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A comprehensive collection of questions and answers related to medical-surgical nursing, focusing on pain management, patient safety, and fluid and electrolyte balance. it covers key concepts such as maslow's hierarchy of needs, pain assessment scales, analgesic administration, and the management of electrolyte imbalances. The questions delve into modifiable and non-modifiable risk factors, the role of various organizations in healthcare, and the physiological effects of pain and electrolyte disturbances. This resource is valuable for nursing students preparing for exams or seeking a deeper understanding of these critical areas.
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List four modifiable risk factors. (general health promotion) - answeight, smoking, sex practices, diet List three non-modifiable risk factors. (general health promotion) - ansage, genetics, sex What type of assessment should the nurse preform prior to initiating health teaching? - anscultural assessment Maslow's Hierarchy of Needs --priorities? --what order? - ansphysiological integrity safety and security belongingness and affection esteem and self-respect self-actualization -- physiologic needs and life threatening issues are a priority -- confirm that these needs are met in the order listed above Organization that identifies health promotion and disease prevention goals and lists strategies along with resources in an attempt to improve the nation's health - ansHealthy People 2020 Organization that recommends ways to strengthen the practice of nursing in order to improve health care. - ansThe Institute of Medicine's report on the Future of Nursing The Joint Commission lists the top patient safety concerns and includes medication safety, infection prevention, surgery-related mistakes, patient identification and improving staff communication. What is this list called? - ansThe National Patient Safety Goals This governs nursing practice and is a law that is put into place to protect the public - nurses must follow and comply with their state's regulations - ansNurse Practice Acts Institute that seeks to strengthen the knowledge, skills, and attitudes of nurses in providing continuous quality improvement in health care - ansQSEN - Quality and Safety Education for Nurses Institute What is pain? - answhatever the patient says it is Pain is associated with __________________________________. - ansactual or potential tissue damage The single most reliable indicator of pain is _______. - ansthe patient's self report Pain stimulates the sympathetic nervous system and could result in an increase in ___________, ___________, and ____________. - ansblood pressure, heart rate, and respirations physiologic effects of unrelieved pain (4) - ansincreases glucagon production decreases insulin secretion depresses immune function can lead to addictive behaviors initiate inflammation and contribute to tissue swelling and pain - ansprostaglandins ______ primarily produce pain relief by preventing prostaglandin formation. - ansNSAIDS _____________ does not have anti-inflammatory properties. - ansAcetaminophen
______________ stimulates the inflammatory response and puts the patient at risk for pain. - anstissue damage manage nociceptive pain with? - anslocal anesthetics, non-opioids or opioids pain that is associated with a noxious stimulus - ansallodynia ________________ could lead to allodynia. - ansnerve route injury What does a comprehensive pain assessment include? - anstiming: onset - when it started duration - where it started frequency - how often/for how long type - includes intensity, associated factors influencing factors - what makes it better/worse intensity - how bad does it hurt quality - what does it feel like location - where does it hurt effects on function/daily activities 10cm line that represents no pain to worst pain on each end of the line and the patient places a mark somewhere between the two ends depending on the severity of pain - ansvisual analog scale ranges from 0 to 10 with 0 representing no pain - ansnumeric rating scale consists of cartoon faces that the patient selects to report their pain - ansWong-Baker FACES Scale (ages 3+) uses words to help individuals describe the intensity of their pain - ansverbal descriptor scale should never be used by the provider to match the patient's facial expression - ansWong- Baker FACES Scale effect produced by topical analgesics - ansproduce a local effect effect produced by transdermal route of analgesics - ansproduces drug absorption into the systemic circulaiton Provide ____________ to help reduce complications related to pain. Used in postoperative patients as a preventative measure for pain. - ansprovide PCA (patient controlled analgesia) Provide administration of analgesics (frequency) for chronic and postoperative pain, never wait for chronic pain to reoccur. - ansaround the clock given for mild to moderate pain - ansaspirin or acetaminophen given for moderate pain - ansNSAIDS given for severe pain - ansopioid analgesics (Morphine)
This mineral/electrolyte is necessary for neuromuscular and cardiovascular function. - ansPotassium EKC/ECG reading for hyperkalemia - anstall tented T waves EKG/ECG reading for hypokalemia - ansinverted T waves The