NUR 105 Essentials of Nursing Care Health Differences Exam 2

Trochanter roll - -Which assistive device will prevent external rotation of the hip when the patient is lying in the supine position? Abductor pillow - -Which assistive device is used to prevent the internal rotation and adduction of the femur? Ankle roll - -Which assistive device can be placed under the patients lower legs to prevent the heels from resting on bed surfaces? Knee spling - -Which assistive device is used to stabilize the knee in an anatomically correct position? Footdrop - -Result of muscles fibers not being able to shorten and lengthen. A splint or foot board is needed to prevent this. monitoring the patient's pulse - -The nurse is assessing an older adult's tolerance for activity while performing activities of daily living. Which is the most important nursing assessment? Assess patients ability to assist with the transfer - -In helping a patient move from the bed to a wheelchair, the nurse should take which action first? to maintain joint flexibility - -What is the theoretical basis for performing passive range of motion exercises? ineffective airway clearance related to bed rest. - -A patient who is immobile and has a history of respiratory infections shows signs of lung congestion. What is the nursing diagnosis? The skin of the feet is intact. - -What observation would indicate that the nurse's application of heel protectors was effective? Decreased blood flow leads to pooling, as skeletal muscles weakened by immobility fail to pump blood back to the heart. - -What physiological change predisposes a patient who is immobile to thrombus formation? immobility - -Decreased calcium is a result of this rather than a cause of it. NUR 105 NUR 105 decrease. - -Blood volume does not change markedly in immobility, but blood flow does _____________ the effort needed for the heart to overcome valvular resistance and push blood out. - What does cardiac workload refers to decreased. - -In immobility as the cardiovascular system weakens, workload is actually ______ the pressure of the bed against the body and the abdominal organs pushing against the diaphragm. - -An immobile patient has difficulty expanding the lungs fully due to Use a lift sheet to move patient up in bed. - -When caring for patient who is bedridden, the nurse should implement which intervention to avoid the effects of shearing? Homan's sign - -The patient is positioned in supine. The therapist maintains the leg in extension and passively dorsiflexes the patient's foot. What is test produces a positive sign indicated by pain in the calf and may be indicative of deep vein thrombosis? plantar flexion - -What is the bending of the sole of the foot by curling the toes toward the ground called? Seepage of liquid stool - -What clinical manifestation is indicative of a fecal impaction? flatulence - -What is result of the action of bacteria on the chyme in the large intestine or swallowed air or gas that diffuses from the bloodstream into the intestines? Tarry stools - -What is the result of action of certain meds or GI bleeding? to regulate volume and composition of extracellular fluid - -What is primary function of kidneys? "The cathartic will reduce your chance of becoming constipated after this test" - -The nurse is administering a cathartic to a patient who has just had a barium enema. The patient says "I don't need this, I just had a bowel movement". Which is the nurses's best response? cathartic - -purgative; medicine that causes the bowels to empty Tap water is a hypotonic solution and can cause rapid fluid shift, fluid overload and water intoxication - -What problem can be caused by administration of more than three consecutive tap water enemas? dry, hard stools - -What are the stools of a dehydrated infant like? NUR 105 NUR 105 dietary intake (red meat) - -What can lead to false positive result when testing patient stool specimen for blood? measures body's ability to carry oxygen. - -What is hemoglobin level? Manual replacement of the foreskin in an uncircumcised patient is essential to prevent this condition - -In catheterizing a male patient, the nurse should implement which action to prevent paraphimosis? paraphimosis - -retraction of the skin of the prepuce causing painful swelling of the skin of the glans penis that prevents the penis from being retracted Neurological impairment (Impaired sensory nerves) - -What is a factor in development of total urinary incontinence stress incontinence - -urinary incontinence that occurs when involuntary pressure is put on the bladder by coughing or laughing or sneezing or lifting or straining Glomerular filtration rate (GFR) - -The quantity (per minute) of glomerular filtrate formed per unit in all nephrons of both kidneys. renal failure - -Decreased GFR is a indication of what? urinary retention - -Constriction of renal arteries likely to cause what? eat foods high in fiber like fresh fruit - -What dietary instruction should nurse teach patient to prevent constipation? Highly refined breads and cereals - -What foods are low in bulk and may actually contribute to constipation? Coffee and Tea - -What drinks are diuretics and can irritate the digestive tract or cause or aggravate diarrhea? no restrictions for showering, barrier is applied around stoma whenever new appliance is being fitted, reusable pouch can be rinsed in lukewarm water, should be emptied when 1/3 to 1/2 full. - -What are the general instructions of ostomy care? normal bowel function for an adult - -passage of a formed, soft stool on regular by highly individualized schedule. Calcium - -What serum electrolyte value will be elevated in a patient who has been immobilized for an extended period? Elevated magnesium - -What is serum electrolyte value is associated with renal failure or adrenal insufficiency? NUR 105 NUR 105 Elevated potassium (decreased potassium excretion and high potassium intake) - -What is serum electrolyte value is associated with renal failure? Elevated sodium - -What is serum electrolyte value is associated with fluid loss and water deprivation? Increase daily intake of oranges and bananas due to those foods having high potassium - -What instructions should be included in a plan of care for a patient who is taking thiazide diuretics? decrease in blood pressure - -Patient is receiving a thiazide diuretic for treatment of fluid volume excess related to hypernatrermia. What observation would indicate that the medication is having the desired effect? metabolic alkalosis - -Gastric suctioning can cause what? Look at pH higher or lower than 7.4 Low=acidosis High=alkalosis Look at HCO3 Low=Metabolic acidosis High=Metabolic alkalosis Look at PaCO2, if normal not respiratory Low=Respiratory alkalosis High=Respiratory acidosis Assess for uncompensated acidosis with low pH alkalosis with high pH - -What are the 4 steps of ABG Analysis? Arterial 7.35 - 7.45 Venous 7.32 - 7.42 - -pH Arterial 22 - 26 mEq/L Venous 19 to 25 mEq/liter - -HCO3- Arterial 35-45 mm Hg Venous 38-52 mm Hg - -PaCO2 Metabolic Acidosis - -Low pH, low plasma bicarbonate concentration (HCO3), low carbon dioxide level and normal oxygen level. Also an elevated potassium level. Metabolic Alkalosis - -high pH, High plasma bicarbonate and low potassium Respiratory Acidosis - -pH is less than 7.35 and PaCO2 is greater than 42 mmHg NUR 105 NUR 105 Respiratory Alkalosis - -arterial pH is 7.45 and PaCO2 is less than 38 mmHg Antibiotic - -Treatment with which type of pharmacological agent may result in magnesium and water imbalance? hypomagnesiemia - -Use of aminoglycoside antibiotics is a risk factor for what? respiratory acidosis - -Use of sedatives is a risk factor for what? Use of bronchodilators - -What has potential for numerous systemic effects, but does not seem to be risk factor for magnesium imbalance? fluid volume excess and to several electrolyte imbalances - -What is can be caused by prolonged use of glucocorticoid? Increased urine specific gravity - -What clinical manifestation is indicative of fluid volume deficit? Elevated hemoglobin levels - -occur with fluid volume deficit, but not a primary indicator occur with fluid volume excess - -Adventitious breath sounds (crackles), full bounding pulse, distended jugular veins, increased blood pressure, slow vein emptying AB Positive - -will not react with donated blood from any blood group,"universal recipient" Hyponatremia - -Postoperative patient is to receive D5W intravenously. The nurse