Fluid and Electrolytes

1. Retaining too much water and sodium in the vascular space.

2. Hypervolemia
3. Decrease in cardiac output, decrease in kidney perfusion, decrease in urine, too much fluid in
the vascular space.

4. If the kidneys are not working then the fluid will be retained in the vascular space.
5. Because sodium causes retention of water
6. Sodium
7. Alka Seltzer has a lot of sodium.so the client taking alka seltzer will retain fluid in the
vascular space.

8. Sodium
9. Increase in sodium intake, causes retention of fluid in vascular space.
10. Aldosterone causes retention of sodium and water in the vascular space.
11. Too much aldosterone cause retention of too much sodium and water
12. Primary Hyperaldosteronism or Cushings
13. ANP-Atrial Natriuretic Peptide
14. ANP works the opposite of aldosterone, so it causes the excretion of sodium and water.
15. Anti-Diuretic hormone. Causes retention of water in the vascular space
16.Too much ADH, causes retention of too much water in the vascular space (SIADH).
17. Pituitary gland
18. Too much ADH causes retention of too much WATERSIADH.
19. Diabetes Insipidus-diurese-shock (losing water)

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20.They distend. (Full)

21.The vascular space gets full and cannot hold anymore, and the fluid eventually leaks into the
tissues

22.Central Venous Pressure. Known as right atrial pressure. It reflects the amount of blood
returning to the heart and the ability of the heart to pump the blood to the arterial system.
Measured at the right atrium of the heart.

23.2-6 mmHg (if measured by a monitor); 5-10 cm H2O if measured with a monometer
24.Increases (More volume=more pressure)
25.Decreases (Less volume=less pressure)
26.Wet: Shortness of Breath can occur; fluid in the lungs
27.Kidneys are trying to compensate by getting rid of the fluid
28.Blood pressure increases because there is so much volume; the pulse increases; heart is trying
to pump faster and harder to keep the blood moving forward; we would rather the blood go
forward instead of backwards into the lungs

29.Increases-excess fluid makes weight increase rapidly

30.Sodium restricted to decrease fluid retention
31.The client will retain more fluid and the condition would worsen
32.Daily weight is the best evaluator of fluid volume status.
33.Because the client has too much volume, and needs to diurese.
34.Hypokalemia
35.Hypokalemia
36. Hyperkalemia
37. ANP & ADH: When you lie supine, blood moves from the lower extremities to the thorax
and to the heart. This increase preload stretches the atria and ANP is released. ANP causes
loss of sodium and water. Bedrest causes ADH release to decrease.

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38.Their heart and kidneys are weak. The heart may not be able to pump the excess fluid
forward, and the kidneys may have problems excreting the excess.

39.Hypovolemia
40.Loss of water & NA from vascular space equally
41.Excessive GI loss can reduce the volume in the vascular space (anytime you lose fluid from
your body, no matter where it comes from, the vascular space can eventually be depleted)

42.Fluid leaves the vascular space and goes somewhere where it does you no good (tissue and
abdomen)

43.Fluid leaves vascular space and goes out into the abdomen; therefore the vascular volume
goes down.

44.Fluid leaves vascular space and goes to the tissue (edema occurs) or out of the body
completely.

45.Because they are trying to get rid of the particles (excess glucose particles) in the vascular
space. The glucose has to go out in volume (with fluid). You have never excreted a sugar
particle!

46.Shock
47.After someone has had polyuria for a long time the vascular volume will eventually deplete
and now the client is shocky. The kidneys are not being perfused well at this point so
therefore they make less urine. Also, the kidneys could start trying to conserve what little
fluid is left in the body therefore decreasing urine output as well. With either of these
conditions the urine output will switch to oliguria and could possibly go all the way to anuria.
If either of these occur, I would have to start worrying about renal failure.

48.Decrease, because there is less volume

49.Blood pressure decreases.less volume, less pressure. The pulse increases, but it is weak
and thready. The pulse increases because your heart is trying to pump what little fluid you
have around the body to perfuse vital organs.

50.Decrease-Less volume=less pressure

51.They get small because there is not much volume to distend them.
52.Peripheral vasoconstriction helps shunt blood to vital organs when you vasoconstrict
peripherally, skin gets cool.
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53.Increases-The kidneys will not be putting out too much urine so what little urine is excreted
will be very concentrated.

54.Increase PO fluids
55.IV fluids
56.FVD less volume, less pressure so orthostatic hypotension. Safety with position changes
and ambulation.
IV Fluids:

57.Isotonic: Isotonic solutions go into the compartment in which they are out and stay there and
build up and build up; therefore, increasing the vascular volume. Examples: 0.9% Normal
Saline or LR (Lactated Ringers) Isotonic fluids stay where you put them.

58.They will increase blood pressure, so more volume, more pressure.

59.FVE, hypertension, hypernatremia
60.Go into vascular space but then shifts out into the cells. They rehydrate. NS, 0.33% NS.
61.Fluid replacement losses by n & v, burns, hemorrhage in the client with hypertension, renal
or cardiac disease.

62.Because the fluid moves out into the cells.

63.They expand the volume by drawing fluid into the vascular space from the interstitial space.
64.When a client has shifted large amounts of vascular volume to a 3rd space.
65.Fluid is shifting from a third space into the vascular space.
Magnesium and Calcium:
Hypermagnesemia:

66. Through our kidneys

67.Because Mg is excreted by the kidneys and if your kidneys are not working you will be
retaining Mg in your blood.

68.Sedative
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69.They will decrease.

70.Yes-Because Mg affects all muscles in the body (sedative)
71.Because vasodilation occurs when you have high magnesium
72.The vasodilation will make the blood pressure decrease. Vasodilation always makes BP go
down.

73.They could go into respiratory distress. (Respiratory muscles could become depressed due to
sedative effect)

74.To help the client get rid of magnesium

75.Calcium gluconate is the antidote for any magnesium toxicity, no matter how it occurs; the
calcium will antagonize the magnesium, therefore decreasing the chance for arrhythmias.