ion for repolarization. - ansPotassium ___________ lowers the resting membrane potential and makes cells less irritable which could result in a(n)_____. - anshypokalemia ileus these drugs should NEVER be used in the presence of renal injury - anspotassium sparing diuretics Check renal function prior to administering ______. - ansPotassium metabolic acidosis results in ____________ - anshyperkalemia the primary factor for osmolality and intravascular fluid volume - anssodium Clinical manifestations of hyponatremia. (8) - ansheadaches seizures lethargy tachycardia decreased blood pressure thready pulse hyperactive bowel sounds abdominal cramps Assess patients for _____________________ in the setting of vomiting, diarrhea, or suctioning. - anselectrolyte imbalance Place patient in what position to prevent aspiration in the setting of mechanical ventilation, altered consciousness, or tube feedings? - anselevate the HOB 30-45 degrees hypercalcemia results in - ansmuscle weakness coma hypocalcemia results in - ansmuscle irritability tetany Classic tests/signs that are indicative of hypocalcemia. - ansChvostek's and Trousseau's Signs Prolonged immobility contributes to shifting of Ca out of the bones leading to ____________. - ansosteoporosis can occur with low Ca and is a medical emergency - anslaryngospasms given to reverse CNS depression caused by magnesium - anscalcium gluconate hormone that promotes fluid re-absorption by the kidneys - ansADH (vasopressin) hormone that promotes sodium retention and potassium excretion - ansaldosterone one of the most powerful vasoconstrictors in the body - ansangiotensin hormone that triggers Na excretion and a decrease in total fluid volume - ansbrain natriuretic peptide (BNP)
moves fluid from the intravascular compartment to the intercellular compartment - anshydrostatic pressure An increase in hydrostatic pressure or a decrease in oncotic pressure could result in _____. - ansedema typical sign of dehydration in the elderly - ansdelirium how to determine skin turgor - anspinching the skin over the sternum or the forehead _____ and _____ contribute to an insensible(non-visible) water loss and contribute to dehydration - ansfever and burns loss of fluid volume could result in? (3) - ansdrop in perfusion hypovolemic shock death signs of fluid volume deficit - anschanges in LOC decreased urinary output dizziness dry mucosal membranes hypotension tachycardia Encourage patient to do these things to help remove secretions and promote lung expansion. - anscoughing and deep breathing use of incentive spirometer A weight gain of __pounds is equivalent to a liter of fluid retention. - ans2.2 pounds What position promotes renal blood flow and the formation of urine? - anssupine Why are the elderly at an increased risk for hypernatremia? - ansimpaired thirst mechanism should never be given with metabolic alkalosis, lactic acidosis, or renal failure - ansLR(Lactated Ringer's Solution) infuse ______ slowly because it could lead to pulmonary edema - ans3% NaCl only solution that can be used with blood transfusions - ans0.9% normal saline these types of fluids cause extracellular fluid volume expanison - ansisotonic This solution is both hypotonic and isotonic and should NEVER be used in the presence of increased intracranial pressure. - ansD5W Give _________ solutions to treat hyperosmolar disorders. - anshypotonic solutions This location for IV therapy increases the risk for thromboembolism. - ansthe leg What size catheter is used to administer blood and viscous solutions? - ans14-18 gauge Use these type of catheters on the elderly patient for IV therapy. - anssmaller size angio- catheters start IV sites where? - ansmost distal area of the arm Prior to initiating intravenous therapy on peripherally inserted central catheters the nurse should do what to check placement of the PICC line? - ansobtain an x-ray puts the client at risk for circulatory overload - ansIV therapy how to position the patient to treat air embolism - ansLeft side in trendelenburg
may trigger an asthma-like reaction - ansaspirating vomitus increase the risk for fluid and electrolyte deficits - ansbowel preps What part of surgical gowns are considered sterile? - ansthe chest to the level of the table and 2 inches above the elbow early signs of malignant hyperthermia (2) - anstachycardia and muscle rigidity antidote for malignant hyperthermia - ansdantrolene life threatening sudden allergic reaction - ansanaphylaxis decreases cellular oxygen requirements - anshypothermia What physiologic condition can increase the risk for surgical site infection? - anshyperglycemia What position should the patient be placed in following a wound dehiscence to reduce tension on the abdominal wound? - anslow fowler's position Symptoms of alcohol withdrawal may occur how long after the last drink? - ans2-4 days priority nursing interventions prior to surgery (legal) - answitness the signing of the consent and clarify what the surgeon stated T/F - Family members can be used as translators for non-English speaking patients. - ansFalse General anesthesia causes loss of _____ and _______ - ansventilatory function and consciousness How to position a patient for a lumbar puncture - ansside-lying knee chest position Who should mark the surgical site? - ansboth the