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PN 110 - Test 3 Exam Questions with Answers
1. Impaired Perfusion or Gas Exchange: Age, diet, exercise, smoking, medica- tions
2. Ventilation: movement of air in and out of the lungs
3. Transport: movement of hemoglobin across cell membranes via RBC's
4. Perfusion: The supply of oxygen to and removal of wastes from the cells and tissues of the body as a result of
the flow of blood through the capillaries.
5. Gas Exchange: the process of obtaining oxygen from the environment and releasing carbon dioxide
6. Ischemia: refers to insufficient flow of oxygenated blood to tissues that may result in hypoxemia and subsequent cell
injury or death.
7. Hypoxia: Insufficient oxygen reaching cells.
8. Anoxia: Total lack of oxygen in body tissues.
9. Alveoli: Site of gas exchange in the lungs. O2 <-> CO
10. Hemoglobin: RBC carries oxygen from the lungs - oxygen binds to hemoglobin
- oxygen released to tissue cells.
11. Risk Factors for Impaired Gas Exchange: *smoking, vaping, environmental toxins
*prolonged immobility, decreased respiratory effort *Disease (pneumonia, pulmonary embolism, abscess, cancer..) *Surgery (atelectasis)
*Trauma (GSW, stabbing) *Chronic medical conditions (COPD, HF, asthma) *Medications *Aging
12. Nursing Assessment - Impaired Gas Exchange: *General assessment (ap- pearance, self-care, posture, gait,
cachexia, distress, air hungry) *Health history (medical, surgical, medications, lifestyle behaviors, problem-based history) *Vital signs; norms: BP 120/80, HR 60-100, Resp 12-20, PO2 92-100% *Review lab results and diagnostic tests *Cardiovascular, Pulmonary, and Peripheral vascular assessment. Take note of skin color, signs of anemia and hypoxemia, clubbing of nails, barrel chest, wheezes/stri- dor, rhonchi, crackles.
13. Nursing Interventions - Impaired Gas Exchange: *Positioning (HOB up 30 degrees, turn q2 hrs)
*Primary prevention (early mobilization, incentive spirometry, cough and deep breath, oral hygiene, smoking cessation) *Secondary prevention (Mantoux skin test/TB test) *Tertiary prevention (medications, additional supports (trach, et, vent, bipap, cpap))
14. Nursing Assessment - Impaired Lung Function: *Impaired lung function: fluid filled, pneumonia, asthma,
brochospasm, COPD, emphysema, abscess, cancer *Nursing Assessment: shortness of breath, dyspnea, pursed lip breathing, acces- sory muscles to breathe, lean forward. Cough/sputum, low O2 saturation, increased resp. rate, tachycardia, spinal scoliosis, thoracic expansion/barrel chest, lung sounds with crackles/rhonchi/wheezes/or absent, nail clubbing.
15. Influenza Exemplar: *Highly contagious disease of upper and lower respiratory tract
*3 main types: A,B,C *Typically infected 2-3 days before the onset of symptoms; very contagious!
*Nursing Assessment: blood pressure, pulses, chest pain, palpitations, lightheaded or dizzy, headache, cool extremities, pallor/cyanosis.
24. Impaired Blood Vessels - Nursing Assessment: *Impaired blood vessels: atherosclerosis, blockage, DVT or clot,
loss of vessel patency (open) or permeability (flow across capillaries). *Nursing Assessment: 6 P's! numbness/tingling, absence of sensation. **Pain, Pallor (color), Paralysis, Poikilothermia (dif temp than surrounding tissue), Pulselessness,
25. Impaired Hgb - Nursing Assessment: *Impaired Hgb: low RBC's due to hem- orrhage, low Hgb due to iron
deficiency, tar and nicotine from smoking block O2 carrying capacity, Sickle cell anemia. *Nursing Assessment: fatigue, light-headed, dizzy, syncope, low O2 saturation, increased respiratory rate, tachycardia, ischemic pain.
26. Nursing Interventions - Perfusion: Position to promote circulation, elevate legs to prevent edema if peripheral
venous disease (PVD), lower legs if peripheral arterial disease (PAD) *Primary prevention: smoking cessation, heart healthy diet, exercise, weight control *Secondary prevention: blood pressure screening *Tertiary prevention: medications
27. Lab Values: *Gas exchange: hemoglobin (Hgb) and hematocrit (Hct), RBC's, WBC's, ABG's, sputum, TB skin
test. *Perfusion: Hgb, Hct, RBC's, WBC's Lipids (Cholesterol, HDL, LDL, Triglycerides), Cardiac enzymes, blood coagulability.
