NFDN 2003 Final Review 2025

NFDN 2003 Final Review 2025 Signs and Symptoms of Metabolic Acidosis - - - headache - decreased BP - *hyperkalemia* - *muscle twitching* - warm, flushed skin (vasodilation) - nausea, vomiting, diarrhea - changes in LOC, confusion, increase in drowsiness - *Kussmal respirations (compensatory hyperventilation)* Signs and Symptoms of Metabolic Alkalosis - -- restlessness, followed by lethargy - dysrhythmias, tachycardia - *compensatory hypoventilation* - confusion, decreased LOC, dizzy, irritable - nausea, vomiting, diarrhea - *tremors, muscle cramps, tingling of fingers and toes* - *hypokalemia* Signs and Symptoms of Respiratory Acidosis - -- hypoventilation -- hypoxia - rapid, shallow respirations - decrease BP with vasodilation - dypsnea - headache - hyperkalemia - dysrhythmias, - muscle weakness - drowsiness, dizziness, disorientation Signs and Symptoms of Respiratory Alkalosis - --seizures -deep, rapid breathing -hyperventilation -tachycardia -decreased or normal BP -hypokalemia -numbness and tingling of extremities -lethargy and confusion -light headedness -nausea, vomiting isotonic - --Osmolality close to that of the blood plasma and do not cause red blood cells to swell or shrink NFDN 2003 NFDN 2003 -Adds volume* ◦Same salt concentration as the normal cells in the body and blood hypertonic - --Osmolality higher than that of the serum (Higher salt concentration than normal cells and blood) -causes cell to shrink* -Draw fluid from the ICF and cause cells to shrink hypotonic - --Osmolality lower then that of the serum (lower salt concentration) -causes cell to swell* -Replace intracellular fluid, causing cells to swell What would put a client at risk for imbalanced fluid and electrolytes? - -dehydration, especially in seniors Too Much fluid in the body is called? - -Hypervolemia What might develop from too much fluid in the body? - -}Weight gain }SOB, wheezing }Tachycardia }Pitting edema }Increased Blood Pressure }Cough }Increased Urinary output }Distended neck veins }Crackles Too little fluid in the body is called? - -Hypovolemia What is the fastest and easiest way to determine fluid balance in the body? - -BP, pulse, ins and outs what assessments are needed with IV's? - -vitals, ins and outs, respiratory and cardio assessment Primary IV describe - -main line for fluids Secondary IV describe - -additional line used to infuse medications piggypacked into the main line (must be compatible) NFDN 2003 NFDN 2003 location of secondary IV bag - -must be kept above the primary line in order to infuse correctly Infiltation - -fluid that has escaped from vein into the tissue surrounding the IV catheter cool to touch, pale in colour, swollen and can be painful* phlebitis - -inflammation of the vein warm* and painful What IV sites are a greater risk for core contamination? - -central lines or central venous catheters need to do sterile technique for all dressing changes and care of lines What diagnostic tool is used to assess brain stem function? - -glascow coma scale Are narcotics given to clients with head injuries? - -no because they can alter the LOC What type of clients get autonomic dysreflexia? - -spinal cord injury Describe autonomic dysreflexia? - -distention of the bowel or retention of urine in the bladder signs and symptoms: sweating and goose bumps What nursing action can eliminate autonomic dysreflexia? - -relieving the retention of the bladder/ or distention of the bowel Why are seizures a possibility with head injuries? - -swelling in the cranium or electrical disturbance from scar tissue or hematoma Priority diagnosis for neurosensory alteration is ? - -airway - breathing - circulation What type of tubing needs to be used for the blood infusion? - -Y setup with a filter What time frame do most infusion reactions happen in for blood infusions? - -15 minutes What assessment do we need to do before during and after the blood infusion? - -vitals- T (change by 1 degree), respiratory/cardio assessment, skin assessment, ins and outs What is the name given for blood that is self donated? - -autologous What are the steps if a reaction happens: stop the blood infusion - -call for help, start infusing a primary line at the nearest port of the tubing near the IV cath site of 0.9%, and monitor for further reactions NFDN 2003 NFDN 2003 What is the easiest way to determine cardiac dysrhythmias? - -BP & pulse rate, apical and radial pulse difference What is the goal of cardiac function? - -adequate cardiac output What are the signs and symptoms of cardiac overload? - -hypervolemia, bounding pulse, increase in pulse and BP, edema, dyspnea, crackles in the lungs What does the nurse do if a reaction blood transfusion happens? - -Stays with client, monitors assessments. Collects all the tubing and blood to be sent back to the Blood bank to be tested. Records all events and reports to Dr. any further variances What do angiograms detect? - -narrowing or decreased flow of blood in arteries If the client has a Myocardial Infarction happens what happens to the heart tissue? - ischemia, and necrosis of tissue After a MI if the AS Node is damaged what happens to cardiac function? - -the cardiac tissue can become damaged and the heart becomes a less efficient pump Define TPN: - -total parenteral nutrition allows a person to receive all the nutrients needed for body to stay nutritionally balanced What may happen when TPN is started? - -hyperglycemia, start slowly to prevent TPN What may happen when TPN is stopped? - -hypoglycemia taper off feed Define NG - -flexible tube inserted through the nose to the stomach. placement with return of gastric acid if less than 100cc return contents to stomach Two types of tubes are inserted describe both: - -nasogastric tube to allow a person to get nutrition (kofeed) to remove fluids from the stomach decompress or air when GI tract is not functioning normally NG put a client at risk for what? aspiration - -aspiration Describe insertion protocol: - -review from powerpoint how to measure head position (slight tilt forward) when to advance (when client swallows) How does the nurse know that the client with a hiatal hernia is being managed? - -less heart burn or regurgitation med is neede