Hypercalcemia:

76.With hyperparathyroidism you have too much PTH. PTH makes you pull calcium from the
bone and put it in the blood; therefore, the serum Ca goes up.

77.Increases serum calcium level. Pulls calcium from bone and puts in blood.
78.Because they cause the retention of calcium.
79.Immobility results in calcium leaking out of the bones. Need weight bearing to keep calcium
in the bones.

80.Weak
81.Decreased
82.Decrease, and yes, they could have an arrhythmia.
83.Yes- Because excess Ca in the blood promotes stone formation.
84.To stress the bones; this makes calcium go back to the bones; bear weight; when Ca moves
back into bones, serum Ca goes down.

85.To prevent kidney stones

86.Phosphorus
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87.Steroids lower the serum calcium level by making you excrete Ca through the GI tract.
88.It helps utilize calcium.
89.Calcitonin; used for osteoporosis
Hypomagnesemia:

90.Because magnesium is in the intestine

91.We get a lot of our Mg through dietalcoholics do not like to eat. Also, alcohol makes you
diurese and you know that Mg is excreted through the kidneys. The alcoholic is not eating
and is diuresing a lot.

92.Tight, hyper-excitable, rigid

93.Yes
94.Because the airway is a smooth muscle, and you can have stridor, laryngospasms.
95.Because the muscles are tight, hyperexcitable. DTRs increase.
96.Yes
97.Disoriented
98.Yes, because the esophagus is a smooth muscle.
99.Because magnesium is excreted by the kidneys; we have to make sure our clients are able to
excrete the excess

100. Because their muscles are tight, hyperexcitable; the possibility of seizure is likely.
101. Flushing and sweating could very easily happen when one is getting Mg. However, these
could be signs that the client is getting toxic. Magnesium makes you vasodilate which makes
you feel flushed and warm. Vasodilation also makes the BP drop.
Hypocalcemia:

102. You dont have enough PTH

103. With these two surgeries the primary healthcare provider could accidently remove one or
more of your parathyroids. IF so, you would not have as much PTH as you used to.
Parathyroid is removed----decreases serum calcium.
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104. A. Muscle tone-rigid & tight because of decreased sedative.

B. Laryngospasm-airway is smooth muscle and you have no sedative.
C. Positive Chvosteks-muscles are tight-no sedative.
D. Positive Trousseaus-muscles are tight-no sedative.
E. Arrhythmias-no sedative-tight muscles.

105. Vitamin D helps us utilize calcium.

106. Hypocalcemia
107. Calcium and Phosphate have an inverse relationship. If we can get rid of phosphate by
giving a phosphate binder, then the calcium level will come up.

108. To increase serum calcium levels.

109. Put them on a heart monitor; calcium is a sedative and it slows down the heart rate. It
widens QRS complex; could turn into asystole.

Sodium:

Hypernatremia:
110. Increase because of the concentration. The more concentrated your blood is the higher the
Na goes.

111. If you are dehydrated then the blood is concentrated (not enough water). Concentrated
makes most numbers go up so the Hemoglobin and Hematocrit would go up.

112. They have too much Na; not enough water.

113. Brain
114. Because the brain cells cannot handle rapid Na shifts.
115. Increase; increase fluid.
116. If you dont give proper amounts of water the client can dehydrate.

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Hyponatremia:

117. Dilute-They have too much water and not enough Na.
118. Water dilutes blood.
119. When you take in an excessive amount of water then the blood becomes diluted and this
would make the serum Na go down.

120. Because the body has too much water and restricting water helps increase Na.
121. NS; LR Be careful with clients with renal or cardiac disease.
Potassium:
Hyperkalemia:

122. Kidneys
123. Not excreting K.
124. K sparing diuretic; therefore, serum K goes up.
125. Muscle weakness, arrhythmias.
126. Life-threatening; V-tach---V-fib----asystole
127. Pull off excess K+
128. Calcium gluconate protects the heart from life-threatening arrhythmias.
129. Insulin will drive the K out of the vascular space into the cells; therefore, lowering the
serum K level. However, the blood sugar is going to drop too; so, we have to give
additional glucose to prevent hypoglycemia.

130. It exchanges sodium for potassium in the GI tract removing the potassium.
131. It exchanges Na for K in the GI tract; therefore, it lowers the K+ level. Na increases.
Hypokalemia:

132. K+ lives in the stomach, so vomiting gets rid of K+.

133. Muscle cramps, muscle weakness, arrhythmias.
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134. When any electrolyte gets out of balance this makes a client prone to Dig. toxicity.
However, the imbalance that will promote toxicity the most is hypokalemia.

135. Aldactone makes you retain K.

136. When you are giving IV potassium the client must have a way to excrete the excess. The
only way to excrete K is through the kidneys. If the kidneys are not working well then K
will be retained.

137. Bananas, dried fruits, melons, baked potatoes, greens, strawberries.

138. GI upset.

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Acid Base

1. Bicarb-base-kidneys
Hydrogen-acid-kidneys
CO2-acid-lungs

2. The pH tells you if the blood is neutral, acidic, or alkaline.

3. The brain
4. Lungs
5. Kidneys
6. Kidneys
7. Lungs
8. CO2
9. Bicarb and hydrogen
10.Yes
11.Yes
12.Not exhaling properly.
13.Exhale
Respiratory Acidosis:

14.Lungs are not working right so kidneys compensate. The bicarb level will start to go up in
the arterial blood and make the pH less acid.

15.It has gone up. Slow or shallow breathing makes the CO2 level increase in the blood. Ex:
too much narcotic, post-op, pain, chest injury.

16.Slowly; makes the CO2 level increase in the blood.

17.Increases
18.It is compensating (building up in the blood), making the client less acid.
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19.Decrease: Anytime the pH is out of balance (whether it is too high or too low) the brain is
unhappy.

