Nursing Test 3

Card Set Information

Nursing Test 3
2010-03-07 23:18:25
TCC Nursing Test 3

Oxygenation, Circulation, Bowel, and Bladder
Show Answers:

  1. Left Sided Heart Failure
    Blood backs up into the lungs
  2. Right Sided Heart Failure
    Systemic; Fluid backs up into the feet and legs
  3. Diastole
    Mitral and tricuspid valves open (S1) "lub"
  4. Systole
    Closure of the aortic and pulmonic valves (S2) "dub"
  5. Cardiomyopathy
    Large heart
  6. The nurse admits an elderly client who complains of severe shortness of breath and fatigue. The nurse auscultates crackles in the client's lungs. Which condition would the nurse suspect the client may be suffering from?
    Left sided heart failure
  7. Ventilation
    the movement of air from the atmosphere through the upper and lower airways to the alveoli
  8. Respiration
    The process whereby gas exchange occurs at the alveolar-capillary membrane
  9. Upper Respiratory Tract
    Nares, nasal cavity, pharynx, and larynx
  10. Lower Respiratory Tract
    Trachea, bronchi, bronchioles, alveoli, and alveolar-capillary membranes
  11. The nurse is caring for a client with a temperature. What upper airway defense mechanisms would the nurse expect theis client to exhibit?
    Increased nasal mucous and sneezing
  12. Atelectasis
    alveoli collapse
  13. The nurse is caring for an elderly client who was in an auto accident The respiratory rate is 10 and the CO2 saturation is 80. What conditions are this client suffering?
    Hypoxia and hypoventilation
  14. Hypercapnia
    evelvated CO2; breathing too slow
  15. An elderly cient with pneumonia is confused and agitated. Upon auscultation, the nurse notes no breath sounds in the bases of the lungs. Which is the best nursing intervention?
    Check the client's CO2 saturation level
  16. Hemtocrit
    the percentage of blood that are erythrocytes
  17. The nurse examines the client's lab work and notes a hemoglobin of 10 and a hemtocrit of 25. Which statement by the client might alert the nurse the client is hypoxic?
    "Would you get those spiders of the ceiling please?"
  18. Restrictive Respiratory Disorders
    Muscle dysfunction, nerve dysfunction, skeletal abnormalities, decreased introthoracic space, and changes in lung compliance
  19. Obstructive Respiratory Disorders
    Mucous, inflammation, infection, tumor, foreign body, constriction of the bronchi
  20. Acute pharyngitis
    sore throat
  21. Decongestants
    shrink mucous membranes
  22. Antitussives
    supress cough
  23. Expectorants
    loosen bronchial secretions
  24. Glucocorticoids and Leukotriene Modifiers
    reduce inflammation (lower)
  25. Antibiotics
    kill bacteria (lower)
  26. The nurse administers an expectorant to an ederly client with COPD. Which is the best nursing intervention?
    observe the color of bronchial secretions
  27. Bronchodilators used in the treatment of bronchial asthma/COPD?
    Isuprel, Albuterol, Epinephrine, Atrovent, Theophylline. Side effects: tremors, elevated heart rate, and nervousness
  28. The nurse administers Theophylline to a client with bronchial asthma. Which is the best nursing intervention?
    Teach the client to avoid roducts with caffeine
  29. The nurse administers albuterol to an elder who has heart disease. Soon after, the client tells the nurse his heart is racing. What nursing intervention is appropriate?
