs, nectar or honey thick, can be long term Mechanically Altered Diet - Correct answer-Regular diet with modifications for texture. Excludes most raw fruits and vegetables and foods with seeds, nuts, and dried fruits. Foods are chopped, ground, mashed or soft. Adequate in calories and nutrients and may be used on a long-term basis Chewing and swallowing difficulties; after surgery to the head, neck, or mouth Nothing by Mouth - Correct answer-NPO before surgery, medical tests, experiencing nausea and vomiting, inability to chew or swallow, or acute/chronic GI abnormalities The following measures may provide comfort to patients who are ordered NPO: -Encourage or provide good oral hygiene. -Provide the patient with ice chips or sips of water as allowed. -Urge the patient to avoid watching others eat. Suggest alternate activities at mealtimes. Cholesterol - Correct answer-fat like substance found only in animal products. Nonessential. Abundant in the brain and nerve cells Fat digestion occurs largely in the small intestine Bile secreted by the gallbladder emulsifies fat to increase the surface area so that pancreatic lipase can break down fat more effectively Principles of Wound Healing - Correct answer-•Intact skin is the first line of defense against microorganisms. •Careful hand hygiene is used in caring for a wound. •The body responds systematically to trauma of any of its parts. •An adequate blood supply is essential for normal body response to injury. •Normal healing is promoted when the wound is free of foreign material. •Presence of biofilm (thick grouping of microorganisms) Systemic Factors Affecting Wound Healing - Correct answer-•Age: children and healthy adults heal more rapidly •Circulation and oxygenation: adequate blood flow is essential •Nutritional status: healing requires adequate nutrition •Wound condition: specific condition of the wound affects healing •Health status: corticosteroid drugs and postoperative radiation therapy delay healing •Immunosuppression •Medication use Wound Complications - Correct answer-•Infection •Hemorrhage •Dehiscence and evisceration •Fistula formation Assessment of Wound Drainage - Correct answer-•Serous •Sanguineous •Serosanguineous •Purulent Serous - Correct answer-clear, watery plasma Sanguineous - Correct answer-bloody drainage Serosanguineous - Correct answer-composed of serum and blood Purulent - Correct answer-containing pus Wound Dehiscence - Correct answer-separation of the layers of a surgical wound; may be partial, or superficial only, or complete, with disruption of all layers Wound Evisceration - Correct answer-protrusion of internal organs and tissues through incision Factors Affecting Pressure injury Development - Correct answer-•Aging skin •Chronic illnesses •Immobility •Malnutrition •Fecal and urinary incontinence •Altered level of consciousness •Spinal cord and brain injuries •Neuromuscular disorders Pressure injury Development - Correct answer-•External pressure compressing blood vessels •Friction or shearing forces tearing or injuring blood vessels Stage I pressure ulcer - Correct answer-nonblanchable erythema of intact skin Stage II pressure ulcer - Correct answer-partial-thickness skin loss Stage III pressure ulcer - Correct answer-full-thickness skin loss; not involving underlying fascia Stage IV pressure ulcer - Correct answer-full-thickness skin loss with extensive destruction Unstageable pressure ulcer - Correct answer-base of ulcer covered by slough and/or eschar in wound bed Measurement of a Pressure Ulcer - Correct answer-•Size of wound •Depth of wound •Presence of undermining, tunneling, or sinus tract Wound Assessment - Correct answer-•Inspection for sight and smell •Palpation for appearance, drainage, and pain •Serous drainage •Sanguineous drainage •Serosanguineous drainage •Purulent drainage •Sutures, drains or tubes, and manifestation of complications Ex: surgery, IV therapy, and lumbar puncture Unintentional Wounds - Correct answer-Occur from unexpected trauma, from accidents, forcible injury, and burns. Contamination is likely. Wound edges are usually jagged, multiple traumas are common, and bleeding is uncontrolled. High risk for infections and longer healing time Ex: Stabbing or gunshot wound Open wounds - Correct answer-Can be intentional or unintentional. Bleeding, tissues damage, increased risk for infection, and delayed healing Ex: incisions and abrasions Closed wounds - Correct answer-Caused by trauma such as a fall, an assault, or a MVC. Skin surface is not broken, but soft tissue is damaged. Internal injury and hemorrhage may occur Ex: ecchymosis and hematomas Acute wounds - Correct answer-Heal within days to weeks. Wound edges are approximated and risk for infection