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 Common problems involved with Metabolic acidosis - excessive vomiting diuretics fluid volume deficit - dehydration fluid volume deficit labs - 1. INCREASED serum osmolality 2. INCREASED hematocrit 3. INCREASED blood urea nitrogen (BUN) 4. INCREASED serum sodium 5. INCREASED urine specific gravity Fluid volume excess - hypervolemia-not hydrated Fluid volume excess labs - 1. DECREASED serum osmolality 2. DECREASED hematocrit 3. DECREASED blood urea nitrogen (BUN) 4. DECREASED serum sodium 5. DECREASED urine specific gravity Hyperkalemia signs and symptoms - M-Muscle Cramps U- Urine abnormal R-Respiratory distress D- Decrease cardiac contractility E- ECG Changes R- Reflexes Tall peaked T wave, Flat P wave, Widened QRS complex, Prolonged PR interval Hypokalemia signs and symptoms - thready, weak pulse orthostatic hypotension shallow respiration hyporeflexia hypoactive bowel nausea/vomiting, abdominal cramping ST depression, inverted T wave, Prominent U wave What can cause an increase in sodium excretion (ultimately making sodium low) - Diaphoresis, diuretic, vomiting, diarrhea, kidney disease What can cause sodium exceeding the limit (ultimately making sodium high) - Corticosteroids, cushings syndrome, kidney disease, hyperaldosteronism Signs and symptoms of HYpernatremia - FRIED SALT F- Flushed skin and fever. R- Restless and irritable. I- Increased blood pressure. E- Edema. D- Decreased Urine output. S- Skin Flushed. A- Agitation. L- Low grade fever. T- Thirst. Signs and symptoms of hyponatremia - SALT LOSS S- Seizures & Stupor A- anorexia L- Lethargic T- Tachycardia L- Limp muscle (weakness) O- Orthostatic hypotension S- seizure headache S- Stomach/cramping calcium and phosphorus work as... - Inverse CA high, p04 low CA low, P04 high Signs and symptoms of hypercalcemia - BACK ME B- Bone pain. A- Arrhythmias. C- Cardiac Arrest. K- Kidney Stones. M- Muscle weakness. E- Excessive Urination. Signs and symptoms of hypocalcemia - Cats go numb C- convulsions A- arrhythmia T- tetany S- spasms and stridor GO NUMBness in fingers, face, and limbs Positive chvosteks sign and trousseau's sign ECG changes for calcium - HYPERcalcemia- short ST segment, widened T wave, heart block HYPOcalcemia- prolonged ST segment and QT interval What is the antidote for magnesium overdose - calcium gluconate Hypermagnesemia signs and symptoms - EVERYTHING IS LOW low energy (COMA) low bp low HR low RR ( shallow) decrease bowel sounds decrease DTRs Hypomagnesemia signs and symptoms - HIGH everything HIGH HR HIGH BP shallow respirations increase DTRs tetany/seizure confusion chvosteks sign trousseau's sign Hyperphosphatemia signs and symptoms - 1. decreased calcium levels 2. decreased HR & pressure drop 3. muscle weakness that affects breathing 4. trousseau & chevostek signs will appear, hyperactive reflexes 5. twitches, tingling, cramps & seizures 6. diarrhea & hyperactive bowel sounds Hypophosphatemia signs and symptoms - 1. high calcium levels 2. impaired clotting 3. muscle weakness (cardiac & respiratory) 4. HR slows 5. decreased reflexes 6. irritable to confused to seizures Maslow's Hierarchy of Needs - (level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization eclectrocardiogram (box) - Small box= 0.04 seconds large box= 0.20 seconds Normal PR interval - 0.12-0.20 seconds Normal ORS range - 0.04 to 0.1 seconds Left sided heart failure symptoms - -Left = lungs (and heart) -Crackles/wheezes -exertional dyspnea - elevated pulmonary pressure -restlessness -cough -tachypnea/tachycardia -cyanosis -orthopnea -blood tinged sputum Right sided heart failure symptoms - May be secondary/chronic pulmonary problem -increase peripheral pressure -JVD -Fatigue - enlarge liver/spleen - weigh gain -ascities -edema -GI distress Beta Blockers - "LOLs" decrease heart rate and dilate arteries by blocking beta receptors ACE inhibitors - "PRIL" Decreases BP, Decreased Aldosterone secretions, Sodium and fluid loss. *Orthostatic Hypotension Calcium Channel Blockers - causing a slowing of the heart rate, a lessening of the demand for oxygen and nutrients, and a relaxing of the smooth muscle cells Angiotensin Receptor Blockers - "Satrans" prevent angiotensin II from reaching its receptors, causing vasodilation 1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if the excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP) - 3. An increase in blood pressure and increased respirations 2. The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Uric acid level of 9.4 mg/dL (557 mcmol/L) - 2. Requires nasogastric suction 3. The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1. U waves 2. Absent P waves 3. prominent U waves 4. Depressed ST segment 5. Widened QRS complex - 1. U waves 3. prominent U waves 4. Depressed ST segment 4. Potassium chloride intravenously is prescribed for a heart failure patient experiencing hypokalemia. Which actions should the nurse take to plan for the preparation and administration of the potassium? Select all that apply. 1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 3. Prepare the medication for bolus administration. 4. Monitor the IV site for signs of infiltration or phlebitis. 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution - 1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 4. Monitor the IV site for signs of infiltration or phlebitis 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution 5. The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1 Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes - 1 Twitching 6. The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment - 4. Prolonged QT interval 5. Prolonged ST segment The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEg/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave 3. Tall peaked T waves 4. Prolonged ST segment 5. Widened QRS complexes - 3. Tall peaked T waves 5. Widened QRS complexes 7. Which client is at risk for the development of a sodium level at 130 mEg/L (130 mmol/L)? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids - 1. The client who is taking diuretics The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine - 3. Hyperactive bowel sounds The nurse reviews a client's laboratory report and notes That the client's serum phosphorus (phosphate) level 15 1.8me/dI. (0.58 mmol/L). Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome - 1. Malnutrition The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 ml. daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract - 3. Integumentary output The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1. A client with an ileostomy 2. A client with heart failure 3. A client on long-term corticosteroid therapy 4. A client receiving frequent wound irrigations - 1. A client with an ileostomy The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased heart rate 3. Decreased hematocrit and increased urine output 4. Increased respirations and increased blood pressure - 1. Weight loss and poor skin turgor On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics who has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease and a 12-year history of diabetes mellitus - 4. The client with kidney disease and a 12-year history of diabetes mellitus Which client is at risk for the development of a potassium level of 5.5 mEg/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn - 4. The client who has sustained a traumatic burn The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco, of 30 mm Hg (30 mm Hg), and HCO, of 20 mEg/L (20 mmol/L). The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated - 2. Respiratory alkalosis, compensated