    Take client's vital signs
  30. Leukotriene receptor atagonists
    reduce inflammatory stress
  31. Glucocorticoids
  32. Mucolytics
    respiratory distress (rotten eggs smell)
  33. Stridor
    struggling to breathe
  34. Inaffective airway clearance
    secretions present (pneumonia)
  35. Impaired Gas Exchange
    signs of hypoxemia (COPD)
  36. Normal Bowel Elimination
    • -3 times/day or 2-3 times/week
    • -150gm/day
    • -Brown in color
    • -Soft and formed
    • -Round in diameter
    • -Pungent odor
    • -5-35 sounds minimum
  37. Gerontologic Considerations
    • -GERD 1-2am
    • -atrophy of gastric mucosa
    • -May not get BM sensation
    • -Salty and sweet decrease
    • -Gums recede
    • -Delayed absorption of fat soluble vitamins
  38. Orange or Green Stools
    Intestinal infection
  39. Pancreatitis
    Stools float
  40. Narrow or Stringlike stool
    Colon cancer or IBS
  41. Clay or White stool
    Obstruction in gallbladder or liver-cirrhosis or stone
  42. Streaking stool
    Hemorrhoids or fissures
  43. Blood imbedded in stool
    Lower GI bleed
  44. Black or tarry stool
    Upper GI bleed
  45. Factors Promoting Normal Bowel Elimination
    Routine schedule, sitting position during defecation, high fiber diet, four servings of fruits and veggies, six to eight glasses of water, daily physical exercise, privacy
  46. Side effects of Anticholinergics
    dry mouth, photophobia, blurred vision, tachycardia, constipation, urinary retention
  47. Bulk Forming Laxatives (natural, least irritating)
    • -absorbs water from the GI tract
    • -stretches wall causing peristalsis
    • -adverse reactions: nausea, vomiting, cramps, intestinal/esophageal obstruction
    • -not immediate result
    • -also given for diarrhea
  48. Surfactant Laxative
    • -Prevent straining at stool
    • -No laxative effect
    • -decreases tension of fecal mass allowing water to penetrate into stool
    • -makes stool easier to expel
    • -Clients with CHF should not take these
    • -Do not give within two hours of other laxatives
  49. Lubricant Laxatives
    • -Increase passage of stool
    • -coats outside of stool preventing fluid absorption
    • -Can interfere with absorption of fat soluble vitamins-
    • -Do not give within two hours of meal
    • -Do not take lying down
    • -Not good for aspirating clients
  50. Saline Laxatives
    • -Stimulates peristalsis
    • -If used more than a week lose muscle tone in bowel
    • -Do not give to cardiac, poor kidney functioning, or Crohn's patients
    • -Strongest and most abused
    • -Irritates GI mucosa and puls water into bowel lumen
    • -Watery stool eliminated
  51. Client Teaching
    • -Never take w/acute abd pain, nausea, or vomiting
    • -takes 2-3 days of normal eating for normal bowel movement
    • -frequent use can cause dependence or electrolyte imbalance
  52. Perceived Constipation
    State in which a person self-prescribes dail use of laxatives, enemas, and/or suppositories to ensure a daily BM
  53. Things that cause Flatulence
    Cabbage, beans, beer, carbonated beverages, dairy, chewing gum, sucking through straw, eating rapidly
  54. Nursing Interventions for Flatulence
    • -NG tube
    • -Rectal tube: secured in place, no more than 20 minutes at a time, reinsert every 2 or 3 hours
    • -Harris flush enema-drains back into container, repeat until no bubbles returned
  55. A 22 year old college student presents to the emergency room at 0200 with severe episiodic abdominal cramping and stated, "I have diarrhea. I think I got it from eating at a restaurant tonight." What information does the nurse need to elicit from this client in order to plan care?
    • -When did the diarrhea start
    • -Frequency of stools
    • -Any recent travel
  56. Nursing interventions for Reducing Diarrhea
    • -discontinue solid foods
    • -avoid milk products, fat, whole grains, fresh fruit and veggies
    • -gradually add semisolids and solids
  57. Pepto-Bismol
    • -30ml or 2 tabs q 1/2 hour to 1 hour, up to 8 doses in 24 hours.
    • -Avoid in clients with hypersensitivity
    • -Interferes with coagulation
  58. Immodium
    • -Opiate
    • -4mg initially, 2mg after each stool to maximal dose of 16mg
    • -most common used
    • -No CNS effects
    • -Decrease intestinal mobility and peristalsis
    • -Increase chance for constipation
  59. Lomotil-atropine sulfate
    • -RX
    • -2.5-5mg bid or qid prn
    • -Derivative of Demerol
    • -Side effects: tachycardia, respiratory depression
    • -Decreases abdominal cramping and reduces loss of water and electrolytes
  60. Nursing Interventions for Replacing Fluids and Electrolytes
    • -Increase fluids to equal approx amount of fluid loss
    • -Encourage liquids at room temperature
    • -Explain effects of diarrhea on hydration
  61. Client Instruction-Bowel
    • -Instruct client to seek medical care if blood in stool, fever of 101F, diarrhea lasts longer than 3-5 days
    • -Stop antidiarrheal drugs when diarrhea is controlled
  62. Normal Patterns of Urinary Elimination
    • -Frequency: 6-8 times/day
    • -Volume: 150-200mL
    • -Bladder control: urgency and frequency common; older adult-enlarged prostate and weakened pelvic floor muscles
    • -Yellow, straw or amber color, clear, pH-4-8
  63. Abnormal Patterns of Urinary Elimination
    • -Dysuria
    • -Anything less than 30mL indicative of renal failure
    • -Blood in urine indicative of cancer, infection, or calculi
    • -Bright red blood-bleeding in urethra
    • -Dark blood-bleeding in the kidneys or ureters
  64. Acute Urinary Incontinence
    • -Delirium or confusion
    • -Infection
    • -Atrophic vaginitis
    • -Pharmacologic therapy
    • -Psychlogical problems
    • -Restricted mobility
    • -Stool impaction
  65. Functional Incontinence
    • Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine. Loss of urine before or during attempt to reach the toilet.