28. Diagnostic Tests - Gas exchange + perfusion: *Gas exchange: Chest x-ray, CT, MRI, ventilation/perfusion
scan, pulmonary function tests, bronchoscopy. *Perfusion: Chest x-ray, CT, MRI, EKG, echocardiogram, cardiac stress tests, car- diac catheterization, arteriogram, veinogram, ultrasound of peripheral vasculature.
29. Anemia Exemplar: *Pathophysiology: reduced number of circulating RBC's or a condition in which the number
of RBC's is insufficient to meet physiologic needs. *Etiology: Anemia results from a lack of RBC's or dysfunctional RBC's in the body. *3 Common Causes: **Excessive loss of RBC's (trauma, hemorrhage, surgery), **Excessive destruction of RBC's (sickle cell anemia), **Deficient/defective RBC production (erythropoiesis)
30. Anemia Signs and Symptoms: fatigue, dizziness, weakness, exertional dysp- nea (using energy excessively
during basic activities), pallor (color), lethargy (no energy).
31. Anemia Treatment: *Medications: iron supplements (Ferrous Sulfate), Folic Acid, Epoetin Alfa (Epogen,
Procrit). *Dietary Sources: Foods that enhance absorption of iron; broccoli, grapefruit, OJ, peppers, strawberries. Foods that contain high iron; beans/lentils, clams/oys- ters/shrimp, beef/turkey/liver.
32. Anemia Diagnostic Testing: Complete Blood Count (CBC)
*Monitor labs and report any abnormalities.
33. Anemia Meds - Ferrous Sulfate: *class: iron supplement
*action: replaces iron- found in hemoglobin, myoglobin, and other enzymes: allows the transportation of oxygen via hemoglobin. *reason: iron-deficiency anemia *side effects: dark stools, abd. pain, heartburn, nausea, constipation, flatulence, vomiting, diarrhea. *NUR considerations: edu. pt. on food that decreases absorption (coffee, dairy, soy, spinach, tea). edu. pt. on food that increases absorption (oj, grapefruit, strawberries). may cause GI irritation - monitor GI function! avoid using in pts. w/ GI disease!
34. Anemia Meds - Epogen Alfa (Epogen, Procrit): *class: human recombinant hormone
*Everyone has a different rate of metabolism *Basal metabolic rate (BMR): energy required to maintain body functions. continu- ous!
41. Carbohydrates: *Simple carbs - broken down and absorbed quickly, provide a quick source of energy (high
fructose) *Complex carbs - starch & fiber, take longer to break down before used by the body (whole grains, fibrous veg, whole fruits)
42. Fiber: Complex carb
*20-35g / day *Whole grains, wheat bran, cereals, fresh fruit, vegetables, legumes.
43. Fat: *essential fatty acids are needed for fuel and energy, promote absorption of vitamins as well as brain
development in infants. *Lipids are fats within the body *Triglycerides are most abundant lipids in food
44. Protein: *used for tissue growth and repair of every cell in the body and brain development
*supports immune system *low protein may cause generalized edema *amino acids - building blocks or protein *every day *dietary sources - meat, legumes, nuts, eggs, tofu, soy, cheese, greek yogurt, spinach, broccoli.
45. Water: *essential for proper functioning
*facilitates metabolic process (metabolism)
46. Vitamins: *fat soluble vitamins: A,D,E,K - stored in tissue and easily overdosed
*water soluble vitamins: C (immune system), B complex (forms RBC's and energy production) B-9 = folic acid, B-12 =
cyanocobalamin
47. Water Soluble Vitamins: Dissolve in body fluids, excreted in the urine
*easily destroyed by air, light, heat *ingested daily *vitamin c = collagen, antibodies *vitamin b complex = forms RBC's, energy production
48. Minerals: *calcium - nerve conduction, muscle contraction, blood vessel ex- pansion/contraction, secretion of
hormones and enzymes (milk, salmon, spinach, orange juice) *phosphorus - helps develop bone, aids in the contraction of muscles, kidney function, nerve conduction, regular heartbeat, use of major nutrients (milk, meat) *magnesium - regulates bp & hr w/ calcium, nerve and muscle function, energy, bone marrow, GABA production (halibut, seeds, nuts, tofu, swiss chard) *potassium, sodium, chloride - maintains fluid balance, nerve conduction, muscle contraction (P- milk, bananas, legumes. NA- smoked meat, salt, olives. Chloride- celery, tomatoes, sea weed, olives).
