Download RASMUSSEN MDC II EXAM 2024 and more Exams Nursing in PDF only on Docsity! 1 | P a g e RASMUSSEN MDC II EXAM 2024 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+ |NEWEST |LATEST UPDATE |GUARANTEED PASS A nurse is educating an esophageal cancer patient about their plan of care. Which topic should be discussed? A-We will only dilate your esophagus ince during treatment B-Whenever you're tired you should take a nap C-You should consider hospice care for end of life care D-We need to monitor your weight. Please weigh yourself daily. D-We need to monitor your weight. Please weigh yourself daily. What is the first step in figuring out a clients ABGs A-Look at the ph and determine what it is B-Look at the CO2 and determine what it is C-Look at the HCO3 and determine what it is D-Determine the compensation A-Look at the ph and determine what it is Sodium bicarbonate is a treatment option for clients in which acid-base imbalance? A-Resp. alkalosis B-Metabolic acidosis C-Metabolic alkalosis D-None of the above B-Metabolic acidosis A client presents to the ER with multiple rib fractures. Which acid-base imbalance so you expect? A-Resp acidosis B-Resp alkalosis C-Metabolic acidosis D-Metabolic alkalosis A-Resp acidosis 2 | P a g e How will the body compensate for a client with metabolic acidosis? A-Hypoventilate B-Hyperventilate C-Produce more urine D-The body can't compensate on its own B-Hyperventilate A 37 Year old Male was Recently dx with oropharyngeal cancer and is struggling financially, who should the referral be made to? A-Social Services B-Physical Therapist C-Psychologist D-Orthapedics A- Social Services Your client has the following ABG results- pH 7.1, CO2 32, and HCO3 20. What is your interpretation? A-Normal B- Uncomp. Resp. Acidosis C- Part. Comp. Metabolic Acidosis D- Part. Comp. Resp. Acidosis C- Partially Comp. Metabolic Acidosis. A patient presents to the ER with a panic attack. This is an example of which acid- base imbalance? A- Resp. acidosis B- Resp. alkalosis C- Metabolic acidosis D- Metabolic alkalosis B- Resp. alkalosis Your patient's lab results reveal a potassium level of 1.8. This could be an indicator of which acid-base imbalance. A-Resp. acidosis B-Resp. alkalosis C-Metabolic acidosis D-Metabolic alkalosis D-Metabolic alkalosis You've been assigned a patient that is in kidney failure. The doc orders an ABG. What do you expect for the results? A-PH. 7.22 CO2 55 HCO3 50 B-PH 7.49 CO2 46 HCO3 55 C-PH 7.28 CO2 30 HCO3 14 D-PH 7.56 CO2 32 HCO3 21 5 | P a g e How would you interpret these results? PH 7.49, CO2 36 HCO3 34 A-Uncompensated metabolic acidosis B-Uncompensated metabolic alkalosis C-Fully compensated metabolic acidosis D-Fully compensated metabolic alkalosis B-Uncompensated metabolic alkalosis A client informs you they are scared of developing oral cancer. Which of these statements is alarming to you? A-I did chew tobacco when I played baseball 10 years ago B-I make sure to wear sunscreen when you in the sun C-I'm a social drinker at weddings D-I do not have dental insurance so I haven't had a check up in years D-I do not have dental insurance so I haven't had a check up in years You're caring for a client with resp. Acidosis you expect theri CO2 level to be low. True False False You're providing discharge teaching to a client with GERD. Which of the following should the client avoid? A-Bread B-Salad C-Coffee D-Low-fat foods C-Coffee Your client with metabolic acidosis is experiencing ECG changes. What is likely the cause of this? A-Hyperkalemia B-Hypokalemia C-Hypernatremia D-Hyponatremia A-Hyperkalemia Your client with GERD just finished eating and wants to lay down. What should your response be? A-Let me remove your tray and help you lay down B-How about you brush your teeth and get ready