patient and the surgeon This exercise helps to eliminate residual anesthetic agents. - ansdeep breathing How should the patient be positioned to prevent aspiration from vomitus? - ansonto their side Post-operatively, these nursing interventions promote venous return in the patient. (4) - ansambulation sequential compression devices anti-embolism stockings sequential teds Increases the risk for DVT when under the knees - ansconstricting blood vessels __________ or __________ could indicate hypoxia. - ansrestlessness or a change in mental status Device used to detect hypoxemia. - anspulse oximetry Nursing interventions to reduce the risk of skin breakdown in the elderly - ansdrink plenty of fluids use lotion assess for signs of skin breakdown change incontinence pads frequently void after intercourse pneumococcal and influenza vaccine cough and deep breathing exercises
sit up when eating When does the nurse educate the patient on signs and symptoms of infection? Why? - ansprior to discharge many postoperative infections are not evident until after discharge Pain stimulates the sympathetic nervous system. What physiologic effects does this have on the body? - ansSNS Response: increased BP, HR, RR*** pupils dilate bronchodialation vasodilation of cardiac vessels vasoconstriction of peripheral vessels inhibits GI/GU (peristalsis) How often should the nurse administer analgesics for chronic and postoperative pain? - ansATC - around the clock Type of analgesic administration that helps reduce complications related to pain. - ansPCA The nurse should report a systolic blood pressure immediately if it is less than ____. - ansless than 90 This reaction creates a state where the cells are not perfused. - ansshock Types of shock: (a) cardiogenic (b) hypovolemic (c) distributive - ansTypes of shock: (a) heart pump fails (b) intravascular volume drops (c) widespread vasodilation along with increased permeability The patient has a decrease in cardiac output. What will the pulse feel like? - answeak thready pulse Nursing priority during hypovolemic shock - ansvolume replacement How should the nurse position the patient when the patient is in shock? - ansflat on their back with legs elevated at a 20-degree angle (knees kept straight) This type of fluid contributes to one's blood pressure or perfusion pressure. - ansintravascular fluid ___________ decreases with hemmorhage. - ansurinary output This age group has a greater risk for hypothermia. - ansthe elderly Report urinary output less that ________mL/hour. - ans30 mL/hour A drop in _________ and __________ could result in bleeding or hemodilution. - anshemoglobin and hematocrit Normal values for Hemoglobin (g/dL) Male
obesity pain abdominal distention Cyanosis occurs when there is a minimum loss of ______g/dL of unoxygenated hemoglobin in the blood. - ans5g/dL T/F - Cyanosis is a late sign of hypoxia. - ansTrue Prolonged hypoventilation could result in ____________. - ansatelectasis What lab test should be done before an antibiotic is prescribed? - ansculture ________ is always a risk of angiography and procedures ending in - oscopy. - ansBleeding This adventitious breath sound changes the E to an A sound with consolidation. - ansegophony Tidaling in the water seal chamber of a traditional water seal chest drainage system indicates what? - ansa secure connection Clubbing of the nails could be indicative of what? - anslong-standing hypoxia Where should the nurse assess the patient for cyanosis? What color will the skin be if the patient has a darker complexion? - ansgrayish cast in darker complexion mouth lips cheekbones earlobes These devices can be used to determine the adequacy of interventions to improve expiratory function. - anspeak flow meters Signs of hypoxia (5) - ansrestlessness confusion pallor tachycardia tachypnea When is postural drainage performed in relation to meals? - ansbefore meals Hypoxia can lead to ___________________ and _______. - anscardiac disrhythmias and death Following a pneumonectomy how should the nurse position the patient? - ansonto the operative side Following a lobe resection how should the nurse position the patient? - ansonto the unaffected side This action by the nurse helps prevent obstructions but could increase negative pressure and damage pleural tissue. - ansmilking the chest tube
The nurse instructs the client to perform coughing and deep breathing exercises to prevent atelectasis. How often should the client perform these exercises? (ventilation - perioperative care) - ansq2h While using mechanical ventilation, the nurse can do this to the tracheostomy device to help prevent aspiration. - ansinflate the cuff on the trach What does a high pressure alarm on a mechanical ventilator signal? - ansobstruction What does a low pressure alarm on a mechanical ventilator signal? - ansair escape When obtaining a peak and a trough, when should the nurse collect the blood sample? - anstrough - just before the infusion peak 30-60 minutes after the infusion ends Normal O2 Saturation Level - ans>95% An overdose of ______ can kill cells and is evident by restlessness, dyspnea, and paresthesias. - ansoxygen toxicity S/S Oxygen Toxicity - ansrestlessness dyspnea paresthesias This type of oxygen mask is the most precise way to deliver a set of concentration of oxygen.
