NCLEX Capstone Exam 1, Exam 1 Capstone

A Nurse is caring for a clients on the med-surg unit. Which client is most at risk to develop a nosocomial infection? A- client with alcohol abuse admitted for detox B- Client with Type I diabetes and peripheral neuropathy C- Client recovering from a cholecystectomy D- Client with full thickness burns, an NG tube and a Foley - D- Full thickness burn, NG tube and Foley Think immunosuppression and avenues for infection Adult vital signs - Temp: 97.5 99.5F HR: 60-100 BP: Systolic 90/140 Diastolic 60/80 Resp: 12-20 o2 95%-100% Celsius to Fahrenheit - (C x 1.8) + 32 Fahrenheit to Celsius - (F-32)/1.8 grading scale for pulses - 4+ = strong and bounding 3+ = full pulse, increased 2+ = normal, easily palpable 1+ = weak, barely palpable 0 = absent, not palpable What type of information is Pain? - Subjective When measuring an apical pulse you should count for a... - A full minute Heart rate slows with ______, ________. _____________. and body temperature will ______ the heart rate - 1. age 2. emotions 3. pain 4. Increase What is all included in a set of vital signs? - Heart rate, Blood pressure, Respiration rate, Oxygen saturation, Temperature, And pain What is sodium level? - 135-145 What is potassium level? - 3.5-5 What is digoxin level? - 0.5-2 What is magnesium level? - 1.5-2.5 mEq/L What is calcium level? - 9-10.5 What is phosphorus level? - 3.5-4.5 What is the normal WBC range? - 5,000-10,000/mm3 What is the normal platelet range? - 150,000-400,000/mm3 What is the normal Hemoglobin range? (male and female) - Male- 14-18 Female- 12-16 What is the normal hematocrit range? (male and female) (always get male wrong) - Male- 45-52% Female- 37-47% what is the normal creatinine range? - 0.5-1.2 mg/dl What is the normal BUN range? - 10-20 mg/dL Cardiac Labs - CK LDH = 140 - 280 (signifies MI Myoglobin = 90 (elevation could indicate MI) Troponin T: 0.2 (↑ = MI) What is the normal APTT, PT, INR - APTT- 30-60 seconds PT- 11-12.5 seconds INR 0.81-1.20 What does the HgbA1c test for? - 3 months average blood sugar Signs and Symptoms of Metabolic Acidosis - - headache - decreased BP - *hyperkalemia* - *muscle twitching* - warm, flushed skin (vasodilation) - nausea, vomiting, diarrhea - *Kussmal respirations (compensatory hyperventilation)* Respiratory Alkalosis Signs/Sx - -seizures -deep, rapid breathing -hyperventilation -tachycardia -hypokalemia -nausea, vomiting Metabolic Alkalosis Signs and Symptoms - -dysrhythmias (tachycardia) -hypoventilation -nausea/vomiting/diarrhea -tremors, muscle cramps -hypokalemia Normal PH level? - 7.35-7.45 Normal PaCO2 - 35-45 Normal HCO3 - 22-26 Respiratory acidosis - pH down PaCO2 up Respiratory alkalosis - pH up PaCO2 down metabolic acidosis - pH down HCO3 down Metabolic alkalosis - pH up HCO3 up PaCO2 involves what acid base imbalance? - Respiratory HCO3 involves what acid base imbalance? - Metabolic Common problems involved with respiratory acidosis - HYPOventilation CNS depressant bronchitis pulmonary edema/emboli Common problems involved with Metabolic acidosis - Diabetes excessive intake of antacid kidney injury Diarrhea Common problems involved with respiratory acidosis - HYPERventilation fever hypoxia pain anxiety