for bed first C-You really should try and remain upright for 1-2 hours after eating D-Remember to lay flat C-You really should try and remain upright for 1-2 hours after eating The provider ordered 80mg of Famotidine at bedtime. Available is 40mg/ tablet. How many tablets to give 6 | P a g e A-1.5 B-2 C-3 D-4 B-2 A 37 Year old Male was Recently dx with oropharyngeal cancer and is struggling financially, who should the referral be made to? A-Social Services B-Physical Therapist C-Psychologist D-Orthapedics A- Social Services Your client has the following ABG results- pH 7.1, CO2 32, and HCO3 20. What is your interpretation? A-Normal B- Uncomp. Resp. Acidosis C- Part. Comp. Metabolic Acidosis D- Part. Comp. Resp. Acidosis C- Partially Comp. Metabolic Acidosis. A patient presents to the ER with a panic attack. This is an example of which acid- base imbalance? A- Resp. acidosis B- Resp. alkalosis C- Metabolic acidosis D- Metabolic alkalosis B- Resp. alkalosis Your patient's lab results reveal a potassium level of 1.8. This could be an indicator of which acid-base imbalance. A-Resp. acidosis B-Resp. alkalosis C-Metabolic acidosis D-Metabolic alkalosis D-Metabolic alkalosis Remaining still for hours, sitting for long periods of time, anything that prevents circulation Clients at risk for DVT - Handrails in bathrooms - Ramps instead of stairs - Wear rubber sole shoes 7 | P a g e - Avoid scatter rugs - Prevent clutter - Avoid slippery floors Prevention of falls - Increased intraocular pressure in a hollow organ. - When the intraocular pressure increase it leads to compression of the retinal blood vessels and photoreceptors and their nerve fibers resulting in hypoxemia and death of the tissue and loss of vision. - Assure the patient can administer own eye drops correctly - Keep follow-up appointments every 1-3 months to evaluate the IOP. - If the patient had surgical treatment be sure to educate on the S&S of hemorrhage and detachment including severe pain, and vision loss. These should be reported immediately to HCP. Glaucoma teaching and pathophysiology - Maintain perfusion, improve comfort, and prevent impaired mobility Prioritization of care for a fracture - Handle with the palms of your hands, have patient report painful "hot spots" under the cast which might indicate area of pressure necrosis, instruct patient to never put anything down into the cast, encourage the patient/family to smell the area for mustiness or unpleasant odor (if ignored the patient may develop a fever). - Assess skin color and temperature, sensation, mobility, pain, capillary refill, and pulses distal to the fracture site. CMS- circulation, movement, and sensation. Cast education and assessment - Infection of the bone. May be acute or chronic. - Educate about medications, encourage compliance and to follow regimen (take full course of medications), inform about signs and symptoms, provide comfort during rest and with positioning, assist in ADL, coordinate physical therapy while in the hospital to help improve mobility especially after surgery, provide mobility assistance devices. Osteomyelitis prevention and treatment methods - Gonioscopy is used when elevation intraocular pressure is diagnosed to determine if the glaucoma is open-angle or closed-angle. It allows the visualization of the angle where the iris meets the cornea. Test to determine open vs closed angle glaucoma - CMS: circulation, mobility, sensation. Assess skin color, temperature, sensation, mobility, pain, capillary refill, and pulses. Neurovascular assessment - P: Palliative, Q: Quality, R: Region, S: Scale, T: Time Pain assessment 10 | P a g e Lying lateral and semi on the stomach (semi-prone). Sim's position Lying on the back supine position - Immobility, acute compartment syndrome, hemorrhage