increased mucous production dyspnea Device used to determine the patient's highest airflow during a forced exhalation. - anspeak flow meter Adventitious breath sign that is indicative of lower airway narrowing. - ansWheezing What type of inhaler is Albuterol? - ansRescue After using a corticosteroid inhaler, the patient should do what to prevent thrush? - ansrinse the mouth These foods/medications may interfere with the accuracy of fecal occult blood tests and should be avoided for how long prior to testing? - ansaspirin red meat turnips vitamin C 72 hours Where does the majority of digestion and nutrient absorption occur in the body? - anssmall intestine MRIs are contraindicated in patients with these devices. (3) - ansaneurysm clips pacemakers internal defibrilators Aid in the digestion of fats, carbohydrates, and proteins. - anspancreatic enzymes (lipase, amylase, and trypsin) Enzyme that aids in the digestion of fats. - anslipase Enzyme that aids in the digestion of carbohydrates. - ansamylase Enzyme that aids in the digestion of proteins. - anstrypsin Any condition that prevents elimination of _______ increases the patient's risk for acidosis. - ansCO Physiological clinical manifestations that increase airway resistance. (4) - ansmucous plugs inflammation loss of lung elasticity bronchoconstriction Hypoventilation leads to _______ and ___________. - anshypoxia and hypercapnia Adventitious breath sound that is continuous and heard during partial airway obstruction. - ansRhonchi In the presence of COPD, limit oxygen delivery to less than _____L/min to prevent oxygen- induced _______________. - ansless than 2L/min hypoventilation Teach patient this exercise to increase airway pressure during exhalation. - anspursed-lip breathing Teach patient this technique/exercise to promote gas exchange. - ansdiaphragmatic breathing
Airflow obstruction can be determined by _______. - ansspirometry The pancreas secretes __________________ to neutralize gastric acid secretions in the small intestine. - anssodium bicarbonate What organ secretes digestive enzymes? - ansPancreas Conditions that interfere with bile secretion may alter the appearance of _____(what color?) and ____(what color?) and impair _____________ which could lead to ___________. - ansstool (clay colored/light grey) skin (jaundice/yellow) fat breakdown steatorrhea - fat in the stool What position should the client be in when administering tube feedings? How long after feedings should the client remain in this position? - anssemi-fowlers one hour post feeding Keep the blue vent of the salem sump tube at what level to prevent gastric reflux? - ansabove the waist What level of suction is used to remove fluid and gas from the upper GI tract? - anslow intermittent suction (30-40mmHg) How should the nurse determine the length of the gastric tube for the patient? - ansNEX+ tip of the nose to the earlobe to the xiphoid process and add up to 6 inches To confirm gastric tube placement, what diagnostic procedure is performed? - ansx-ray Gastric tubes increase the risk for what type of infection? - ansaspiration pneumonia How does the nurse prevent overfeeding via G-tube? - anscheck residual prior to each feeding check residual q4h for continuous feedings A residual volume of _____ increases the risk for aspiration in the patient with a GI tube. - ans200mL or higher How often should the tubing and feeding container be changed? Why? - ansq24h to prevent infection Always use this device to reduce the risk of accidental administration of a large amount of feeding from a closed delivery system. - ansfeeding pump A G tube tract can take up to _________ to form. - ans3 months Parenteral nutrition should not be used if it is ______ or ______________. - ansoily or contains precipitate How often should transparent dressings over a central line be changed? - answeekly unless soiled, damp, or loose Inflammatory conditions along the GI tract increase intraluminal pressure and increase the risk for ___________. - ansperforation Position that delays stomach emptying and decreases the risk of dumping syndrome. - anslow-fowler's position NG tubes are contraindicated following _________________ because they could lead to __________. - ansbariatric surgery
