NR 226 Exam 2 Questions and Answers

NR 226 Exam 2 Questions and Answers True or False: Someone who is dehydrated may benefit more from an isotonic or hypotonic solution. True 1 multiple choice option What is water intoxication? someone who drinks an abundance of water What type of solution should be given to someone who has water intoxication? hypertonic solution 1 multiple choice option What is the order that fluid moves to the cell? -Vascular system -Capillary Membrane -Interstitial Area -Cell Membrane What is osmolarity? the amount of particles within a fluid contributing to the fluid concentration What is hydrostatic pressure? a force pushing outward against a surface What is osmotic pressure? an inward pulling pressure from high concentration to low concertation What is active transport? using energy to move electrolytes across cell membranes What is the normal value for blood tests for osmolarity? 280-300 mmol/kg What is the normal value for urine specific gravity? 1.002-1.030 What is the most abundant electrolyte in the interstitial compartment? sodium 1 multiple choice option What is the most abundant electrolyte in intracellular compartment? potassium 1 multiple choice option What are causes of electrolyte imbalances? -Infection or Environment: excessive vomiting, diarrhea, sweating, Clostridium difficile -Medication Side Effects: furosemide injection -Organ System Problems or Failure: kidney failure When replacing electrolytes, should you go fast or slow? slow 1 multiple choice option What can happen if electrolytes are administered too quickly? -Potassium can cause arrythmias -Sodium can cause neurological damage and phlebitis What can be used to assess fluid volume status? -Weight -Input and Output Measurements -Blood pressure and pulse -Orthostatic vital signs -Jugular Veins -Edema and Lung sounds: crackles mean increased fluid volume What are the three main types of IV fluids? -hypertonic -hypotonic -isotonic What are some safety considerations before giving intravenous fluids? -Will you need a pump to infuse the solution? -Are you giving anything that could cause significant discomfort or phlebitis? -Are you replacing electrolytes? -What type of fluid might be optimal for this client? Which client diagnosis should the nurse consider using an IV pump for more careful fluid monitoring? kidney and heart failure What medication should be given slowly to avoid venous inflammation? potassium chloride What percentage is normal saline? 0.9% 1 multiple choice option What percentage is half normal saline? 0.45% 1 multiple choice option What are the three major components of IV fluids? -Dextrose -Saline -Lactated Ringers What is Dextrose? -a simple sugar and chemically identical to glucose -5% is the most common amount What are Lactated Ringers? -contains sodium chloride, sodium lactate, potassium chloride, calcium chloride, water -given specifically when fluid and electrolyte replacement is necessary What are some considerations before starting an IV catheter? -Reason for Therapy -Possible Ideal Location -Known Skin Allergies -Surrounding Conditions and Possible Challenges -Supplies Needed -Fluids to Be Infused What are things to do before starting an IV? -Review agency policies -Identify patient -Patient education What is the most common risk associated with central line placement? infection True or False: Central access means that the entrance to the device is outside the body, but the tip sits close to the entrance of the heart (usually in the superior vena cava) True 1 multiple choice option True or False: Central access devices require sterile process and often need a chest x-ray to verify their placement. True 1 multiple choice option True or False: Central access devices are usually placed by healthcare providers like physicians, nurse practitioners, and other specialists. In some cases, they are placed in a radiology department, or by a nurse certified to place the device. True 1 multiple choice option What are safety considerations of central venous access devices? -devices are inserted using sterile technique -chest x-ray is used to verify the correct placement on the device -dressing changes are done using a sterile procedure -infection-reducing items like infused gauze disks may be used to reduce infection risk -client education on s/s of infection is essential What actions will reduce the risk of catheter infection? -having the client wear a mask -wearing a mask during the procedure -using a sterile central line dressing change kit Where are central lines most commonly inserted? subclavian vein Where are alternate insertion sites? -internal jugular -femoral veins What is the risk of inserting a central line in the subclavian? pneumothorax (collapsed lung) which in turn can be a risk for infection