or hypovolemic shock, fat embolism syndrome, venous thromboembolism, infection, avascular necrosis, delayed union, and complex regional pain syndrome Complication of fractures - Related to the muscle, blood vessels and nerves are caught within the fascia leading to the increase in the venous pressure and the resulting edema. Compartment syndrome Wood or plastic device to assist with moving the patient Transfer board Hydraulic devices to transfer patients Mechanical lift - Heavy belt several inches wide to facilitate transfer or secure holding the patient while they ambulate. Transfer belt - Health history, demographic data, genetic considerations, menstrual and menopause history, nutrition, endocrine history, physiological changes, assess pain level with activity, assess for fractures, assess mobility function, and assess the patient psychosocial status. Assessment of osteoporosis Consolidation and remodeling of bone continue to meet mechanical demands. This process may start as early as 4 to 6 weeks after fracture and can continue for up to 1 year. Depends on the severity of the injury and the age and health of the patient. Fifth stage of bone healing - Perform "heel pump" activities - Drink adequate fluids - Compression stockings - Exercise - Remain active DVT prevention - Increased cardiac workload, risk for orthostatic hypotension, risk for venous thrombosis Cardiovascular effects of immobility 11 | P a g e - Decrease muscle size, tone, and strength. Decreased joint mobility and flexibility. Bone demineralization. Decreased endurance and stability. Increased risk for contracture formation. Musculoskeletal effects of immobility - Decreased depth of respiration, decreased rate of respiration, pooling of secretions, and impaired gas exchange. Respiratory effects of immobility - The second step of the nursing process. This is the phase in which you use your critical-thinking skills to analyze the assessment data. Nursing diagnosis - Release of fat globules from the yellow bone marrow into the blood vessels within 12 to 48 hours following the fracture. Fat embolism syndrome - Independent joint movements. It requires the client to move the joint through its full ROM. Active ROM - Dependent joint movement. Is used when the client is unable to exercise each joint independently. Instead, you support the body and move each joint through its ROM. Passive ROM - Goal: Maintain optimum vision by complying with treatment regimens. - Treatment: Prescribed eye drops every 12 hours Glaucoma goals and treatment - The surgeon views the fracture site and places pins, screws, plates and sometimes prosthesis to allow the bone to heal. Open reduction internal fixation (ORIF) - Opioid-Oxycodone, Non-opioid, anti-inflammatory, and muscle relaxants Pain management with fracture patients - You must determine the status, or type, of each nursing diagnosis (or patient concern). Is it an actual (signs and symptoms are present), risk (potential- problem may occur), possible (problem may be present), syndrome (several related problems are present), or wellness nursing diagnosis (no problem is present)? Identifying priority nursing diagnosis Also called nearsightedness. Occurs when the eye overbends the light and images converge in front of the retina. Near vision is normal, but distance is poor. Myopia 12 | P a g e Within 24 to 72 hours a hematoma forms at the site of the fracture. First stage of bone healing Occurs in 3 days to 2 weeks when granulation tissue begins to invade the hematoma. This prompts the formation of fibrocartilage, providing the foundation for bone healing. Second stage of bone healing Occurs as a result of vascular and cellular proliferation. Within 3-6 weeks the fracture site is surrounded by new vascular tissue (callus is the