______ deficiency interferes with the digestion and absorption of nutrients and leads to nutritional deficits. - ansenzyme What type of foods stimulate peristalsis and help prevent constipation? - anshigh residue and high fiber foods water fruits and vegetables Diarrhea could lead to metabolic _________ and electrolyte imbalances, specifically _____________ and ___________. - anshypernatremia and hypokalemia T/F - Avoid antidiarrheal agents in the setting of infectious diarrhea. - ansTrue Dietary choices that stimulate peristalsis. - anscaffeine carbonated beverages extreme food temperatures What are the classic S/S of malabsorption? - ansfoul smelling stools and steatorrhea (fat in the stool) Compensatory respiratory mechanism for acidosis. - anshyperventilation This condition causes a rigid board like abdomen with pain, fever, and leukocytosis. - ansperitonitis Level of activity which may be ordered to help decrease peristalsis in the setting of inflammatory bowel diseases. - ansbed rest Bulk forming laxatives should be taken with and followed by __________________. - ans ounces of water Avoid laxative use in the setting of ______________, _____, and ______. - ansabdominal pain, fever, nausea Medication used for yeast infections on the skin. - ansNystatin powder Vomiting fecal matter suggests ______________. - ansobstruction in the ileum Foods that increase the odor of stool. - ansasparagus, cabbage, eggs, fish, high cellulose products, onions Foods that minimize the odor of stool. - ansspinach and parsley What patient should the nurse educate on foods that increase and decrease the odor of stool? - ansclients with an ostomy Monitor levels of _______ when parenteral nutrition is administered. - ansglucose levels Perforation could lead to ___________ and ____________. - ansperitonitis and septic shock Cardinal signs of malignancy of cancer. (2) - answeight loss and fatigue Risk of ____________ increases with chemotherapy. - anspancytopenia - a reduction in the number of red and white blood cells, as well as platelets Vitamin necessary for prothrombin synthesis. - ansvitamin K This condition may suggest a decreased platelet count. - anspurpura - red or purple discolored spots on the skin that do not blanch on applying pressure Safety education given by the nurse to a patient with thrombocytopenia would include: (7) - ans1. use a soft toothbrush or toothette
pressure ulcers thrombophlebitis constipation ___________________ results in Type 1 diabetes and _______________ results in Type 2 diabetes. - ansdestruction of beta cells insulin resistance Three long term complications of diabetes. - ansmacrovascular microvascular neuropathy Only type of insulin that can be administered via IV. - ansRegular insulin This class of drugs stimulate insulin secretion and could lead to hypoglycemia. - anssulfonylureas This drug should be stopped ____hours before and after the administration of iodinated contrast medium. - ansMetformin 48 hours In the absence of insulin _________ is used for energy resulting in ______________ which increases the risk for DKA(metabolic syndrome). - ansfat ketone production DKA These hormones contribute to insulin resistance which could lead to gestational diabetes. - ansplacental hormones List classic signs of diabetes (5) - anspolydipsia polyphagia polyuria vaginal infections poor wound healing Blood sugar and HgbA1 levels that are indicative of diabetes. How many tests are needed to determine this? - ansfasting > casual or random glucose > HgbA1 >6. 2 Tests What physiological effects does an elevated blood glucose level have on the body? - ansimpair blood flow destroy cells increase the risk for retinopathy, nephropathy, and neuropathy In which situations should the diabetic patient not perform exercise? - ansketonuria blood sugar >250mL/dL A 45-year-old client is diagnosed with high-renin hypertension. What type of drug would the nurse expect the physician to order?
ACE inhibitors Beta-blockers Diuretics Calcium channel blockers - ansBeta-adrenergic blockers are the drugs of first choice for clients younger than 50 years of age who have high-renin hypertension, tachycardia, angina pectoris, myocardial infarction, or left ventricular hypertrophy. When the postcardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? - ansHyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion without change in T wave formation. When the patient diagnosed with angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing which type of angina? - ansUnstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Patients who are taking beta-adrenergic blocking agents should be cautioned not to stop taking their medications abruptly because which of the following may occur? - ansPatients taking beta blockers are cautioned not to stop taking them abruptly because angina may worsen and myocardial infarction may develop. Beta blockers do not cause the formation of blood clots, internal bleeding, or thrombocytopenia. Treat hypogylcemia with _______ and not _______ when alpha-glucosidase inhibitors are used. - ansglucose and not sucrose What should the nurse give to the patient to offset hypoglycemia? - ans15g of fast acting carbohydrate Compensatory mechanism to rid the body of acid. - anskussmaul respirations Why should the patient rotate insulin administration sites? - ansto avoid lipohypertrophy Classic signs of adrenocortical hormone deficit - anshypoglycemia hypotension hyponatremia hyperkalemia Addisonian crisis could result in what? - anscirculatory collapse, shock, and death In the setting of hypoparathyroidism, what diet should the patient receive? - anshigh in calcium low in phosphorus