20.Decreases
21.Restlessness and tachycardia
22.The breathing has to be fixed. How we fix it depends on the Cause. If they have a
pneumothoraxchest tubes. If they have thick pulmonary secretionspush fluids to
liquefy secretions. If they have shallow respirationsTurn, Cough, Deep breathe, incentive
spirometry. Whatever it takes to fix the problem. Every client is different.
Respiratory Alkalosis:

23.Kidneys-They are going to excrete bicarb and retain hydrogen.

24.Fast. (That is what caused their problem to start with).
25.They are exhaling out too much CO2.
26.Increased
27.Decrease
28.Because they are hyperventilating (blowing off CO2).
29.Have client breathe into bag. Re-breathe CO2. (Take it back in).
30.Respiratory alkalosis. Because they are breathing off too much CO2.
31.Decrease RR; retain CO2.
Metabolic Acidosis:

32.Kidneys. Bicarb and hydrogen.

33.Decreased. Retaining too much hydrogen and excreting too much base (bicarb).
34.Lungs; CO2.
35.Lose CO2
36.Acid
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37.Increase-to blow off CO2

38.In DKA, the cells are not getting enough glucose because there is not enough insulin to
carry the sugar into the cells. The cells are starving so they start breaking down fat and
protein for energy. When you break down fat you get ketones. Ketones are acids. So the
client gets acidotic.

39.When you are starving you start breaking down fat. Fat breakdown produces ketones and
ketones are acids.

40.Acids-makes your blood acidic.

41.Lower GI is base; when you are losing base in the form of diarrhea, you get left with acid.
42.Increase-hyperkalemia-muscle weakness and life threatening arrhythmias.
Metabolic Alkalosis:

43.Kidneys-bicarb and hydrogen

44.Lungs-CO2-their RR will decrease to retain CO2.
45.When you lose stomach acid you are left alkalotic inside.
46.Because antacids contain bicarb or base ingredients.
47.The K+ always goes down in alkalosis, and hypokalemia can cause arrhythmias.
48.You must fix the cause.

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Burns

1. Increased capillary permeability. (Vessels are leaking).

2. Pulse increases to compensate for decreased volume. Blood pressure decreased because
there is no volume. (Less volume=less pressure)

3. Volume is decreased in vascular space; therefore, there is less volume to pump out.
4. Deficit
5. Decreased renal perfusion and the kidneys are trying to conserve what they have.
6. These help retain Na & H2O and increase vascular volume.
7. 100% O2. Because the client is hypoxic. By giving 100% O2 we are increasing the
probability that O2 will bind with the hemoglobin before carbon monoxide can.

8. When you have burns in this area you have to worry about airway damage and edema.
9. Singed nose hair, singed facial hair, soot, you know the black stuff all over the face,
coughing up stuff with dark specs or the secretions could be really black, blisters found on
the oral/pharyngeal mucosa.

10.Estimate of total Body Surface Area that has been burned: Head=9; each Arm=9; each
Leg=18; Anterior trunk=18; Posterior trunk=18; Genitalia=1.

11.Calculate what is needed the first 24 hours and give during first 8 hours; 2nd 8 hours give
of total volume; 3rd 8 hours give of total volume.

12.Intake and output because we are expecting the client to gain weight based on the amount
of fluid that we are administering.

13.It helps hold fluid in the vascular space.

14.The immune globulin gives immediate protection because it is the injection of antibodies
(passive immunity). Toxoid: Body has to make antibodies (active immunity).

15.Relieves pressure and restores circulation.

16.Potassium because when the cells rupture they leak potassium and the client can be
hyperkalemic.

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17.For stress ulcers.

18.To ensure that the supplement is moving through the GI tract.
19.To prevent resistance of bacteria. Dont want bacteria to build tolerance.
20.V-fib
21.24 hours
22.Toxins build up and damage kidneys. Electricity destroys any circulation; kidneys are very
vascular.

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Oncology

1. 40
2. Because these tumors grow fast.
3. Rotate assignments daily; nurse should care for only one radiation client per shift.
4. To help prevent dislodgment that could occur if intestines become distended.
5. To help keep bladder non-distended (could promote dislodgment). If bladder becomes
distended the implant could be pushed out.

6. To help prevent dislodgment.

7. Get gloves; using forceps pick it up and put it in a lead lined container- call radiation
department.

8. Do not wash them off or put lotion on them.

9. Alopecia; decrease in appetite; N/V, Pancytopenia, impaired taste, decreased WBC.
10.A chemo drug. If a vesicant infiltrates it will cause massive tissue necrosis.
11.Stop infusion, ice packs to promote vasoconstriction and decrease absorption of drug.
12.Tissue necrosis
13.Private room; wash hands; have own supplies in room; limit people (visitors and nurses) in
room; change dressing and IV tubing daily; cough and deep breathe; no fresh flowers or
potted plants; avoid crowds, do not share toiletries; bathe warm moist areas twice a day
(groin and under the arms); wash hands after touching pet; avoid raw fruits and vegetables;
drink only fresh water; slight increase in temp may mean sepsis; absolute neutrophil count
is most important lab value.

14.Hemorrhage; pelvic congestion of blood.

15.Avoid high fowler; Supine would be the best position, but we have to worry about
aspiration too. If head is up too much, more blood could pool in pelvis.

16.Elevate arm on the affected side; protect the extremity, brush hair, squeeze tennis ball, wall
climbing-promote circulation and mobility; check for bleeding.

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17.Lymphatic system may have been damaged, and this will prevent swelling.
18.Promotes circulation and mobility.
19.No constriction, no blood pressure or injections, wear gloves when gardening, watch for
cuts, protect extremity.

20.Gag reflex.
21.Respiration depression, hoarseness, dysphagia, SQ emphysema.
22.Best time to obtain is in the morning-should be sterile-client should rinse mouth with water
first. Do not let lips touch cup.