49. Antioxidants: *may protect body cells against free radical effectd
*may improve immune function and lower risk of infection and cancer *sources - beta carotene, lutein, lycopene, selenium, vitamins A,C,E
50. Risk Factors for Poor Nutrition: all potentially at risk, poor and underserved, lifestyle, underlying medical
conditions, very young children! older adults!
51. Poor Nutrition - General Health: *severe malnutrition caused by low protein, protein helps balance intra and
extracellular fluid. when insufficient, there is fluid retention and severe edema. *inadequate calories/carbs cause lack of energy, lack of fuel for every cell *low protein and lower functioning cells cause a weak immune system and delayed wound healing
*Decreased cardiac output *Inadequate micronutrient and electrolytes cause impaired cardiac function (rate, rhythm, and pressure) *High cholesterol and hyperlipidemia cause atherosclerotic heart disease (ASHD). This may lead to a myocardial infarction (MI) due to blocked blood flow to heart tissue. *Higher BMI increases risk for hypertension and hyperlipidemia
55. Poor Nutrition - Respiratory System: Weakened respiratory muscles reduces strength of coughing and deep
breathing. This results in a build up of respiratory secretions and an inability to cough them out. Increases risk for atelectasis (blockage in alveoli) and pneumonia.
56. Poor Nutrition - GI System: *Deficiencies of vitamin C result in gingivitis and loose teeth.
*Constipation - malabsorption causes GI upset, bleeding, firm abdomen, tender- ness. Inadequate fiber causes slow gut and constipation. *Diarrhea - decreased blood flow to the intestines causes poor absorption of water, electrolytes and nutrients. This worsened the malnutrition and may result in diarrhea.
57. Poor Nutrition - GU System: *Reduced cardiac output results in reduced renal perfusion and glomerular filtration
rate thus causing decreased urinary output and kidney damage.
58. Poor Nutrition - Psychological Function: *Apathy - lack of feelings
*depression *anxiety *low self-esteem *poor body image *self-neglect
59. Assessment of Nutrition: *General health Hx: recent change in weight or appetite
*Nutrition Hx: food diary, screening for malnutrition in older adults (mini nutrition assessment) *Height, weight, BMI, waist-to-hip ratio, skin fold measurements *Special focus on GI and bowel elimination. Evaluate issues of oral intake, digestion, absorption.
60. Assessment of Nutrition (2): *Physical Assessment
*Cachectic - seen in people suffering from terminal illnesses who are unable to consume adequate intake of food. *Hair - thinning with dry, stiff texture; lack of shine; may lose all pigment and appear pale. *Skin - dry, rough appearance, pallor; may bruise easily, poor skin turgor; lips may be dark red and can have lesions and cracks. *Dentition - lost, cracked, painful teeth affects eating. *Dysphagia - at risk for aspiration.
61. Assessment of Nutrition (3): *Laboratory Tests
*Albumin, pre-albumin *blood glucose and A1C *lipid profile *electrolytes *hemoglobin and hematocrit *blood urea, nitrogen, creatinine
62. Nutrition - Nursing Interventions: *Educate on healthy diet
*Trend weight, BMI, dietary intake *Maintain special diets *Provide for food preferences *Assist with feeding *Carefully monitor NPO patients
70. Physiology - Peristalsis: Series of involuntary wave-like muscle contractions which move food along the
digestive tract. *Medications, disease processes, diets can all cause disruptions in peristalsis.
71. Factors Effecting Bowel Elimination: -diet and hydration
-physical activity -psychological factors -personal habits
- posture
- pain
- pregnancy
- age -surgery and anesthesia
- medications -diagnostic tests
72. Incontinence: Loss of voluntary control of fecal and gaseous discharges through the anus.
-skin breakdown -changes in daily activities -changes in social relationships
73. Diarrhea: Loose, water BM's more than 3 times/day with hyperactive bowel sounds, urgency, abdominal
pain, and cramping. -acute: 2-3 days, new onset -chronic: 3weeks+
74. What is happening in the body with diarrhea?: Too much fluid, disruptive materials, antibiotics changing
gut flora.
75. What can prolonged diarrhea lead to?: Cannot absorb nutrients, dehydration, decreased electrolytes,
malnutrition, muscle wasting, esteem, infection (cdiff, skin breakdown)
76. What factors cause diarrhea?: Certain foods, medications, viruses, allergies, stress, antibiotics, laxatives,
diagnostic testing, tube feeding, cdiff, alcohol.
77. Constipation: Infrequent or difficult bowel movements, <3 BMs/week
78. What is happening in the body with constipation?: Colon sucks H2O out and feces become hard and dry - slow
movement, not enough nutrients and hydration.