beginning of a nonbony union). Third stage of bone healing In 3-8 weeks, the callus is gradually resorbed and transformed into bone. Fourth stage of bone healing PT PAP HOT ▪ Pituitary ▪ Thyroid ▪ Pancreas ▪ Adrenals ▪ Parathyroid ▪ Hypothalamus ▪ Ovaries ▪ Testes What are the glands of the endocrine system? (SATA Q?) Grave's disease an autoimmune disorder that is caused by hyperthyroidism and is characterized by goiter and/or exophthalmos 15 | P a g e INCREASED: ▪ Prolactin - this might be the answer to the Q ▪ Cortisol ▪ TSH ▪ LH (men) ▪ FSH (men) ▪ Glucose DECREASED: ▪ Gonadotropin Anterior HYPERpituitarism (SATA Q?) ▪ Laboratory Tests ▪ Prevent infection because they are immunosuppressed ▪ handwashing HYPERcortisolism (aka Cushing's Disease) Priority Intervention diabetes insipidus ▪ Deficiency of ADH resulting in large volumes of dilute urine ▪ A disorder of the posterior pituitary gland 16 | P a g e They are losing a lot of water: • polyuria • polydipsia • dehydration • fluid/electrolyte imbalance • dilute, low urine specific gravity (<1.005) • high plasma osmolarity • output does not decrease when fluid intake decreases remember! your s/s are going to look like dehydration • tachycardia • hypotension • poor turgor • dry mucous membranes • decreased cognition • ataxia • irritability Posterior Pituitary Gland: Diabetes Insipidus: ▪ What will the patient present with?/Key Symptoms ▪ desmopressin acetate (a synthetic form of vasopressin) ▪ can be PO, SL, or intranasal Posterior Pituitary Gland: Diabetes Insipidus: ▪ Drug Therapy 17 | P a g e Addison's disease What is adrenal gland hypofunction? ▪ If the patient remains alert and oriented x 3 Addison's Disease ▪ How do you know the therapy is working? ▪ Glucocorticoid drugs MUST be withdrawn slowly so you don't wind up with Addison's or adrenal insufficiency ▪ This allows for pituitary protection of ACTH and activation of the adrenal cortex to produce cortisol Addison's Disease ▪ How do you discontinue glucocorticoid therapy to avoid secondary adrenal insufficiency? ▪ Muscle weakness ▪ Muscle/joint pain ▪ Fatigue 20 | P a g e ▪ Do not smoke ▪ Do not drink caffeine ▪ Do not change position suddenly ▪ Eat a diet rich in calories, vitamins, and minerals (avoid tyramine foods) Any of the above can cause a hypertensive crisis (closely monitor their BP!) never palpate or can give pt a massive rush of catecholamines (epinephrine) Pheochromocytoma ▪ Patient Education Cold intolerance Other S/S: ▪ think dehydration: fatigue, weakness, lethargy, constipation, dry skin ▪ poor memory ▪ fatigue ▪ lack of energy -> sleeping more frequently ▪ muscle aches ▪ stiff muscles Hypothyroidism ▪ Hallmark assessment Improvement usually occurs within 2 weeks Thyroid Therapy ▪ When will a patient feel therapeutic effects? 21 | P a g e iatrogenic hypoparathyroidism What does a thyroidectomy cause? Thyroid surgery can cause parathyroid gland injury which results in tetany and hypocalcemia Assess for: ▪ muscle twitching ▪ muscle spasms ▪ tingling around the mouth ▪ tingling of the toes and fingers ▪ hoarseness ▪ stridor ▪ suture line pressure ▪ thyroid storm Thyroid Surgery (thyroidectomy) ▪ What is the biggest thing we are watching for post-op? Think hypocalcemia S/S ▪ muscle cramps ▪ muscle spasms of the hands and feet. ▪ Mild tingling/numbness to muscle tetany ▪ Seizures w/o loss of consciousness ▪ Irritability ▪ Positive Chvostek's and Trousseau's Signs 22 | P a g e Hypoparathyroidism ▪ Signs & Symptoms thyroid storm priority: maintain a patent airway and adequate ventilation. ▪ a relatively rare, life-threatening condition caused by exaggerated hyperthyroidism ▪ an individual's heart rate, blood pressure, and body temperature can soar to dangerously high levels. Even with treatment may lead to death. DECREASE - hypothyroidism As a person ages, thyroid levels may ______________. INCREASED ▪ TSH ▪ Serum thyroglobulin level (Thyroid Cancer) DECREASED ▪ T3, T4 Hypothyroidism ▪ Diagnostic Labs 25 | P a g e ▪ Rashes ▪ Skin infections ▪ Peripheral neuropathy Type I Diabetes ▪ Signs & Symptoms INCREASED: ▪ Hemoglobin A1C ▪ Random blood glucose ▪ Fasting blood glucose Type I or Type II Diabetes ▪ Laboratory tests Normal range: fasting glucose <110 mg/dL Normal range: hemoglobin A1C < 6.5% ▪ They may have eaten poorly the night before (had alcohol or a high carb dinner) but otherwise have been compliant the past 3 months. How would you interpret? ▪ A patient has a fasting blood glucose level of 260 mg/dL and a hemoglobin A1C of 6.0% Normal range: fasting glucose <110 mg/dL Normal range: hemoglobin A1C < 6.5% 26 | P a g e ▪ They tried to eat well a few days leading up to the test but have not been compliant the past 3 months. How would you interpret? ▪ A patient has a fasting blood glucose level of 99 mg/dL and a hemoglobin A1C of 9.0% Normal range: fasting glucose <110 mg/dL Normal range: hemoglobin A1C < 6.5% ▪ They have not been compliant at all! How would you interpret? ▪ A patient has a fasting blood glucose level of 260 mg/dL and a hemoglobin A1C of 10.0% This is a short-acting, regular insulin ▪ at the peak point (half-life), which for Novolin R is at 2.5-5 hrs ▪ this means they need to plan to eat something at that time ▪ not recommended to take before bedtime b/c of this issue If we are giving a patient Novolin R, when are they at the greatest risk for hypoglycemia? p. 1294 ▪ onset: 1-5 hours ▪ peak: 4-12 hours 27 | P a g e NPH (intermediate-acting insulin) ▪ Onset, Peak p. 1294 ▪ onset: 2-4 hours ▪ peak: 6-12 hours Long-acting insulin ▪ Onset, Peak p. 1294 Kussmaul breathing _____________ is a type of hyperventilation that is the lung's emergency response to acidosis. It causes a labored, deeper breathing rate. It is most commonly associated with conditions that cause metabolic acidosis, particularly diabetes ▪ IV normal saline ▪ regular, short-acting insulin ▪ hydration "Hydration...Insulin...Electrolyte Replacement" ▪ assess airway, LOC, hydration, electrolytes, and blood glucose 30 | P a g e Hypoglycemia ▪ Patient Education ▪ How to do fingersticks or give injections ▪ S/S of hypoglycemia and DKA ▪ Inspect feet at least once a day ▪ Wear closed-toed shoes that are sturdy Diabetes in General ▪ Patient Education ▪ dehydration ▪ electrolyte loss ▪ fluid loss Observe for fungal or yeast infections, which appear as dark red rashes with "satellite" lesions. What do you monitor for in a patient with diarrhea? ▪ chronic or recurrent diarrhea ▪ constipation ▪ abdominal pain ▪ bloating remember! it's unique bc you get both diarrhea and constipation 31 | P a g e Irritable Bowel Syndrome ▪ Signs & Symptoms ▪ diet modification ▪ stress reduction ▪ adhere to medications such as bulk forming laxatives, antidiarrheal agents Irritable Bowel Syndrome ▪ Treatment/Nursing Interventions/Education non-mechanical bowel obstruction If someone is post-op and they have no bowel sounds and have not passed gas, what would you suspect? Call the MD, this indicates a lack of tissue perfusion (ischemia) If a patient is post-op from a colostomy or ileostomy and you discover a blue stoma what would you do? beefy red What color is a stoma supposed to be? 32 | P a g e • Appearance of a normal stoma (beefy red) • Signs and symptoms of complications • Measurement of the stoma • Choice, use, care, and application of the appropriate appliance to cover the stoma • Measures to protect the skin adjacent to the stoma • NUTRITION changes to control gas and odor • What to expect in terms of stool consistency • Resumption of normal activities, including work, travel, and