23.Position on affected side-affected side will fill with fluids; good side (non-surgical side)
should be up to promote lung expansion; want the affected side to fill; avoid severe lateral
positioning---could promote a mediastinal shift.

24.Because the epiglottis has been removed (no airway protection left).
25.To decrease edema; to decrease edema around airway.
26.To protect suture line.
27.To prevent mouth bacteria from moving down to surgical site or to lungs.
28.Sterile procedure; hyperoxygenate before and after; stop advancement of catheter when you
meet resistance; suction on the way out and no more than 10 seconds; watch for vagus
nerve stimulation (pulse drops).

29.Chronic irritation
30.When a piece of the ileum is used to make a bladder. One end of ileum has the ureters
plugged into it; the other end is brought to the abdominal surface as a stoma.

31.Painless hematuria
32.If urine output is dropping then the surgical area could be becoming edematous; therefore,
causing urine backup into kidneys increasing chance for renal failure.

33.Yes

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34.Because output is at its lowest in the a.m. (Dont want to let urine get on skin as excoriation
will occur.)

35.The enlarged prostate is squeezing the urethra therefore cutting off urine flow.
36.Hesitancy, nocturia, frequency, retention, bladder infection-because urine pathway is
blocked; prostate restricts urethra.

37.PSA-prostate specific antigen and the acid phosphatase.

38.They go through the urethra.
39.Hemorrhage
40.No nerve involvement-no incision.
41.Maintain patency. Flushes out clots. We do not want any clots because this could occlude
the urinary tract and promote renal failure. The fluid is instilled into the bladderflushes
out blood and then the irrigant (fluid) drains down into Foley catheter drainage bag.

42.Strengthens pelvic floor muscles; helps prevent incontinence.

43.To prevent hemorrhage.
44.To prevent straining-straining promotes bleeding.
45.No HCL in the stomach.
46.No- This could disrupt the suture line.
47.Dumping syndrome-B-12 deficient anemia.
48.Abdominal pain/distention; N/V.

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Endocrine

1. Nervous, decreased weight. Hot sweaty, exophthalmos, increased appetite, fast GI,
increased blood pressure, irritable, decreased attention span, enlarged thyroid.

2. Graves Disease
3. Too much T3, T4- too much energy
4. Increases the pulse and blood pressure. When the pulse and blood pressure are increased,
this increases the workload on the heart.

5. Iodine
6. PTU, Tapazol-stops thyroid from making thyroid hormones.
7. PTU, Tapazol
8. Decreases vascularity; decrease chance of hemorrhage Remember the drug Iodine is
different than the Iodine that you eat.

9. Because they stain teeth.

10.Decrease HR/BP; decrease anxiety.
11.Destroys thyroid cells
12.Rebound effect; could cause thyroid storm (is a rebound effect).
13.We do not want to stress the suture line.
14.Fowlers-decrease edema.
15.This is where pooling could occur.
16.Needed for emergency airway. Airway swelling or Laryngospasms could occur.
17.Listen for hoarseness.
18.Because they are close to the thyroid; could have been accidentally removed.
19.Watch for muscle rigidity-tight muscles; Tetany. Look for S/S of hypocalcemia.
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20.Myxedema
21.Decreased
22.Fatigue, GI slow, increased weight, slow speech, cold
23.Hypothyroidism present at birth (retardation can occur).
24.Give thyroid hormones-Synthroid, Proloid, Cytomel.
25.Permanent
26.Hypercalcemia
27.Because calcium is being pulled from the bones-put into blood-osteoporosis.
28.Too much calcium in the blood.
29.Hypocalcemia
30.DTRs increased- muscle tone is tight; rigid; laryngospasm; Trousseaus + Chvosteks
31.To reduce stimuli-they are at risk for seizures.
32.To provide emergency airway in case of laryngospasm.
33.Serum phosphorus is high already.
34.Problems with adrenal medulla-benign tumors that secrete epinephrine and norepinephrine,
these make blood pressure increase and heart rate increase.

35.Increase
36.VMA-vanillylmandelic acid test- 24 hour urine specimen; looking for increased levels of
epi/norepi

37.Change mood; breakdown protein/fat, alter defense mechanisms (suppresses immune

system); inhibits insulin.

38.Aldosterone
39.Makes you retain Na and H2O

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40.Steroids-adrenocorticotropin hormones (ACTH), cortisol.

41.They inhibit insulin blood sugar goes up.
42.Blood volume increases- (retaining Na and H2O).
43.Body doesnt have enough steroids (aldosterone)- Na and H2O is lost- K+ is retained (think
shock and hyperkalemia).

44.Hyperkalemia
45.Muscle weakness; decreased bowel sounds, anorexia, GI upset; arrhythmias.
46.Yes- too much K+ can cause arrhythmias.
47.Not enough
48.Losing volume; not enough Aldosterone.
49.To retain volume in vascular space. (Theyre losing their Na).
50.Because this client has a severe fluid volume problem.
51.Deficit
52.Decreases
53.Moon face, buffalo hump, women with male traits, FVE, skinny arms/legs, large abdomen.
54.a. Cortisol depresses growth hormones
b. Protein wasting due to catabolic effects of cortisol
c. Inhibits the immune response and the inflammatory response
d. Insulin resistance and gluconeogenesis
e. Psychic stimulation

55.Fluid Volume Excess

56.Because they are in a fluid volume excess.
57.Because they have too much aldosterone (so they retain Na and H2O and lose K+).
58.Because steroids decrease serum calcium level by making you excrete it through the GI
tract.

59.Low. Na makes you retain H2O. This client doesnt need more fluid retention because they
are already in an excess.
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60.Because insulin is inhibited and blood sugar increases and excess spills into urine. Fats
are being broken down and this produces ketones.

61.Its not normal- only have protein if there is a glomerular damage. The Cushings client
does not have glomerular damage.