    • -Etiology: altered environment, mobility deficit, diminished bladder cues and impaired ability to recognize bladder cues, decreased bladder tone
  66. What would be an appropriate intervention for functional incontinence?
    -reduce environmental barriers
  67. Nursing Interventions for Functional Incontinence
    • -reduce environmental barriers
    • -provide bedside commode
    • -Offer toileting every 2 hours
    • -dress in easy to manipulate clothing
    • -provide dressing aids
    • -refer to OT for evaluation
    • -provide means for summoning assistance
  68. Anticholinergics
    • -increases bladder capacity and decreases frequency of voiding in clients with neurogenic bladder
    • -Side effects: dry mouth, drowsiness, blurred vision, constipation, urinary retention
  69. Stress Incontinence
    • -Experiences an involuntary passage of rine of less than 50ML occuring with increased intra-abdominal pressure
    • -Most common incontinence in women
    • -dribbling of urine with increased inta-abdominal pressure
  70. Stress incontinence may be contributed to which of the following?
    -Weak pelvic muscles and structural supports
  71. Stress Incontinence Etiology
    • -degenerative changes in pelvic muscles and structural supports associated with aging or multiple pregnancies or prostate surgery
    • -high intra-abdominal pressure
    • -incompetent bladder outlet
  72. Which intervention would the nurse perform first for incontinence?
    -Limit coffee, tea, and alcohol
  73. Stress Incontinence-Nursing Interventions
    • -Pads
    • -Toilet every 3 hours
    • -Kegal exercises 15 reps 3 times/day for 6 weeks
    • -bent knee situps
    • -avoid anything increasing intra-abdominal pressure
    • -lmit coffee, tea, and alcohol
    • -encourage fluid intake of 1500-2000ML/day
  74. Commonly used drugs that can influence bladder function
    Antidepressants, antipsychotics, sedatives/hypnotics, diuretics, caffeine, anticholinergics, alcohol, narcotics, alpha-adrenergic blockers, alpha-adrenergic agonists, beta-adrenergic agonists, calcium channel blockers, ACE inhibitors
  75. Common medications Used to Treat Urinary Incontinence
    • -Pseudoephedrine: decreased estrogen and increases chance of stress incontinence. 15-30mg TID
    • -Vaginal Estrogen Cream: 0.5 to 1g QHS
    • -Make sure with Detrol and Ditropan no underlying eye issues
  76. Urge Incontinence
    • -Involuntary passage of urine soon after a strong sense of urgency to void
    • -Inability to suppress detrusor muscle contractions until reaching an appropriate receptacle
    • -Urinary urgency
    • -Urinary frequency
  77. Urge Incontinence-Nursing Interventions
    -Incontinence pads, clothes adapted for quick removal, toilet every 2 hours, gradually increase intervals between voiding to every 4 hours, kegals, regulate fluid intake
  78. Urinary Retention
    • -Incomplete emptying of the bladder
    • -Commin in males with enlarged prostate
    • -Absence of urinary ouput over several hours, distended bladder, 100mL or more residual urine, sensation of pressure, discomfort, tenderness over symphasis pubis, overflow incontience/dribbling/dysuria, restlessness, diaphoresis
    • -Quad patients can die from this
  79. Urinary Retention-Etiology
    • -Obstruction of urine flow
    • -Alterations in motor sensory
    • -Inability to relax external sphinchter
    • -Use of medications with urinary retention as adverse response
  80. Medications that may cause Urinary Retention
    -Benzodiazepines, Antocholinergics, Antiparkinson agents, Tricyclic Antidepressants, Antipsychotics, Narcotic Analgesics
  81. Medications to Treat Urinary Retention
    • -Alpha Blockers-watch for orthostatic hypotension, decreased semen, effect on retina
    • -Anti-Androgens-decreased prostate, not immediate, hormone, enlarged breasts and decreases libido
    • -Parasympathomimetics/Cholinergic
  82. Urinary Retention-Nursing Interventions
    -help client to assume normal position to void, stimulate reflex voiding center, remove blockage if possible, catheterize with intermittent or indwelling catheter, teach client and family about medications if precribed
  83. UTI Risk Factors
    • -Indwelling urinary catheters