sexual intercourse Stoma ▪ Patient Education ▪ pain management ▪ sitz baths ▪ keep their stool as liquid as possible (use bulk producing agents) ▪ administer medications as prescribed (i.e. antibiotics) ▪ post-operative care (i.e. incision and drainage) Anorectal Abscess ▪ Nursing Interventions & Treatments anorectal abscess Collection of perianal pus resulting from an infection in the anal glands. Usually a result of an obstruction (feces, foreign bodies, or trauma) 35 | P a g e ▪ nutritional therapy ▪ antidiarrheal ▪ salicylates ▪ steroids ▪ modify diet ▪ psychological support ▪ surgical interventions: restorative proctocolectomy with ileo pouch-anal anastomosis, total proctocolectomy with a permanent ileostomy Ulcerative Colitis ▪ Treatment Stools: 10-20 liquid, bloody stools Rectum --> Cecum If a patient has ulcerative colitis, what are the stools like and where is the inflammation generally at? Crohn's disease ▪ classified as an inflammatory bowel disease in which part of the GI tract becomes inflamed and can result in the development of abscesses, fistulas, and fissures 36 | P a g e ▪ weight loss ▪ fever ▪ abdominal pain ▪ blood in the stool ▪ diarrhea ▪ steatorrhea malabsorption syndrome is a complication, treated with TPN Crohn's Disease ▪ Signs & Symptoms Stools: 5-6 soft stools Terminal ileum --> all bowels If a patient has Crohn's disease, what are the stools like and where is the inflammation located? Think of fluid volume overload for S/S ▪ weight gain (fluid retention) ▪ N/V ▪ tachycardia ▪ hypertension ▪ bounding pulse ▪ confusion ▪ increased thirst ▪ muscle weakness ▪ weakness ▪ fatigue ▪ seizures SIADH ▪ Signs & Symptoms 37 | P a g e Diuretics, 3% hypertonic saline, declomycin -Want to remove fluid and add sodium SIADH ▪ Medications to Treat ▪ decreased urine osmolarity (becoming less concentrated) ▪ increased urination (water is finally leaving) ▪ weight loss (water is finally leaving) SIADH ▪ How do we know treatment is effective? INCREASED ▪ urine osmolarity (concentrated urine) ▪ GFR DECREASED ▪ serum sodium (hyponatremia r/t fluid retention) SIADH ▪ Lab Values 40 | P a g e melena black, tarry stool with occult blood indicates minimal bleeding from ulcers diverticular disease herniation or outpouchings of the mucosa membrane of the bowel caused by an increase of pressure within the colon ▪ stool softeners ▪ fiber ▪ fluids avoid: laxatives, enemas Diverticulitis ▪ Treatment ▪ monitor vital signs (BP) to determine fluid volume status ▪ monitor fluid and electrolytes ▪ monitor intake and output ▪ assess abdomen for bowel sounds, distention, flatus ▪ manage nasogastric (NG) tube 41 | P a g e - monitor drainage - ensure tube patency - check tube placement - irrigate tube as prescribed ▪ keep patient NPO ▪ provide frequent oral and nares care ▪ ambulate patient ▪ semi-fowler's position ▪ administer medication for pain Small Bowel Obstruction ▪ Nursing Interventions malabsorption syndrome the small intestine is unable to absorb nutrients INCREASED ▪ fecal fat analysis (steatorrhea) DECREASED ▪ MCV ▪ MCH ▪ MCHC ▪ hydrogen breath test ▪ lactose tolerance test ▪ Schilling test (B-12) Malabsorption Syndrome ▪ Laboratory Tests 42 | P a g e ▪ weight loss ▪ bloating ▪ bruising ▪ + hydrogen breath test Malabsorption Syndrome ▪ Signs & Symptoms computed tomography (CT) What diagnostic test is used to determine distention, abscess, or perforation? ▪ Severe pain that then stops and changes to tenderness on palpation ▪ Abdominal pain (often severe and diffuse) ▪ Severe abdominal cramping. ▪ Bloating. ▪ N/V ▪ A change in bowel movements or habits. ▪ Rectal bleeding. ▪ Fever (usually not immediately) ▪ Chills. GI medical emergency: Perforation ▪ Signs & Symptoms 45 | P a g e ▪ family history (1st degree relative) ▪ Inflammatory