62.Because there is no insulin.

63.The cells are starving for energy, so the body tries to get energy from other places.
64.Ketones
65.Acids
66.Metabolic acidosis. Because fat is being broken down for energy and this produces ketones
which are acids; therefore, more acids in blood.

67.a. Kidneys are trying to excrete glucose.

b. Losing a lot of fluid and fat and protein breakdown.
c. They have excessive thirst from losing volume.
d. They are hungry because they are breaking down protein and fat, and all cells are
hungry.

68.They stimulate the pancreas to make insulin. sitagliptin (Januvia), pioglitazone (Actos),
metformin (Glucophage)

69.Because they dont produce insulin; pancreas is not working. Type Is cant produce insulin
even with stimulation.

70.Blood sugar is high and bacteria can grow rampantly, and poor circulation.
71.a. Diet and exercise

b. Oral agents

c. Insulin

72.Because of possible kidney damage. Diabetics tend to have kidney damage and excess
glucose destroys vascularity in kidneys. We always limit protein with kidney problems.

73.There is a lot of glucose in the blood and it deposits just like fat (arteriosclerosis occurs).
74.Helps maintain steady blood sugar level by slowing the absorption of glucose in the GI
tract and preventing glucose spikes.

75.Exercise lowers blood sugar; eat a snack of fruit, low fat milk before exercise.
76.To prevent hypoglycemia.
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77.Weight, 32-80 units/day

78.Regular
79.Daily
80.No more glucose or ketones in the urine
81.Basal: long-acting Bolus: rapid acting
82.Basal: Daily

Bolus: Prior to meals

83.The clients diabetes has not been controlled properly for the last 3 months. Normal should
be 4-6% or less

84.Rapid acting
85.The pancreas naturally releases a steady amount of insulin to cover the bodys need. The
glargine does the same thing. When we eat a meal that increases the serum glucose, our
pancreas sends a bolus of insulin into the blood stream to cover this sugar. The rapid acting
or bolus insulin works in the same way.

86.Decrease: they are at risk for hypoglycemia

87.Inform client to eat on time; take insulin regularly; eat healthy snacks.
88.To prevent tissue damage, lipodystrophy decreases absorption.
89.Increase
90.Increase
91.DKA
92.Shaky, weak, decreased LOC, cool clammy skin, nervousness, increased pulse, nausea,
sweating, HA; Simple Sugar (PO).

93.Give complex carb and protein (peanut butter and crackers, cheese and crackers) and milkso blood sugar wont drop again.

94.Because brain cells can die without glucose.

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95.Hypoglycemic
96.To prevent hypoglycemia-keep blood sugar WNL.
97.Not enough insulin-blood sugar increase-polyuria, polydipsia, polyphagia-fat breakdown
(acidosis)-Kussmauls Resp.

98.Because insulin returns sugar and K+ back into the cell. Worry about hypokalemia and
hypoglycemia.

99.Decrease-insulin drops the blood sugar.

100. Decreases- because insulin makes K+ leave the serum and go into the cell.
101. Risk for hypokalemia; chance of arrhythmias.
102. Because polyuria could turn to oliguria then anuria (renal failure).
103. Kidney failure-because the kidneys arent being perfused properly.
104. Clip nails straight across; be careful with lotions; inspect feet each day; dry in between toes
very well; wear leather shoes all the time.

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Cardiac

1. Preload Amount of blood returning to the right side of the heart and the stretch it causes.
Afterload Pressure in aorta and peripheral arteries that the left ventricle has to pump
against.

2. The amount of blood being pumped out of LV.

3. No
4. Heart rate, blood volume, decreased contractility
5. Decrease
6. Yes
7. Because there is no perfusion. (Peripheral vasoconstriction in an effort to shunt blood to
vital organs).

8. The heart is not pumping the fluid out to the body, so it backs up to the lungs.
9. Because the heart is not pumping out to the periphery.
10.Decrease; decrease renal perfusion.
11.Because the heart is not pumping out as much volume. Less volume=less pressure
12.Decrease, because heart is not pumping out much volume; heart is pumping slowly.
13.Decrease- ventricles cant fill up; dont have time to fill because the heart is beating so fast.
14.CO decreases-Dead muscle doesnt pump well.
15.Decrease-Heart cant pump as much blood out against the high pressure.
16.Review in your Hurst Student Book.
17.Decreased blood flow to the myocardium ischemia.
18.Blood flow decreases (decreased O2) and causes chest pain (pressure sensation).
19.To relieve the pain-vasodilates which increases blood/O2 to heart.

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20.Blood flow-O2.
21.1 every 5 min. X 15 mins. (3 doses max)
22.Some preparations of Nitroglycerine burn and that is normal.
23.Headache
24.Vasodilate-decrease
25.They decrease workload of heart and decrease contractility; decrease blood pressure.
Inderal-Lopressor

26.To prevent platelet aggregation and vasoconstriction which will decrease the likelihood of
a thrombus.

27.Because these increase the workload of the heart.

28.To decrease workload of heart.
29.Yes
30.Sit down, nitroglycerin makes them dizzy; they may faint.
31.Because contrast dye is used and it contains iodine.
32.Warm/flushing/sweating
33.Bleeding/hematoma
34.Assess circulation. Pulses, skin temperatures; capillary refill; skin color.
35.Because of decreased blood flow and oxygen to the myocardium.
36.No
37.Severe, non-stop pain; chest pressure; radiation to left arm and jaw.
38.Decreased CO (Dead tissue doesnt pump well).