79. What are some causes of constipation?: No urge to go, immobility, anesthe- sia, not enough nutrients and
hydration, advanced age, certain diseases, certain foods.
80. Impaction: Large, hard mass of fecal material that gets stuck so badly in the colon or rectum that person cannot
push it out. -constant watery ooze, N/V, distended stomach.
81. Elimination - Nursing Assessment: -health hx (surgeries, diseases, medica- tions)
-bowel elimination pattern, patient's perception of normal -diet hx (usual diet, hydration, preferences, availability, ability to swallow/chew, food intolerance) -physical, mental, and functional abilities, home environment, transportation for groceries, social support. -family hx (GI cancer, Crohn's disease)
82. Elimination - Nursing Assessment (2): -GI abdominal assessment:
-inspection: look! -auscultation: listening to bowel sounds (RL, RU, LU, LL) -palpitation: soft? Tenderness? Masses? Enlarged organ?
-maintenance of regular toileting -document last BM & intervene if >3days
87. Clinical Judgment: Combines critical thinking, critical reasoning, and repetitive decision-making skills of a nurse.
Sound clinical judgment requires knowledge to assess and observe situations, identify priority patient concerns, and implement evidence-based interventions to provide safe patient care.
88. Critical Thinking: Applying knowledge and experience to identify patient prob- lems and to direct clinical
judgments and actions that result in positive patient outcomes. Nurses make life-and-death decisions on the basis of critical thinking influenced by scientific research and best practices.
89. Clinical Reasoning: Ability to focus and filter data and to recognize what is most and least important, so the nurse
can identify if an actual problem is present. Nurses use clinical reasoning skills when considering the context and concerns of a patient or family while observing changes in a clinical situation.
90. Deep Knowledge: -lifelong learner
-remain up-to-date on new technology/research -know sources of information -evidence-based practice
91. Strong Clinical Skills: - accuracy
- precision
- efficient
- timely
92. Effective Critical Thinking: Depends on specific components ch as knowledge base, reasoning, inference,
validation, and attitudes that promote learning. -baseline knowledge includes content learned in prerequisite courses. -data collection is an important concept for professional nursing practice and is integral to assessment, the first step in the
nursing process. -knowledge and data is needed for nurses to find answers when faced with new problems, questions, and situations.
93. Clinical Judgment Components: Interpretation of:
-assessment data -physiology of disease, injury -lab values -diagnostic tests
- medications -health care team perspectives Ability to differentiate significant from insignificant data Validation of thinking with mentor/expert Intuition "trust your gut" - the feelings that you know something without evidence: requires analysis and evidence to support actions. Interpretations - must be differentiated from facts and evidence because they are depending on personal conceptions, experiences, and perspective.
94. What attitudes are necessary for critical thinking?: Clarity, confidence, think- ing independently, fairness, logic,
responsibility, and accountability, risk taking, dis- cipline, perseverance, creativity, curiosity, integrity, and humility.
95. Complex health care environments demand what?: High level clinical judg- ments
96. Experience DOES matter but...: It is NOT solely responsible for clinical judg- ment
97. What factors influence ur thinking?: Factor that can influence thinking may be according to past experiences,
cultural beliefs, emotions, sates of mind, and other interpersonal and intrapersonal causes.
reasons for them. Erroneous assumptions can lead to safety issues in the clinical setting.
103. How to Improved Your Clinical Judgment: -honest reflection
-talk through scenario with peer/expert -commit to being a lifelong learner -case studies -concept maps
- simulation -written work that encourages thinking -practice questions
104. Critical Thinking in the Nursing Process: Assess: gather the subjective and objective assessment data
Diagnose: what nursing problem can we help? Plan: write a plan on how to meet the goals Implementation: carry out the plan Evaluation: evaluate if the plan worked, revise if needed
105. Clinical Concept Map (CCM): 1. Complete assessment data
2. Complete lab, diagnostic test and medication data
3. Stop, think, analyze, interpret
4. Identify main problems for patient. Look at abnormal from your assessment. Consider if there is a problem
with a nursing concept (eg. Infection). May be a problem with a physiologic system (eg. Cardiac). Review Giddens concepts or NANDA nursing diagnosis.
5. Prioritize the problems
6. What is this related to?
7. As evidence by which assessment data?
8. Determine patient goal (SMART)
9. Determine nursing interventions that will help the pt meet this specific goal.
- assess
- administer
- monitor
- educate
10. Each intervention must have a rational/evidence based practice
11. Evaluate the plan of care
-goal met -goal partially met (why?) -goal not met (why?)
