Download Nursing Exam Review and more Exams Nursing in PDF only on Docsity!
NUR 120 Final Exam
ABCDE method of assessing skin lesions - ansA: asymmetry (one half is different than the other half) B: Border irregularity (the edges are notched, uneven, or blurred) C: Color (the color is uneven, shades of brown, tan, and black are present. D: Diameter (greater than 6mm) E: Evolving (mole is changing in size, shape, or color) ABG (Arterial Blood Gas) - ansessential part of diagnosing & managing oxygenation status and acid-base balance of high-risk patients ABG's values (normal) - anspH:7.35-7. Pco2: 45-35 (lungs/respiratory) Hco3: 22-26 (kidneys/metabolic) acute otis media - ansis an ear infection. Most frequently in child and can last for 6 weeks. Caused by bacteria or virus. Ear pain, fever, and hearing loss. Should be treated with antibiotics if it is bacterial infection. Tubes will be inserted into the ear if needed. after cast is removed - ansthe extremity may be smaller in size and weaker warn patient before taking it off Anesthesia types - ansGeneral, moderate or conscious , local, regional, spinal anoxia/hypoxia - ansDeficiency of oxygen in the blood. Clubbing of the fingers can be due to anoxia. Skin color is pasty. Yellow and pale. Barrel chest can be due to long term anoxic effects appendicitis - ansmost common reason for emergency abdominal surgery -right lower quad pain -nausea -rebound tenderness -constipation ASSESSMENT... when did it start? aspiration pneumonia - anscan occur when a foreign substance, such as vomit, is inhaled into the lungs Often in right lung* bacterial vaginosis: Gardnerella vaginalis - ansovergrowth. Gray color with fish-like odor TX: metronidazole & clindamycin
Blood Transfusion - ansblood must be started within 15-20 minutes from obtaining the blood. 18G needle prefered (20 or higher can be used) Blood Transfusion Consent - ansA patient's written permission to receive blood or blood products. IF the patient is unable to sign and it is an emergency situation two doctors can sign the consent. blood transfusion procedure - ansany allergies?- type & cross match blood, check blood for bubbles, dark color, or cloudiness- change IV line (per policy usually one or two units of blood per line)- ID check by two nurses- baseline vitals- start with normal saline- run blood slowly for first 15 minutes- stay with client for 15-30 min- recheck vital signs after 15 of infusing blood- if no adverse affects increase rate- take vital signs every hour until completed and then every 3 hours (or per facility protocol)- inform pt to report any s/s of reactions BPH (benign prostatic hyperplasia) - ansnoncancerous enlargement of the prostate BPH manifestations - ans-diminished force of the urinary stream -hesitancy in initiating voiding -nocturia -urinary retention -frequency, urgency buck's traction - ansskin traction to the lower leg. Weight should hang freely, not touching the bed or floor, do not remove weights buffer systems in the body - ansLUNGS AS A BUFFER- primary control of body's carbonic acid supply. KIDNEY AS A BUFFER-works by concentration of bicarb in body. Kidneys either excrete or hang on to bicarb in the response to the pH of blood. Acidosis- kidney excretes h ion & conserves bicarb. Alkalosis - kidneys retain H ions. ECF, ICF, HGB are other buffer systems for maintain acid-base balance calculi (stones) - anscan form in urinary tract or kidney candidiasis - ansyeast, itching, burning, thick white discharge TX: antifungal (diflucan/fluconazole), internal cream may be prescribed- if so educate on cleaning applicator properly cataracts - ansAn opacity or cloudiness of the lens; increased with aging; by age 80 years, more than half of all americnas have cataracts, leading cause of disability in US. Do not hurt, blurry vision, surroundings dimmer, sensitivity to glare, reduced visual acuity. Medical management: stop smoking, adequate BMI, control BS levels
cultural nursing assessment - ansSystematic way to identify the beliefs, values, meanings, and behaviors of people while considering their history, life experiences, and the social and physical environments in which they live. "Know Thyself" know your own cultural attitudes, beliefs. Recognize that every one has cultural "baggage" do not judge anyone for their beliefs cutaneous urinary diversion - ansUrine drains through an opening created in the abdominal wall and skin TYPES: ileal conduit, cutaneous ureterostomy, vesicostomy, nephrostomy decreased platelet count - ansthrombocytopenia -acute leukemia, thrombocytopenic purpura, during chemotherapy, aplastic anemia dietary education for calculi - ansavoid caffeine, alcohol, tea, soda, high calcium digital rectal examination (DRE) - ansfinger palpation through the anal canal and rectum to examine the prostate gland (African american males and males with family hx are higher risk) documenting skin lesions - anscolor, heat, redness, pain, swelling, size, location, patterns, distributions Electrolyte values - ansSodium: 135-145 (-natremia) Chloride: 96-106 (-chloremia) Calcium: 8.5-10.5 (-calcemia) Potassium: 3.5-5.5 (-kalemia) Magnesium: 1.5-2.5 (-magnesemia) Phosphorus: 2.7-4.5 (-phosphatemia) Fat embolism syndrome - ansfat emboli enter circulation following orthopedic trauma; especially long bone fractures** more common in men age 10- TX is supportive (vasopressors, mechanical ventilation, sometimes corticosteriods) first dressing change post-op - ansusually done by the surgeon or a member of the surgical team. Changes after this are often done by the nurse. Five P's of compartment syndrome - anspain, pallor, pulselessness, paresthesia, paralysis Five signs of inflammation - ansredness, warmth, swelling, pain, loss of function. flowmax - ans"maximum flow" tx for BPH foley catheter care - ans• Empty foley bag q8hr at least, keep below level of bladder, do not let bag lay on floor
- DC catheter correctly!