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39.Troponin
40.Good
41.V-fib
42.D-fib
43.Amiodarone(Cardarone)
44.Oxygen, Aspirin chewable, Nitroglycerin, Morphine
45.They dissolve the clot that is blocking blood flow to the heart muscle. They decrease size
of the infarction. Streptokinase, TPA, Reteplase

46.Hemorrhage
47.Any past bleeding problems, stroke, pregnancy, surgery, bleeding ulcer.
48.To prevent hemorrhage. They will bleed anywhere they have been stuck.
49.Balloon to open coronary arteries to enhance blood flow-MI.
50.Increase
51.Trendelenburg position; hypervolemia; supine, elevate legs.
52.Standing upright; hypovolemia; less volume; lower legs; raise HOB
53.Amount of pressure in the aorta that the ventricle has to pump against.
54.Decrease
55.Lungs
56.Dyspnea, cough, pulmonary congestion, blood tinged sputum; restlessness, tachycardia;
blood backs up into lungs.

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57.Because they are hypoxic.

58.When they lie down more blood can go back up to heart and lungs.
59.Blood is backing up in the lungs.
60.Enlarged organs, edema, weight gain, distended neck veins, ascites; blood backs into venous
system engorging everything.

61.Venous
62.Pressures inside the heart
63.Helps determine the cause of decreased cardiac output.
64.Arterial line: in artery-measures continuous BP on a monitor.
65.Skin temp, color, pulse, capillary refill: These need to be checked because the A-line could
decrease heart perfusion so the line is normally placed in the radial artery.

66.Apply pressure to the artery

67.To prevent backflow of arterial blood: If you did not place pressure on the flush bag, the
high pressure of the artery would force blood back up through the tubing and fill the flush
bag with blood.

68.Because the heart muscle is pumping so hard, it hypertrophies.

69.ACE Inhibitors ARBS
70.Digoxin slows down the heart rate which gives the ventricles more time to fill with blood.
Then the heart can squeeze down with a stronger contraction and more blood; therefore, it
increases cardiac output.

71.The elderly have decreased renal function and are at high risk for dig toxicity.

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72.A. Increase
B. lungs should be dry
C. urine output will increase
D. skin should feel warmer
E. should improve
F. should go up

73.To decrease the circulating volume

74.Diuresis may occur
75.So the client will not be up all night using the bathroom
76.SA Node
77.Depolarize heart muscle-shoot electricity through muscle.
78.Yes, but not for long
79.Demand-kicks in only when the client needs it to.
Fixed-fires at a fixed rate constantly.

80.If rate decreases any.

81.The wires need time to embed in the heart; if the arm is moving too much the wires (leads)
could pull out.

82.Make sure pacemaker stays within range its set on.

83.Can alter or damage the pacemaker. Old microwaves, MRI machine, airport security
84.Pulmonary edema
85.The sudden onset of fluid accumulation in the lungs leading to severe hypoxia.
86.The left ventricle is failing so the blood is not being pumped forward into the systemic
circulation; therefore, the blood backs up into the lungs.

87.At night-because when lying down preload increases so we are dumping more blood into
the right side of the heart and into the lungs.

88.Severe hypoxia, sudden onset, breathless, restless/anxious, productive cough.

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89.Hypoxia
90.Because they cannot handle the volume of blood in their lungs.
91.The fluid makes it hard to breath and exchange oxygen. Administer at levels to keep
oxygen sats above 90%.

92.Natrecor is the same as BNP. It vasodilates veins and arteries. It is short term therapy and IV
Natrecor must be turned off for 2 hours prior to drawing a BNP level.

93.To decrease venous return.

94.Increased CVP and decreased BP
95.The heart is being squeezed so the heart pressures (CVP) are high but the output is low which
drops the BP.

96.Car accident, right ventricular biopsy, MI, pericarditis or hemorrhage post CABG.
97.The pain that develops as a result of inadequate oxygenation in an extremity associated
with arterial problems.

98.Coldness, numbness, decreases pulses, atrophy of the extremity occur because oxygenated
blood is not getting to the extremity. You may even see ischemia and gangrene.

99.Yes-Because oxygenated blood is not getting there.

100. Angioplasty will restore oxygenated blood flow to an area. (opens up the artery)
101. No
102. Elevate
103. The blood can get to the area. The problem is once it gets there it cannot get away. So you
get stagnation of blood flow in one area.

104. To decrease the chance of a new clot forming and to keep the present clot from getting
larger.

105. They enhance venous return; decrease pooling

106. Warm moist heat to decrease inflammation.
107. Ambulate and hydrate
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Psychiatric Nursing

1. Due to decreased serotonin because serotonin is a mood elevator.

2. The depressed person likes to be alone but interacting with others actually makes the client
feel better even if they dont want to do it.

3. It goes up because they now have the energy to go ahead and complete the task.
4. You let the client know that you accept that he or she needs the belief, but you do not believe
it.

5. This is an attention getting mechanism and they have no inhibitions.

6. Manipulation makes them feel secure and powerful so you have to set limits and the staff
must be consistent.

7. This will increase their anxiety level.

8. Laughing and smiling while talking about their mother who died a tragic death.
9. Always seek clarification. You say, I dont understand.
10.To provide a safe environment. We need to safe-proof the room.
11.Check them every 15 minutes and dont forget hydration, nutrition and elimination.
12.Be reliable. If you say you will do something, you must do it. The number one thing you
are trying to build is trust.

13.Because they can not make decisions.

14.Their anxiety level goes up if they cant perform this ritual.
15.Alcohol makes you diurese. And the two electrolytes you lose when you diurese are
magnesium and potassium.

16.To make sure they dont go and throw up.

17.It takes a while to desensitize someone. The anxiety presents itself as a phobia.
18.They must first learn how their anxiety feels when it starts to come on. Thats the first thing
they have to do is learn how it feels in the early stages.
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19.If you touch them without saying something first it could scare them. When they get scared,
they can get violent.

20.So they wont aspirate. To dry up secretions so they wont aspirate.

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Renal

1. Streptococcus
2. Fluid volume excess
3. Build up of toxins
4. Because the kidneys are failing
5. They are unable to excrete the urea and creatinine through the kidneys.
6. Because the glomerulus has holes in it, so protein can leak out.
7. This is costovertebral angle tenderness. It is when you tap over the kidneys and tenderness
occurs.