and bleeding What is the main concern for inserting a central line in the internal jugular? discomfort and loss of mobility in the neck Where are peripherally inserted central catheter lines inserted? basilic vein around the antecubital area and are threaded all the way into the superior vena cava What are indications for a central venous access device? -when it is too difficult to start a peripheral IV -when a client needs an infusion for an extended period of time -when medication may be hard on smaller veins or there is a high risk of injury with infiltration What access device is used for long-term infusions? port-a-cath or port How long a can a port-a-cath stay inserted? months to years True or False: Heparin is used at the end of an infusion to keep blood from clotting in the port. The dose of heparin to maintain the line patency is much lower than a heparin dose that would be used therapeutically as a blood thinner. true 1 multiple choice option What are the different types of catheters? -Dialysis Catheters -Swan Ganz Catheter -Arterial Line What are Dialysis Catheters? -need to maintain a high flow rate for dialysis -used for short or intermediate term dialysis until a shunt or a fistula can be surgically completed What is a Swan Ganz Catheter? -utilized in surgery and incentive care units -the catheter allows for the measurement of pressures inside the heart, and its main purpose is to assist healthcare providers with the use of certain medications during critical periods What is a Arterial Line? -specially for monitoring and drawing blood -medication is never delivered through these catheters -only used in surgery and intensive care Who are universal donors? Type O- What are the main types of components used in packed red blood cells? -red blood cells -fresh frozen plasma -platelets What is the advantage of fresh frozen plasma? this contains a large number of clotting factors When are platelets appropriate to be given? -clients with liver disease -clients undergoing chemotherapy How long is blood reserved for after a match is done? 72 hours What are client issues to consider before preparing to administer blood or blood products? -sensitive to large volumes (ex. heart failure) -unusual antibodies as part of their blood typing -religious preferences What are considerations when preparing to administer blood or blood products? -Review facility policies and protocols for blood and blood product administration. -Verify that the donor and client's blood types are matched. -Plan steps to obtain, transport, and store blood or blood products. -Stay with the client for at least the first 15 minutes of transfusion. -Take baseline vitals before the transfusion starts. -Be sure the catheter size is at least 20 g, and preferably 18 g or larger. -Use blood tubing for administration. What are required items when administering blood or blood products? -blood transfusion tubing (usually Y set with a clot filter) -Normal saline 09% for priming and flushing the tubing What are additional items that can be used when administering blood or blood products? -pressure bag: to force for quicker administration -pump: to control the and ensure the client does no get too much fluid too quickly -blood warmer -leukocyte reduction filters What are common steps prior to administering blood products? -Inform the client of the procedure and possible complications. Gather supplies, wash hands, and put on gloves. -Check and verify the client's wristband with blood bank name and label, blood type of donor and recipient match, and a hospital ID number. This is usually done with another nurse (check the facility policy). -Spike and prime blood Y-tubing with 0.9% normal saline. -Spike and hang the blood and flush through to the hub of the tubing. -Collect the client's baseline vital signs, including temperature. -Start blood administration slowly. -Recheck vital signs after 15 minutes, addressing any abnormalities immediately. -Documentation usually includes a label on the bag and the time the blood is started. What are possible reactions to transfusions? -Acute Intravascular Hemolytic -Febrile non-hemolytic -Mild Allergic -Anaphylactic What is an Acute Intravascular Hemolytic? -Cause: antibodies attack red blood cells -Reason: reaction to receiving incompatible blood -Symptoms: fever, chills, low back pain, flushing, fast breathing and heart rate, low blood pressure, blood in the urine, suddenly reduced urination, shock, cardiac arrest, and death What is a Febrile Non-hemolytic Reaction? -Cause: antibodies attack white blood cells -Symptoms: fever, chills, headache, anxiety, and muscle pain What is a Mild Allergic Reaction? -Cause: antibodies attack plasma proteins -Symptoms: flushing, itching, and hives What is a Anaphylactic Reaction? -Cause: antibodies attack plasma -Symptoms: hives, shortness of breath, wheezing, cyanosis, hypotension. shock, and death What do you do when a client has a blood transfusion reaction? -Stop the infusion immediately -Change the IV tubing down to the catheter hub with new tubing and run 0.9% NaCl (normal saline). Do not use tubing with the remaining donor blood present -Report to the HCP or emergency response team -Remain with the client, record signs and symptoms, and monitor vital signs at 5-minute intervals -Prepare to administer emergency drugs such as antihistamines, vasopressors, fluids, and corticosteroids per the healthcare provider's order or protocol. Prepare to perform cardiopulmonary resuscitation -Save the blood container, tubing, attacked labels, and transfusion record for return to the blood bank -Collect blood HCP order or protocol What are the functions of sleep and rest? -restoration of biological processes including tissue renewal (cell division and synthesis of protein) -recovery from illness -memory consolidation -mental relaxation -preparation for wakefulness -dreaming is important for learning, memory, and stress adaptation -rapid eye movement (REM) sleep is associated with early brain development, cognition, and memory What happens without proper sleep and rest? Decreased: -ability to concentrate -ability to make judgments -ability to participate in daily activities -body functionality (mood, motor performance, memory) -immunity -metabolism Increased: -irritability -confusion -risk for chronic diseases (hypertension, diabetes mellitus, obesity) -health care costs and hospitalization -risk for motor vehicle and industrial accidents How many times will a person pass through a sleep cycle? 4 to 6 How long is each sleep cycle? 90 to 110 minutes and consists of 3 non-rem stages (N1, N2, N3) and one REM stage. What is Stage N1? -the lightest level of sleep -last a few minutes -vital signs and metabolism slightly fall -easily aroused and day dreaming What is Stage N2? -last 10-20 minutes -progressing relaxation -slowing vital signs and metabolism -easily aroused What is Stage N3? -deepest stage of sleep -significant decrease in brain and muscle activity -difficult to arouse and rarely moves What is REM? -90 minutes after sleep has begun -increases by 20 minutes each cycle -dreaming, rapid eye movement, fluctuation in heart/respiratory/blood pressure rates -loses skeletal muscle tone -gastric secretion increases -difficult to arouse How much sleep do neonates (up to 2 months) need? 15-16 hours a day How much sleep do toddlers (u to 5 years) need? 12 hours How much sleep do preschoolers and school-age children need? 9-12 hours How much sleep do adolescents (12 and up) need? 8-10 hours How much sleep do young and middle adults need? 6-9 hours What are factors that affect sleep? -physical illness -age/development cycle -medications and substance use disorder -emotional stress -environmental factors -lifestyle -sleep patterns -exercise -fatigue food and caloric intake What is the primary nursing goal for acute pain? -allows the client to participate in their recovery, prevent complications, and improve their functional status What is the primary nursing goal with chronic pain? improve functional status with the encouragement of both non-pharmacological management in collaboration with a primary hcp What are factors that influence pain? -physiological factors: age, fatigue, genetics, neurological function -social factors -psychological factors -cultural factors; perception, adaptation, and expression What are factors impacted by pain? -quality of life and daily activities -self care and physical limitations -work -social support What are physiological reactions to pain? -Lungs: increased respiratory rate (need more oxygen) -Heart: increased heart rate (oxygen is transported throughout the body) -Arms/Legs: increased blood pressure, pallor (peripheral vasoconstriction to shift blood supply to skeletal muscles/brain) -Muscles: increased muscle tension (preparing muscles for action -Eyes: pupils dilate (better vision) -Intestines: decreased GI motility (need to free up energy for immediate action) -Blood Levels: increased cortisol level; increased glucose level (stress response; burst of energy, lower sensitivity to pain, heightened memory; need for additional energy) What are patient-controlled analgesia devices? -allows clients to control and self-administer a prescribed amount of medication on demand and maintain a steady plasma level of pain medication while avoiding the issues associated with taken as needed (PRN) dosing -available in parenteral (IV or SQ) and oral What are examples of self-management strategies? -regular exercise -sleep hygiene and improvement techniques -herbals -nutrition practices