- Peri care- do not go up tubing, always go away from where catheter exits body
- Sterile specimen can be taken from port on catheter using sterile syringe w/needle- check facility policy fractures - ansClosed fx (simple fx): one that does not cause a break in the skin Open fx: the skin or mucous membrane wound extends to the fractured bone Incomplete/greenstick: break through only part of the cross section of the bone (often in kids) Comminuted: produces several bone fragments FVD (fluid volume deficit) - anshypovolemia FVE (fluid volume excess) - anshypervolemia gas bubble insertion - ansthe gas bubble is in place where the tear is and will seal it off if the patient is in a prone position. They must stay in this position. glaucoma - ansincreased intraocular pressure results in damage to the retina and optic nerve with loss of vision AKA "silent thief" Treatment: goal is to prevent further optic nerve damage, maintain IOP within 10- 21mmHg, medications used before surgery management slows progression but does not cure it : an o hemodialysis - ansthe process by which waste products are filtered directly from the patient's blood used when pt is acutely ill until kidneys resume function or long term replacement in CKD or ESKD Herpes type 2 infection (herpes genitalis) - ansA recurrent life-long viral infection. Causes painful itching and burning herpetic lesions. C-section may be required to reduce risk of infant becoming infected HPV (human papilloma virus) - ansmost common STI among sexually active young people; VACCINE available for males/females ages 11-12 Hyperthyroidism - ansoveractive thyroid condition Hyperthyroidism symptoms - ansheat intolerance, weight loss, sweating, anxiety, irritability, hyperactive reflexes, palpitations, EXOPTHALMOS (lid lag when gaze moves from downward to upward) Hypertonic IV solution - ansd5.45 NS, D5.9NS, D5LR Hypothyroidism - ansA disorder caused by a thyroid gland that is slower and less productive than normal
Expected returns depend on where the ostomy is located. PREOP: offer emotional support, focus on client/caregiver teaching, psychological support, Diet high calorie low residue high protein high carb, bowel cleansing enemas, referral to se enterostomal therapist. POSTOP: NG tube on low suction, NPO until peristalsis returns, clear liquid diet progressing to solid over 6-8 weeks, monitor and record condition of stoma. IF stoma becomes dark blue/purple notify IMMEDIATELY. Intra Operative Care: - ansPrimary concerns of the nurse is the safety & advocacy for the patient during surgery as the patient is unable to protect or advocate for himself. It is the responsibility of all of the surgical team members to protect the patient. Isotonic IV solutions - anslactated ringers ringers 0.9% NS D5W IV Push Potassium - ansCAN STOP A HEART!!! NEVER PUSH IV POSTASSIUM j-tube (jejunostomy tube) & G-tube - ans- go straight into stomach -is inflated with a balloon inside stomach -if it is pulled out, insert a foley to keep holeopen -head of bed remains at 30 degrees -monitor blood sugar and lung sounds Jehovah's Witness - ansNo blood products should be used Kaexylate - anscan be used as an enema or taken orally It causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. IF the pt does not have stools the drug will not work properly Kaposi sarcoma (KS) - anstype of skin cancer often seen in patients with AIDS; consists of brownish-purple papules that begin in skin and spread to internal organs. lactulose - anslaxative used to reduce serum ammonia levels long bone fracture - ansSource of fat embolism malignant disorders of the female reproductive tract - ansCervical, uterine, vaginal, vulvar, and ovarian cancers. Manifestations= -Early disease may not have symptoms -Signs and symptoms depend upon location and may include vaginal discharge, pain, bleeding and systemic symptoms (weight loss and anemia)
Prevention, screening, and early detection are vital. Malignant hyperthermia symptoms - anshigh fever, rigid jaw, tachynea, and tachycardia a severe reaction to anesthesia drugs Malignant hyperthermia treatment - ans-must be prompt -early detection/diagnosis
- Dantrolene sodium (skeletal muscle relaxant) 2-3 mg/kg
- Stop all inhalant anesthesia agents
- Intubate, ventilate with 100% O2 with high flow rate