8. Retaining fluid
9. Increases
10.Because protein makes your urine level in your blood go up.
11.Increase
12.For diuresis and toxins make you fatigued
13.To account for the insensible fluid loss
14.FVD
15.Protein
16.Fluid
17.Goes out into the interstitial space tissue
18.Decreases the volume in the vascular space
19.Fluid volume deficit
20.Anasarca
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21.To decrease inflammation; to decrease the size of the holes in the glomerulus so protein can
no longer leak out.

22.Low-sodium diet is needed to decrease further edema.

23.High-protein diet to help offset the amount of protein this client is losing through their
glomerulus.

24.Decreases perfusion
25.Decreased perfusion
26.Decreased perfusion
27.Decreased perfusion
28.Vascular damage
29.Urine can be trapped in the kidney
30.Urine can be trapped in the kidney
31.Urine can be trapped in the kidney
32.Because the client is unable to excrete urea and the creatinine.
33.It usually goes up, but it can also become fixed. When it becomes fixed this means that the
clients urine specific gravity does not respond to high volumes of fluids or restriction of
fluids. It stays the same.

34.Because erythropoietin can be altered.

35.Because they are retaining fluid.
36.Because they are retaining fluid.
37.Because of build up of toxins.
38.Urea builds up in the blood and eventually will escape through the pores onto the skin.
39.Because the renal failure client retains phosphorus; therefore, that makes them excrete their
calcium, which lowers the serum calcium then the client starts pulling calcium from the bone.

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40.Urine output has decreased.

41.Retaining fluid
42.Unable to excrete potassium
43.Increasing
44.Losing volume
45.Decrease
46.Increase-trying to compensate for the decrease in volume.
47.Because potassium is being excreted through the kidneys.
48.Because heparin is used during the procedure.
49.No
50.Yes, because between treatments the client is unable to excrete excess electrolytes and
fluids.

51.No blood pressures, no punctures in the extremity, do not wear a watch on that extremity,
check it for adequate circulation.

52.Because these could cause a clot to occur in the circulatory access device.
53.Fluid is instilled into the abdomen. Fluid stays in for a period of time, then it is drained out
of the abdomen along with all of the excess electrolytes and toxins that have accumulated
in the clients body.

54.Abdomen-Peritoneal cavity
55.Turn the client from side to side or reposition the client.
56.Clear and straw colored.
57.Cloudy or dark fluid return.
58.This client needs protein because protein can leak into the peritoneal cavity during the
procedure. The client needs fiber because of the constipation problems they have due to
decreased peristalsis.
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59.The dialysate that is used is a high glucose content.

60.Hematuria and pain
61.Fluids, fluids, fluids
62.Because creatinine is constantly produced in our bodies due to skeletal muscle breakdown.
63.Blood
64.Yes

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Gastrointestinal

1. Endocrine-insulin; Exocrine-digestive enzymes

2. Gall bladder disease and alcoholism.
3. A gallstone can block the pancreatic duct trapping the enzymes inside the pancreas.
4. A. Losing fluid into the abdomen.
B. A large pancreas.
C. Possible hemorrhage
D. Possible hemorrhage
E. Inflammation
F. Liver involvement
G. Bleeding or ascites

5. To decrease inflammation of the pancreas

6. To dry secretions
7. Yes-because the pancreas is damaged; steroids; and TPN.
8. We want to ease them back into a diet, for a period of time they may receive TPN
9. Liver cells are destroyed and are replaced with connective and scar tissue; therefore the blood
pressure in the liver goes up and the client has portal hypertension.

10.Increased-portal hypertension
11.Firm, nodular liver-due to connective and scar tissue
Abdominal pain-liver capsule has been stretched
Chronic dyspepsia-GI tract is altered
Change in bowel habits-GI tract is altered
Ascites-liver is not producing albumin as it should; therefore we lose fluid out of the
vascular space into the abdomen
Increased ALT & AST-liver enzymes are increased because the liver is altered.

12.A build up of ammonia

13.PT; PTT-One of the main functions of the liver is to help our blood to clot. After
puncturing into the liver there is a chance our blood may not clot as quickly as it should.

14.We are worried about hemorrhage.

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15.On their back with the right arm behind the head.
16.On the right side to hold pressure.
17.To get the diaphragm out of the way.
18.Because we have a client with a fluid volume problem due to the ascites
19.To rest the liver because toxins make you tired
20.Because the liver is responsible for the production of clotting factors
21.We are measuring the abdominal girth to see how much fluid the client is accumulating in
their abdomen. The more fluid the client accumulates in the abdomen indicates that the
vascular volume is going down.

22.Removal of fluid from the peritoneal cavity.

23.Sit them up
24.Do not want to puncture the bladder.
25.Because you are worried about throwing the client into a Fluid Volume Deficit.
26.Deficit
27.Sclera of the eyes
28.Alternation in skin integrity
29.Because the liver cannot metabolize narcotics so you can get a build up of narcotic effects
and depress the respirations.

30.Decrease
31.To decrease ascites
32.Ammonia
33.Because the liver is unable to convert ammonia to urea.
34.Minor mental changes; decreasing LOC, Asterixis, decreased reflexes; slowing EEG and
fetor. All of these symptoms are due to a build-up of ammonia in the blood.
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35.Lactulose because it decrease ammonia.

36.Increase because the liver cannot convert ammonia to urea.
37.Protruding vessels in the esophagus waiting to rupture.
38.The back pressure in the liver forces the vessels in the esophagus to protrude.
39.Because the client is anemic and we want what few blood cells they have to be hyperoxygenated.

40.It decreases the blood pressure in the liver and hopefully the bleeding will subside.
41.Causes vasoconstriction in other parts of the body.
42.To hold pressure on the bleeding varices.
43.Keep scissors at the head of the bed; make sure the tube is not coming out. Mark the tube at
the nares and observe maintenance of tube position. If respiratory distress occurs 2 to tube
dislodgement, have scissors available to cut the tube and deflate balloon.