    • -Bladder distention
    • -Shorter urethra in women
    • -Obstruction of flow of urine with stasis
    • -Poor perineal hygiene practices
    • -Increased urinary pH
  84. S/S of Urinary Tract Infections
    • -Upper UTI: fever/chills, nausea and vomiting, headache, malaise, hematuria, flank pain
    • -Lower UTI: frequency, urgency, dysuria, incontinence
  85. Sulfonamides
    • -Most widely used for UTI, Bacteriostatic, Increased sensitivty to sunlight, drug fever, check for bleeding, take on empty stomach, drink 2000mL water per day
    • -Used to treat E Coli
    • -Increases antcoagulant effect
  86. Urinary Tract Antiseptics
    • -Bacterialcidal
    • -Effective against most Gram-negative bacteria that commonly cause UTI
    • -Adverse reactions:dizziness, headache, nausea, photophobia
    • -Antacids decrease absorption
  87. Urinary Tract Analgesics
    • -Relieves symptoms of dysuria, burning, frequency and urgency
    • -No anti-infective action
    • -Turns urine orange-red
    • -Contraindicated in renal insufficiency and hepatitis
    • -Stains clothing
    • -Does nothing for bacterial action
  88. UTI-Nursing Interventions
    • -1500-2000mL fluid/day
    • -Avoid bladder irritating foods: tomatoes, spicy food, chocolate, carbonated beverages
  89. Hypertension
    • Persistant elveation of:
    • -Systolic blood pressure greater than or equal to 140
    • -Diastolic blood pressure greater than or equal to 90
    • -Current use of antihypertensives
  90. Prehypertension
    • -Systolic blood pressure 120-130
    • or
    • -Diastolic blood pressure 80-89
  91. Isolated Systolic Hypertension
    Systolic BP greater than or equal to 140 with Diastolic BP greater than or equal to 90
  92. Etiology of Hypertension
    Increased SNS activity, increased sodium retaining hormones and vasoconstrictors, Diabetes Mellitus, higher ideal body weight, increased sodium intake, excessive alcohol intake
  93. Etiology of Secondary Hypertension
    Coarctation of aorta, renal disease, endocrine disorders, neurlogic disorders, cirrhosis, sleep apnea
  94. Risk Factors of Hypertension
    age, alcohol, cigarette smoking, diabetes mellitus, elevated serum lipids, excess dietary sodium, gender, family history, obestity, ethnicity, sedentary lifestyle, socioeconomic status, stress
  95. Lifestyle Modifications for Hypertension
    • -less than 2.4g of sodium/day
    • -men no more than 2 drinks/day women 1 drink/day
    • -30 minutes of physical activity a day
    • -avoid tobacco
    • -Stress management
  96. Nursing Diagnoses for Hypertension
    • -ineffective health maintenance
    • -anxiety
    • -sexual dysfunction
    • -ineffective therapeutic regimen management
    • -disturbed body image
    • -ineffective tissue perfusion
  97. Isolated Systolic Hypertension
    • -most common form in individuals over 50
    • -systolic pressure at or above 140 and diastolic under 90
  98. Hypertensive Crisis
    • -severe abrupt increase in DBP
    • -rate of increase in BP is more important than absoute value
    • -occurs in patients with HTN who fail to comply with medications or under medicated
    • -Hypertensive encephalopathy, cerebral hemorrhage
    • -acute renal failure
    • -myocardial infarction
    • -heart failure with pulmonary edema
  99. A new patient is seen at an outpatient clinic for a routine health examination. To determine the patient's baseline blood pressure accurately, the nurse will?
    Have the patient sit with the arm supported at the level of the heart and measure the BP in each arm
  100. The nurse obtains the following information about hypertension risk factors from a patient with prehypertension. The risk factor that will be most important to address with the patient is that the patient?
    Gets no regular aerobic exercise
  101. The nurse measures the BP of a 78-year-old patient and finds it to be 168/86 in both arms. The nurse will plan to teach the patient that?
    It is important to address the increased BP
  102. A patient with hypertension asks the nurse why lifestyle changes are needed when the patient has no symptoms from the high BP. The response by the nurse that is most likely to improve patient compliance with therapy is that hypertension?