- packed in ice/cool compresses to remove body temp Maslow's Hierarchy of Needs - ans(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization mastoidectomy - ansremoval of diseased bone, air cells, and cholesteatoma to create a non infected healthy ear. They do not need to blow their nose and sneezing with their mouth open and no heavy lifting. No water swimming or showering. May need to re-evaluate their hearing. Make sure they are not having vertigo or facial dropping because that can result from nerve damage from surgery. Meniere's disease - ansis too much fluid in the inner ear. They will have vertigo, ringing and some sort of hearing loss. They will also have nausea and vomiting and the feeling of pressure. Treated by decreasing amount of fluid or low sodium diet, meclizine and may drain the fluid. metabolic acidosis symptoms - ansSecondary hyperventilation (Kussmaul breathing) Nausea, vomiting, lethargy, decreased BP, headache, warm flushed skin, confusion Metabolic Alkalosis S/S - ansrestlessness, dysrhythmias (tachycardia), compensatory hypoventilation, confusion, decreased level of consciousness, dizzy, irritability, n&v, tremors, tingling of fingers/toes, hypokalemia NG tube - ans-nasoduodenal & nasojejunal tube feedings reduce risk of aspiration -keep pts HOB @ 30 degree angle at all times -check residual -monitor for dumping syndrome (if pt gets a bolus feeding & then have loose watery stools) -if residual is more than 250mL stop feeding & contact MD normal aging of skin - ansthinning of skin, uneven pigmentation, wrinkling, skin folds, and decreased elasticity, dry skin, diminished hair, increased fragility and increased potential for injury, reduced healing ability
platelet count (PLT) - ansnumber of platelets present; used to diagnose bleeding disorders or bone marrow disease -140,000-400,000/mm3 (0.14-0.4X10^12/L) PLISSIT model - ansPermission Limited Information Specific Suggestions Intensive Therapy Post liver biopsy positioning - ansPatient should be lying on his right side for several hours after the procedure in order to promote hemostasis and thereby prevent hemorrhage and bile leakage Post Op Drains - ansDrains are tubes that exit the peri-incisional area, either into a portable wound suction device (closed) or into the dressings (open). The principle involved is to allow the escape of fluids that could otherwise serve as a culture medium for bacteria. In portable wound suction, the use of gentle, constant suction enhances drainage of these fluids and collapses the skin flaps against the underlying tissue, thus removing "dead space." Types of wound drains include the Penrose, Hemovac, and Jackson-Pratt drains post-op urinary diversion - ansrisk for impaired skin integrity, acute pain, disturbed body image, potential for sexual dysfunction, deficient knowledge post-operative pain management - anspain is what the patient says it is! Assess patient, administer medication as it is ordered, offer non-pharmacological methods such as re-positioning patient, guided imagery, breathing techniques pre-op urinary diversion - ansrelieve anxiety, imbalanced nutrition, answer questions/concerns Pre-operative teaching - ansteaching done by members of the health care team to prepare a person and his or her family members for surgery; during pre-operative teaching, the person learns about the surgical procedure, its benefits and possible risks, and what can be expected during the post-operative recovery period. -- this can greatly relieve pre-procedure anxiety primary lesions - ansinitial lesions, characteristic of disease Macule flat, nonpalpable skin color (freckles) Paulette elevated, palpable with circumcised border Nodule elevated, palpable deeper than Paulette & larger (carcinoma) Vesicle fluid-filled and elevated (herpes, poison ivy, blister) Wheal elevated mass with irregular border (insect bites) Pustule Cyst
prostate cancer - ans2nd most common in men. Detected by Hx, blood test, and rectal exam early disease has few or no symptoms symptoms of metastasis may be first s/s (hip/back pain, perineal discomfort, weight loss, oliguria) prostate-specific antigen (PSA) - anssensitive test for prostate cancer. values less than 4ng/mL are considered normal abnormal values does not always indicate cancer prostatitis often has elevated PSA prostatitis - ansinflammation of prostate gland typically caused by an infectious agent Type I-IV tx: appropriate anti-infective agents and medications to alleviate pain & spasms Pulmonary emboli - ansis an obstruction of the pulmonary artery or one of the branches by a blood clot. Will have absent or diminished blood flow. Wont effect the breathing but it will effect the perfusion. pyridum - ansantispasmodic; turns urine orange reactions during blood transfusion - ansstop the blood first! restart saline, notify health care provider, may use supportive care (benadryl, oxygen, corticosteriods) reduce risk of fat emboli - ansimmediate immobilization of fx, including early surgical fixation, minimal fx manipulation, & adequate support for fx bones during turning & positioning, & maintenance of fluid & electrolyte balance respiratory acidosis - ansA drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2. s/s: rapid, shallow respiratoins; drowsiness, dzziness, disoriented; decreased BP. headache, dyspnea, hyperkalemia, hyperreflexia respiratory alkalosis - ansArise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2. s/s: seizures, lethargy & confusion, light headed, n&v, hypokalemia, hypervnetilation, deep rapid breathing secondary lesions - ans, results from changes in primary lesions; scratching, trauma, infections Erosion: loss of superficial epidermis that doesn't extend to dermis (stretch marks) Ulcer: skin loss that extends past epidermis (pressure ulcer) Fissure: Linear crack in skin (chapped lips) Scales: Flakes secondary to dead epithelium (dandruff) Crus: dry residue left on skin (left after vesicles ruptures) Scar: left after healing of wound Keloids: scar tissue areas that are secondary to excessive collagen formation