Bowel Disease (Crohn's or U.C.) Colorectal Cancer ▪ Risk Factors assess patency of the NG tube Patient with NG tube is uncomfortable, what intervention would you do first? abdominal x-ray Gold standard to confirm placement of NG tubes ▪ Explain procedure ▪ Checking Placement ▪ Assessing patency ▪ Maintenance of NG tube Steps of the NG tube process islets of Langerhans (beta cells) The region of the pancreas that is responsible for insulin production 46 | P a g e Peritonitis inflammation of the peritoneum (membrane lining the abdominal cavity and surrounding the organs within it) ▪ abdominal pain ▪ abdominal distention ▪ N/V ▪ fever ▪ rebound tenderness ▪ decreased urine output ▪ tachycardia ▪ hypotension ▪ diminished bowel sounds Peritonitis ▪ Signs & Symptoms Post-surgical ▪ Monitor the patient's level of consciousness, vital signs, respiratory status (respiratory rate and breath sounds), and intake and output at least hourly immediately after abdominal surgery. ▪ Maintain the patient in a semi-Fowler's position to promote drainage of peritoneal contents into the lower region of the abdominal cavity. This position also helps increase lung expansion. ▪ administer IV fluids ▪ administer antibiotics ▪ daily weight ▪ monitor vital signs 47 | P a g e ▪ monitor fluid & electrolytes ▪ manage nasogastric tube ▪ supplemental oxygen ▪ post-operative care ▪ NG tube ▪ antibiotics ▪ pain management ▪ surgical interventions: exploratory laparotomy, wound exploration Peritonitis ▪ Nursing Interventions flatus How would you know a bowel obstruction is resolving? ▪ N/V ▪ abdominal pain ▪ abdominal distention ▪ decreased bowel sounds Bowel Obstruction ▪ Signs & Symptoms Wound ostomy continence nurse (WOCN) a nurse specially educated to care for ostomy patients 50 | P a g e ▪ dietician ▪ diabetes educator ▪ cultural assessment ▪ interpreter Type II Diabetes ▪ Multidimensional Care Glucose is the main fuel for the CNS because the brain cannot produce or store glucose Why is it important to keep glucose maintained? loss of muscle tissue. It can also result in Cushing's syndrome (aka hypercortisolism), which can lead to: a fatty hump between your shoulders, etc. (think of Cushing's S/S) Side effects of long-term glucocorticoid use Aging hormone excess/deficiency or poor hormone-receptor interactions resulting in decreased responsiveness of the target tissue 51 | P a g e What are contributing factors to endocrine changes? ▪ diuretic and hydration therapy to help reduce serum calcium levels. Ex: LASIX ▪ Monitor for: tingling/numbness in extremities, cardiac function during rehydration ▪ Pt high risk for fractures Hyperparathyroidism ▪ Treatments ▪ Laxatives are products that help people to poop by causing bowel movements. ▪ Stool softeners are a type of laxative that works by drawing water into the stool, making it softer and more comfortable to pass. Answer: Stool softeners, such as docusate sodium (Colace) What is the difference between a laxative and a stool softener? Which one should a healthcare provider prescribe before and after surgery? look at pH What is your first step when interpreting ABGs? Respiratory acidosis 52 | P a g e What acid-base imbalance would you expect to see in an asthmatic patient? COPD asthma muscle weakness ▪ inadequate chest expansion ▪ pneumonia ▪ pulmonary edema ▪ sleep apnea ▪ respiratory depression r/t: drugs, alcohol, anesthesia, electrolyte imbalance ▪ high ICP Common causes of Respiratory Acidosis Vital Signs, think LOW & SLOW ▪ bradycardia, thready weak pulses ▪ hypotension ▪ hypoxia Electrolyte Imbalance ▪ hyperkalemia Skin ▪ pale, cyanotic CNS Depression, think LOW & SLOW ▪ lethargy ▪ confusion ▪ stupor ▪ coma ▪ headache Musculoskeletal, think LOW & SLOW ▪ hyporeflexia 55 | P a g e overproduction of hydrogen ions