    Damages the blood vessels leading to risk for heart attack, stoke, and kidney failure
  103. ACE Inhibitors
    • -Inhibits formation of Angio II and blocks aldosterone
    • -Facilitates excretion of Na and H2O causing K to be retained
    • -Meds end in "pril"
    • -Side effects: cough, increased K, hypotension
    • -Not for African Americans and elderly
  104. Angiotensin Receptor Blockers
    • -Similar to ACE Inhibitors, prevents release of aldosterone
    • -Not for African Americans
    • -Side effect: angioedema
  105. Calcium Channel Blockers
    • -Decrease calcium levels promoting vasodilation increasing muscle contraction and BP
    • -Best for African Americans
    • -Side effects: flushing, HA, dizziness, bradycardia, AV block
    • -Do not drink grapefruit juice within 2 hours of these meds
  106. Diuretics-Thiazides and related
    • -works to get rid of Na, Chloride and H2O. Used to treat HTN and edema. A moderate decrease in BP in 2 to 4 weeks
    • -Can not be used with patients in renal failure
    • -Side effects: hypokalemia, hypomagnesemia, hyperlipidemia, hypercalcemia, bicarb loss
    • -HCTZ
  107. Diuretics-Loop
    • -inhibit body's ability to reabsorb Na, leads to retention of H2O in the urine, less effective for treatment of HTN
    • -Potent in promoting diuresis
    • -Fast effects
    • -Lasix
    • -Side effects: fluid and electrolyte imbalance, metabolic alkalosis, orthostatic hypotension
  108. K Sparing Diuretics
    • -works on facilitating Na and H2O loss and K retention
    • -Not potent
    • -Fast effects, not as fast as thiazides and loops
    • -Side effects: hyperakalemia, decreased excretion of hydrogen, calcium, magnesium, nausea, vomiting, diarrhea, rash, dizziness, headache, weakness, dry mouth
  109. Aldosterone Receptor Blockers
    • -Cause kidneys to get rid of extra salt and fluid help hold on to K because of this they are called K sparing diuretics
    • -Potent
    • -Fast
    • -Side effects: hyperkalemia, nasuea, vomiting, leg cramps, dizziness
  110. Beta Blockers
    • -Lower BP by reducing the effect of excitement/physical exertion on heart rate and force of contraction, dialtion of blood vessels and opening of bronchi, reduce breakdown of glycogen
    • -Not for African Americans, COPD, 2nd and 3rd degree AV block, CHF, and Bradycardia
    • -Side effects: decrease HR and severe decrease in BP and bronchoconstriction.
    • -Cannot discontinue due to rebound HTN
  111. Paresthesia
    • -shooting or burning pain in extremity
    • -present near ulcerated areas
    • -produces loss of pressure and deep sensations
    • -injuries often go unnoticed
  112. Peripheral Arterial Disease
    -thin, shiny, taut skin, loss of hair on lower legs, diminished or basent pedal, popliteal, or femoral pulses, pallor, reactive hyperemia, pain at rest
  113. Risk Factors for PAD
    • -smoking
    • -hyperlipidemia
    • -hypertension
    • -diabetes mellitus
  114. Treatment of Superficial Thrombophlebitis
    • -Upper extremity caused by IV
    • -Lower extremity caused by varicose veins
    • -Elevate extremity
    • -Hot therapy
    • -ASA, NSAID, Tylenol
    • -Use compression stockings
  115. DVT
    • -May have no symptoms
    • -Homan's sign not reliable
    • -PE and Chronic venous insufficiency most serious consequence
  116. Prevention and Treatment of DVT
    • -Early ambulation
    • -Dorsi-flex feet and rotate ankles
    • -OOB 3 times/day
    • -TED hose
    • -Elevate, warm compresses
    • -elastic compression hose for 3 to 6 months
  117. Meds for DVT
    • -Heparin
    • -Coumadin: takes 48-72 hours to start working. Vitamin K is antidote. Can give oral with IV
  118. Interferes with Anticoagulants
    ASA, NSAID, Dilatin, Barbiturates, Vitmain E, Alcohol
  119. During an assessment of a 63-year-old patient at the clinic, the patient says, "I have always taken an evening walk, lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should?
    Attempt to palpate the dorsalis pedis and posterial tibial pulses
  120. The nurse performing an assessment with a patient who has chronic peripheral arterial disease of the legs would expect to find?
    Prolonged capillary refill
  121. The nurse identifies the nursing diagnosis of ineffective peripheral perfusion related to decreased arterial blood flow for a patient with chronic PAD. In evaluating the patient outcomes following patient teaching, the nurse determines a need for further instruction when the patient says?
    "I will use a heating pad on my feet at night to increase the circulation and warmth in my feet."