- Monitor for respiratory distress-appparatus at bedside (trach set, 02 tank and suction machine)
- Check for edema and bleeding by noting dressing
- limit talking
- monitor for laryneal nerve damage
- monitor for hypocalcemia and tentancy
- CALCIUM GLUCONATE at bedside
- Monitor for thyroid storm Thyroiditis: Hashimoto's - ansinflammation of the thyroid gland resulting in abnormalities of function. -Women age 30-50 years of age. -avoid aspirin bc of bleeding issues -tumors are characterized as goiters and will be biopsied total parenteral nutrition (TPN) - ansnutrient-complete solution given directly into bloodstream when person cannot eat by mouth -high risk of infection -assess & do good central line care -Must have order -keep eye on temperature (elevated often sign of infection) -monitor I&O and blood sugar trans-cultural nursing - ansproviding care to patients and families across cultural variations. Acknowledge, respect, & adapt to patient. Culture can strongly influence a patients thinking, doing, and being. Trichomonas vaginalis - ansSTI; frothy foul smelling dishcarge TX w/ metronidazole. BOTH partners must be treated TURP (transurethral resection of the prostate) - ansexcision of benign prostatic hyperplasia using a resectoscope through the urethra most common method used tympanic membrane perforation - anscaused by infection or trauma. Usually heals on their own and spontaneously. Assess for CSF leakage from ear if trauma and no water should be induced to the ear. Surgery may be needed. Types of urinary incontinence - ansstress- sneeze/cough/position change urge-urge to void cannot be suppressed function- function is intact, cognitive impairment is present (alzheimers) latrogenic- loss of urine due to intrinsic factor urinalysis (UA) - ansurine screening test that includes physical observation, chemical tests, and microscopic evaluation specific gravity
urinalysis: dehydration - ansUrinalysis can tell us a lot about dehydration. The color and clarity of urine, the urine's specific gravity (the mass of urine is compared with that of equal amounts of distilled water), and the presence of ketones (carbon compounds that signify dehydration) in the urine may all help to indicate the degree of dehydration. urinary diversion reasons - ansbladder cancer or other pelvic malignancies, birth defects, trauma, strictures, neurogenic bladder, chronic infection or intractable cystitis, used as a last resort for incontience urinary diversions - ansNephrostomy: Frank incision and insertion of tube into renal pelvis. Pt will have penrose drain and surgical dressing. Ureterosigmoidostomy: ureters detached from bladder and anastomosed to sigmoid colon. Encourage voiding q2-4h via rectum. No enemas or cathartics. Cutaneous Ureterostomy: Stoma formed from ureters excised from bladder and brough to abdominal wall. Stoma will be on right side below waist. Ileal Conduit: Ureters are replanted into portion of terminal ileum and brought to abdominal wall. Kock Pouch: does not have continuous flow like the ileal conduit, ureters transported into pouch made from ileum with one-way valve. Drainage of pouch by catheter is under the control of the client. Needs to be drained at regular intervals. urinary elimination - anspH of urine should be between 4.5-8.0. Specific gravity between 1.010-1.030 (how concentrated the urine is or isn't) If high it is concentrated if not then it is dilute. Output should be 1000-2000 ml a day and clear/yellow Adequate intake of fluids around 1500-2000 cc/day Clients should not hold urine or postpone using bathroom which can lead to infection Kegel exercises recommended to help strengthen the pelvic floor muscle, bladder training may be required to establish normal elimination, specific time intervals. urinary tract infection (UTI) - ansinfection of one or more organs of the urinary tract most common reason healthcare common site of acquired infection UTI assessment findings - ansfrequency burning urgency elderly may have confusion mid stream clean catch vaginitis - ansirritating, itching, burning, increased discharge ventilation acquired pneumonia - ansthe patient has been endotracheally intubated and has received mechanical ventilatory support for at least 48 hours The incidence of VAP increases with the duration of mechanical ventilation.