is decreased. Move through healing process without difficulty Ex: surgical incisions Chronic wounds - Correct answer-Healing process is impeded. Wound edges are not approximated and risk for infection increases. Normal healing time is delayed. Remain in the inflammatory phase of healing Ex: arterial or venous insufficiency wounds and pressure ulcers Autolytic debridement - Correct answer-uses occlusive dressings like hydrocolloids or transparent films and uses body's own enzymes and defense mechanisms to loosen and liquefy necrotic tissue Mechanical debridement - Correct answer-external physical force to dislodge and remove debris and necrotic tissue. Wound irrigation with pulsed pressure lavage (washing), whirlpool therapy, ultrasound or laser treatment, or with surgical debridement Enzymatic debridement - Correct answer-application of commercially prepared enzymes to speed up the body's autolytic process Biosurgical debridement - Correct answer-uses sterile fly larvae that secretes an enzyme that liquefies dead tissue which is ingested by the larvae, clearing the wound of bacteria and infection Bones Classified by Shape - Correct answer-Long bones: upper and lower extremities Short bones: wrist and ankle Flat bones: ribs and skull bones Irregular bones: spinal column and jaw Four Basic Elements of Normal Movement - Correct answer-Body alignment (posture) Joint mobility Balance Coordinated movement Body Alignment/Posture - Correct answer-Brings body parts into position that promotes optimal balance and body function Person maintains balance as long as line of gravity passes through center of gravity and base of support Joint Mobility - Correct answer-ROM is maximum movement possible for joint ROM varies and determined by: --Genetic makeup --Developmental patterns --Presence or absence of disease --Physical activity Balance - Correct answer-Smooth, purposeful movement Result of proper functioning of: --Cerebral cortex: Initiates voluntary movement --Cerebellum: Coordinates motor activity --Basal ganglia: Maintains posture Coordinated Movement - Correct answer-Complex mechanisms Proprioception --Awareness of posture, movement, changes in equilibrium --Knowledge of position, weight, resistance of objects in relation to body Abduction - Correct answer-Movement away from the midline of the body Adduction - Correct answer-Movement toward the midline of the body Circumduction - Correct answer-circular movement of a limb at the far end Flexion - Correct answer-Bending a body part Extension - Correct answer-Straightening a body part Hyperextension - Correct answer-extension beyond anatomical position Dorsi flexion - Correct answer-bending foot up Plantar f lexion - Correct answer-bend foot down Internal rotation - Correct answer-turning the joint inward No apparent increase in blood flow to other parts of the body Isokinetic excercise - Correct answer-Muscle contraction or tension against resistance Can either be isotonic or isometric Person moves (isotonic) or tenses (isometric) against resistance An increase in blood pressure and blood f low to muscles occurs Aerobic Exercise - Correct answer-Activity during which the amount of oxygen taken in the body is greater than that used to perform the activity Improve cardiovascular conditioning and physical fitness Anaerobic Exercise - Correct answer-Activity in which the muscles cannot draw enough oxygen from the bloodstream Anaerobic pathways are used to provide additional energy for a short time Used in endurance training for athletes Benefits of Exercise to the Cardiovascular System - Correct answer-Increased efficiency of the heart Decreased heart rate and blood pressure Increased blood f low to all body parts Improved venous return Increased circulating fibrinolysin (substance that breaks up small clots) Exercise heart benefits - Correct answer-Increases HR, strength of contraction, and blood supply to the heart and muscles Mediates harmful effects of stress Immobility heart effects - Correct answer-Diminished cardiac reserve Increased use of the Valsalva maneuver Orthostatic hypotension Venous vasodilation and stasis Dependent edema Thrombus formation Excercise Respiratory benefits - Correct answer-Increase ventilation and oxygen intake improving gas exchange Prevents pooling of secretions in the bronchi and bronchioles Immobility Respiratory effects - Correct answer-Decreased respiratory movement Pooling of respiratory secretions Atelectasis Hypostatic pneumonia Exercise Musculoskeletal benefits - Correct answer-Increased muscle efficiency (strength) and flexibility Increased coordination Reduced bone loss Increased efficiency of nerve impulse transmission Nourish joints Immobility Musculoskeletal effects - Correct answer-Disuse osteoporosis Disuse atrophy Contractures Stiffness and pain in the joints Exercise Metabolic/Endocrine benefits - Correct answer-Improve appetite Facilitates peristalsis Elevates the metabolic rate Decreases serum triglycerides and cholesterol Stabilizes blood sugar and make cells more responsive to insulin Immobility Metabolic/Endocrine effects - Correct answer-Constipation Decreased metabolic rate Negative nitrogen balance Anorexia Negative calcium balance Exercise Psychological benefits - Correct answer-Elevates moodRelieves stress and anxiety Improves quality of sleep for most individuals Immobility Psychological Effects - Correct answer-Decline in mood elevating substances Perception of time intervals deteriorates Problem-solving and decision-making abilities may deteriorate Loss of control over events can cause anxiety Exercise effect on the Immune System - Correct answer-Pumps lymph fluid from tissues into lymph capillaries and vessels Increases circulation through lymph nodes Strenuous exercise may reduce immune function --Leaving window of opportunity for infection during recovery phase Exercise effect on Cognitive Function - Correct answer-Positive effects on decision-making and problem solving processes, planning, and paying attention Induces cells in the brain to strengthen and build neuronal connections Exercise effects on spiritual health - Correct answer-there is evidence that certain types of exercise increase spiritual health Immobility effects on integumentary system - Correct answer-causes decreased skin turgor and skin breakdown Difficult to arouse Not disturbed by sensory stimuli Skeletal muscles very relaxed Reflexes are diminished Snoring is likely to occur Swallowing and saliva production reduced Essential for restoring energy and releasing important growth hormones Physiological changes in NREM sleep - Correct answer-BP falls Pulse rate decreases Peripheral blood vessels dilate CO decreases Skeletal muscles relax BMR decreases 10% - 30% GH levels peak Intracranial pressure decreases Characteristics of REM sleep - Correct answer-Acetylcholine and dopamine increase Most dreams take place Brain is highly active Brain metabolism increases as much as 20% Distinctive eye movements occur Voluntary muscle tone dramatically decreased Deep tendon reflexes absent May be difficult to arouse or may wake spontaneously HR and RR often are irregular Regions of brain associated with learning, thinking, organizing information stimulated Sleep cycle - Correct answer-The person passes consecutively through four stages of NREM sleep. The pattern is then reversed. --Return from stage IV to III to II --Enter REM sleep instead of re-entering stage I The person re-enters NREM sleep at stage II and moves on to III and IV. Factor affecting sleep - Correct answer-Developmental considerations Motivation Culture Lifestyle and habits Environmental factors Psychological stress Illness Medications Illnesses associated with bad sleep - Correct answer-Gastroesophageal reflux Coronary artery diseases Epilepsy Liver failure and encephalitis Hypothyroidism End-stage renal disease Dyssomnias - Correct answer-sleep disorders characterized by insomnia or excessive sleepiness Parasomnias - Correct answer-Somnambulism REM behavior disorder (RBD) Sleep terrors Nightmares Bruxism Enuresis Sleep-related eating disorder Insomnia - Correct answer-Difficulty falling asleep Waking up frequently Difficulty staying asleep Daytime sleepiness Difficulty concentrating Irritability Risk factors --Older age --Female Sleep apnea - Correct answer-Caused by lack of hypocretin in CNS that regulates sleep Clients have sleep attacks Sleep at night usually begins with sleep-onset REM period Parasomnia - Correct answer-Behavior that may interfere with or occur during sleep Arousal disorders --i.e., Sleepwalking, sleep terrors Sleep-wake transition disorders --i.e., Sleep talking Associated with REM sleep --i.e., Nightmares Others --i.e., Bruxism Treatment for Dyssomnias - Correct answer-Pharmacologic therapy --Sedatives --Hypnotics Nonpharmacologic therapy Cognitive Behavioral Therapy (CBT) Na (ECF) K (ICF) -Na/K pump Filtration - Correct answer-passage of f luid through a permeable membrane from the area of higher to lower pressure Solutes - Correct answer-substances dissolved in liquid (electrolytes and non electrolytes) Solvent - Correct answer-solution that can dissolve solute --Ex. Sugar or salt in water (sugar, salt is solute, water is solvent) (water) Osmotic pressure - Correct answer-power of a solution to draw water across a semipermeable membrane Isotonic - Correct answer-same concentration of particles as plasma Hypertonic - Correct answer-greater concentration