aspirin toxicity ▪ kidney failure, liver failure, pancreatitis ▪ diarrhea (ACI-dosis sounds like ASS) ▪ dehydration ▪ ingestion of acids: ethanol, methanol, salicylate acid ▪ lactic acidosis ▪ diabetic ketoacidosis, starvation ▪ hypermetabolism: excessive exercises, seizures, fever, hypoxia Causes of Metabolic Acidosis Vital Signs, think LOW & SLOW Kussmaul respirations ▪ bradycardia, thready weak pulse ▪ hypotension ▪ hypoxia Electrolyte Imbalances ▪ hyperkalemia ▪ hyperglycemia (if the cause is DKA) Skin ▪ warm, flushed, dry (due to vasodilation) CNS depression, think LOW and SLOW ▪ lethargy ▪ confusion ▪ stupor ▪ coma ▪ Headache Musculoskeletal, think LOW and SLOW ▪ hyporeflexia 56 | P a g e ▪ muscle weakness ▪ flaccid paralysis Cardiac ▪ heart dysrhythmias (due to hyperkalemia) ▪ increased cardiac output ▪ EKG changes - tall T waves, wide QRS, prolonged PR interval S/S of Metabolic Acidosis (acidosis has similar s/s no matter if met. or resp.) Peaked T waves Wide QRS Prolonged PR interval How does the EKG change for a patient with metabolic acidosis? administer sodium bicarbonate ▪ insulin (if cause is DKA) ▪ fluid/electrolyte replacement (remember some causes are dehydration/diarrhea) ▪ treat underlying cause... Treatment for Metabolic Acidosis Mechanical ventilation question will ask which intervention is NOT included in treatment for Metabolic Acidosis Mechanical ventilation Treat underlying cause 57 | P a g e Fluid replenishment I & O ▪ Monitor ABGs, electrolytes (especially potassium) ▪ Monitor neuro status for decline ▪ Monitor I&O ▪ Perform skin assessment ▪ Seizure precautions ▪ Provide periods of rest ▪ Provide oral care Nursing Interventions for Metabolic Acidosis excessive loss of CO2 from hyperventilation (tachypnea) ▪ fear ▪ anxiety ▪ shock ▪ high altitude ▪ fever ▪ embolism ▪ aspirin toxicity ▪ salicylate toxicity ▪ mechanical ventilation: improper vent settings ▪ early stage acute pulmonary problems Causes of Respiratory Alkalosis 60 | P a g e ▪ Normal or low BP (hypotension) ▪ Decreased respiratory effort Electrolytes ▪ Hypocalcemia ▪ Hypochloridemia ▪ Hypokalemia CNS Excitement ▪ increased activity ▪ anxiety ▪ irritability ▪ tetany ▪ seizures Musculoskeletal ▪ Hyperreflexia: - Positive Chvostek's sign - Positive Trousseau's sign ▪ Muscle cramps/weakness/twitching ▪ Paresthesia Cardiac ▪ Changes in EKG (low T waves that merge with P waves) S/S of Metabolic Alkalosis (alkalosis has similar s/s no matter if met. or resp.) ▪ O2 ▪ IV Fluids ▪ IV ammonium chloride ▪ Antiemetics ▪ Diamox ▪ Discontinue suctioning or diarrhetic ▪ Restrict oral intake ▪ Nutritional support ▪ Provide oral care 61 | P a g e ▪ Monitor I&O ▪ Monitor ABGs, electrolytes ▪ Seizure precautions ▪ Treat the underlying cause Treatment for Metabolic Alkalosis Provide nutritional support Question asks what the priority nursing intervention is for Metabolic Alkalosis: Suction patient Assist with endotracheal intubation Provide nutritional support Provide emotional support respiratory alkalosis metabolic acidosis Aspirin toxicity causes which two conditions? 21-28 mEq/L acidic-basic HCO3- (bicarbonate) normal range 45-35 acidic-basic PaCO2 normal range 7.35-7.45 acidic-basic pH normal range Cancer patient with no dental care access 62 | P a g e Which patient is most at risk to develop stomatitis? airway may need endotracheal tube Complications of surgery for oral cancer ▪ PPIs ▪ sit upright an hour after eating Treatments for GERD ▪ PPI ▪ antacids ▪ dietary modification (soft diet) ▪ weight loss ▪ elevate head when sleeping ▪ splinting while coughing ▪ don't do any heavy lifting/overwork yourself ▪ Nissen fundoplication surgery ▪ incentive spirometer postoperatively ▪ intermittent suctioning Treatment options for Hiatal Hernia (Select All That Apply)