of particles than plasma shriveled Hypotonic - Correct answer-lesser concentration of particles than plasma inflated Saline Solutions - Correct answer-Isotonic - same osmolality, 0.9 % NS Hypertonic - higher than body f luids, 3 % NS Hypotonic - lower osmolality, 0.45 % NS Factors affecting Diffusion - Correct answer-size of molecules concentration of solution temperature of solution Capillary Filtration - Correct answer-esults from the force of blood "pushing" against the walls of the capillaries --At arterial end, filtration is dependent primarily on arterial BP --At venular end, filtrations is dependent on venous blood pressure Source of Fluids for the Body - Correct answer-Ingested liquids Food Metabolism Fluid Losses - Correct answer-Kidneys: urine Intestinal tract: feces Skin: perspiration Insensible water loss Body fluid regulation - Correct answer-Fluid output -1200 -1500 ml/24 hour (normal) Homeostatic mechanisms-Kidneys-ADH - antidiuretic hormone (hypothalamus)-Renin-angiotensin- aldosterone-ANF - atrial natriuretic factor Fluid intake - thirst center (hypothalamus) mechanism -primary regulator Electrolytes balance - Correct answer-Ions --Cations: positive charge --Anions: negative charge Homeostasis: total cations equal to total Extracellular electrolytes - Correct answer-sodium, chloride, bicarbonate Intracellular electrolytes - Correct answer-potassium, magnesium, phosphate Sodium - Correct answer-controls and regulates volume of body fluids Most abundant cation in ECF Normal serum level -135 -145 mEq/L Must be consumed/diet daily to maintain normal levels Potassium - Correct answer-chief regulator of cellular enzyme activity and water content major cation in ICF Normal serum level - 3.5 - 5.0 mEq/L Vital for skeletal, cardiac, smooth muscle activity Source - dietary Calcium - Correct answer-nerve impulse, blood clotting, muscle contraction, B12 absorption 99% in the skeletal system, 1 % in ECF - vital -muscle contraction, relaxation, neuromuscular function, cardiac function ECF Ca - regulated by interaction of parathyroid hormone, calcitonin, calcitriol (a Vit D metabolite) Low Ca in ECF = parathyroid hormone and calcitriol -release of Ca from bones to ECF, increase absorption of Ca in intestine , increase Ca serum level, aging changes Magnesium - Correct answer-metabolism of carbohydrates and proteins, vital actions involving enzymes Metabloic Acidosis - Correct answer-Low pH, low HCO3 (bicarbonate) cause- renal failure, ketacidosis, starvation, salicylate intoxication, treatment- restore tissue perfusion to hypoxic tissues Metabolic Alkalosis - Correct answer-High pH. High HCO3 (bicarbonate) cause- excess antacid use, HCO3, lactate in dialysis (excess base), loss of acids, vomiting, treatment: Diuretics, most difficult to treat FACTORS AFFECTING BODY FLUID, ELECTROLYTE, ACID-BASE BALANCE - Correct answer-AGEGENDER BODY SIZE ENVIRONMENTAL TEMPERATURE LIFESTYLE Hypovolemia - Correct answer-deficiency in amount of water and electrolytes in Extracellular fluid with near-normal water/electrolyte proportions Dehydration - Correct answer-decreased volume of water and electrolyte change Third-space fluid shift - Correct answer-a distributional shift of body fluids into the transcellular compartment such as the pleural, peritoneal (ascites), or pericardial areas, joint cavities, bowel, or an excess accumulation of fluid in the interstitial space Hypervolemia - Correct answer-excessive retention of water and sodium in Extra cellular fluid Edema - Correct answer-excessive ECF accumulates in tissue spaces Pitting Edema scale - Correct answer-Grade 1+: The pressure applied by the doctor leaves an indentation of 0-2 millimeters (mm) that rebounds immediately. This is the least severe type of pitting edema. Grade 2+: The pressure leaves an indentation of 3-4 mm that rebounds in fewer than 15 seconds. Grade 3+: The pressure leaves an indentation of 5-6 mm that takes up to 30 seconds to rebound. Grade 4+: The pressure leaves an indentation of 8 mm or deeper. It takes more than 20 seconds to rebound. Interstitial-to-plasma shift - Correct answer-movement of fluid from space surrounding cells to blood Hyponatremia - Correct answer-low sodium in the blood under 135 mEq/L Hyponatremia S/S - Correct answer---sodium may be lost through vomiting, diarrhea, fistulas, sweating, or as the result of the use of diuretics --Leads to swelling of the cells, resulting in confusion hypotension, edema, muscle cramps and weakness, and dry skin --Cerebral edema can lead to seizures --Permanent neurologic damages and death can result from severe hyponatremia Hypernatremia - Correct answer-high sodium in blood over 145 mEq/L Hypernatremia S/S - Correct answer---Caused by excess water loss or an overall excess of sodium. Fluid deprivation, lack of fluid consumption, diarrhea, and excess insensible water loss leads to excess sodium --Results in neurologic impairment including restlessness, weakness, disorientations, delusion, and hallucinations --Permanent brain damage can occur Hypokalemia - Correct answer-low potassium less than 3.5 mEq/L Hypokalemia S/S - Correct answer---Skeletal muscles are generally the first to demonstrate a potassium deficiency. --Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias Hyperkalemia - Correct answer-high potassium more than 5.0 mEq/L Hyperkalemia S/S - Correct answer-May result from renal failure, hypoaldosteronism, or the use of certain medications such as potassium chloride, heparin, angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs --Nerve conduction as well as muscle contractility can be affected. --Skeletal muscle weakness and paralysis may occur. --A variety of cardiac irregularities may result, including cardiac arrest if hyperkalemia is not corrected Hypocalcemia - Correct answer-deficient calcium in the blood less than 8.5 mg/dL Hypocalcemia S/S - Correct answer-Common causes related to a calcium deficit involve inadequate calcium intake, impaired calcium absorption, and excessive calcium loss. Manifestations include irritability, fatigue, weakness, paresthesias, confusion, seizures, and coma. Hyperphosphatemia - Correct answer-high phosphate more than 4.5 mg/dL Hyperphosphatemia S/S - Correct answer-Common causes are impaired kidney excretion and hypoparathyroidism. Hyperphosphatemia can result in tetany, anorexia, nausea, muscle weakness, and tachycardia. Parameters of assessment of electrolytes - Correct answer-Nursing history and physical assessment Fluid intake and output Daily weights Laboratory studies Lab Studies to Assess for Imbalances in electrolytes - Correct answer-Complete blood count Serum electrolytes, blood urea nitrogen, and creatinine levels Urine pH and specific gravity Arterial blood gases (ABG) Risk Factors for Imbalances - Correct answer-underlying acute and chronic illnesses Abnormal losses of body fluids Burns Trauma Surgery Therapies that disrupt fluid and electrolyte balance Nursing Diagnoses Related to Fluid Imbalances - Correct answer-Excess fluid volume Deficient fluid volume Risk for imbalanced fluid volume Expected outcomes of Fluid imbalance - Correct answer-Maintain approximate fluid intake and output balance (2,500-mL intake and output over 3 days). Maintain urine specific gravity within normal range (1,010-1,025). Practice self-care behaviors to promote balance. Neuropathic pain - Correct answer-pain from damage to neurons of either the peripheral or central nervous system Neuropathic pain treatment - Correct answer-Anti-convulsants (ex: gabapentin) Phantom pain - Correct answer-pain felt in a body part that is no longer there responses to pain - Correct answer-physiologic, behavioral, affective Patient-controlled analgesia (PCA) - Correct answer-Drug delivery system that allows patients to self- administer analgesic medications on demand. Acute pain - Correct answer-pain that is felt suddenly from injury, disease, trauma, or surgery Foods Affecting Bowel Elimination - Correct answer-Constipating foods Foods with laxative effect Gas-producing foods: Constipating foods - Correct answer-cheese, lean meat, eggs, pasta Foods with laxative effect - Correct answer-fruits and vegetables, bran, chocolate, alcohol, coffee Gas-producing foods - Correct answer-onions, cabbage, beans, cauliflower Aspirin, anticoagulants stool effect - Correct answer-pink to red to black stool Iron salts stool effect - Correct answer-black stool Antacid stool effect - Correct answer-white discoloration or speckling in stool Antibiotics stool effect - Correct answer-green-gray color Stool Collection - Correct answer-Medical aseptic technique is imperative. Hand hygiene, before and after glove use, is essential. Wear disposable gloves. Do not contaminate outside of container with stool. Obtain stool and package, label, and transport according to agency policy. Patient Guidelines for Stool Collection - Correct answer-Void first so that urine is not in stool sample. Defecate into the container rather than toilet bowl. Do not place toilet tissue in the bedpan or specimen container. Notify nurse when specimen is available. stool using the technique "timed specimen" - Correct answer-When collecting stool using the technique "timed specimen,"the nurse should consider the first stool passed by the patient as the start of the collection period. esophagogastroduodenoscopy (EGD) - Correct answer-examines the esophagus, stomach, and upper duodenum through an optic scope.