44.Burning pain in the mid epigastric area. The pain may go all the way through to the back
and heart burn or dyspepsia.

45.NPO-pre, they will be sedated; a tube will be placed in the throat and through the
esophagus into the stomach.

46.Because we do not want them to aspirate.

47.Pain
48.To decrease acid- liquid to coat the stomach
49.To decrease acid-famotidine (Pepcid), ranitidine (Zantac)
50.To form a barrier over the wound so acid cannot get on the wound.
51.Because stress increases stomach acid.
52.Smoking increases stomach acid.
53.Eat what you tolerate but avoid extra spicy foods.

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54.The location
55.When part of the stomach moves up into the thoracic cavity.
56.Heartburn, regurgitation, difficulty swallowing
57.Sit up after meals and elevate the head of the bed. We are trying to keep the stomach down
in the abdominal cavity.

58.When the stomach empties too rapidly after a gastrectomy, gastric bypass, or with
gallbladder disease

59.Gastrectomy, Gastric Bypass, Gallbladder Disease

60.Fullness, palpitations, faintness, weakness, cramping and diarrhea
61.Lie back when eating then lie flat after meals; drink fluids between meals; do not drink fluids
with meals.

62.Ulcerative colitis is a large intestine disease. Crohns disease is a small intestine disease.
63.Diarrhea, rectal bleeding, weight loss, vomiting, cramping dehydration, blood in stool,
anemia, rebound tenderness and fever.

64.Regional Enteritis
65.Low fiber diet because a high fiber diet would increase motility.
66.These will increase motility.
67.To decrease inflammation.
68.Continuous liquid drainage.
69.These will increase motility and therefore make the client lose even more water.
70.To replace fluid and electrolytes.
71.Because they are always a little dehydrated.
72.Potassium
73.Bowel training and irrigation will be needed.
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74.Because the appendix fills with bowel contents and becomes inflamed and can rupture.
75.Right lower quadrant pain and an elevated white blood count; may have some nausea and
vomiting and rebound tenderness.

76.Because we do not want to rupture the appendix.

77.Elevate the head of the bed and to decrease stress on the suture line.
78.Because they are so many particles in TPN that it will eat up peripheral veins.
79.To avoid throwing the client into hypoglycemia. TPN solutions are packed with glucose.
80.Because TPN is a nutritional substance, we want the client to gain weight or at least
maintain the blood sugar within a normal range.

81.Because TPN has such a high glucose load in it they may need additional insulin to
maintain the blood sugar within a normal range.

82.Checking urine for glucose and ketones

83.Because the clients needs will change every single day, we monitor the electrolytes daily
to determine what the client needs for the next 24 hours.

84.Because it is full of electrolytes that need close monitoring of their rate.

85.To prevent infection.
86.The client is placed in trendelenburg position (to distend the jugular and subclavian veins).
87.Jugular vein or the subclavian vein
88.The air will go into the right atrium and be pumped to the lungs (pulmonary embolus); to
prevent passage to the lungs the client should be placed on their left side to prevent forward
movement of the air and preferable left side trendelenburg.

89.Placement and Pneumothorax

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Respiratory

1. Removal of fluid from the pleural space.

2. Pleural space
3. It is the potential space between the visceral and parietal pleural.
4. Collapse
5. Fluid volume deficit anytime you pull fluid from the body the vascular space could deplete.
6. Because the doctor could puncture all the way into the lung
7. The lung is collapsed
8. To promote one-way flow of air out of the pleural space. If there was no water seal or if the
water seal was broken, air from the outside environment could go backwards into the
pleural space and re-collapse the lung.

9. Re-expand
10.Pulse oximetry of 90%; drainage is 100 mL or greater.
11.To prevent gravity flow of drainage into the pleural space.
12.a. Reconnect ASAP
b. Set upright and check water levels for proper height
c. Normal: Gentle continuous in suction chamber when connected to wall suction and/or
intermittent bubbling in the water seal chamber with coughing or sneezing.
d. Problem: Continuous bubbling in the water seal chamber.

13.Hook it back up unless you happen to have a sterile connector in the room. Then you would
use a brand new sterile connector.

14.Tension Pneumothorax
15.Blood in pleural space
16.Air in the pleural space
17.Collapse
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18.Leave it in place
19.The pressure has accumulated in the pleural space and has collapsed the lung and pushed
everything to the opposite side.

20.Tracheal deviation
21.Three-the fourth side acts as an air vent. There is a chance there is some air that will need
to come out so you will have to leave a way for it to come out.

22.Because it hurts; respiratory acidosis

23.Do not want to depress the respirations even more.
24.Multiple rib fractures
25.When your chest does not rise and fall symmetrically; you are said to have a seesaw chest.
26.Because of the broken ribs.
27.To expand the chest to realign ribs.
28.Positive end expiratory pressure
29.Continuous positive airway pressure
30.PEEP exerts pressure at the end of exhalation and CPAP is pressure throughout the
breathing cycle.

31.Blood becomes thick and could form a clot.

32.Because a thrombus can form and dislodge and go to the lungs.
33.Hypoxia
34.Sharp; stabbing
35.It will increase the workload on the right side of the heart.
36.Inflammation
37.Hypoxia

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38.Will decrease the formation of new clots and keep the clot that has already developed from
getting any larger.

39.Warfarin (Coumadin), enoxaparin (Lovenox), dabigatran etexilate (Pradaxa)

40.Ambulate and hydrate

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Orthopedics

1. To prevent further trauma.

2. Fat embolus
3. Cover it with something sterile.
4. Checking pulses, color, movement, sensation, capillary refill, skin temperature.
5. a. Neuro-movement and sensation
b. Vascular-capillary refill, skin temp, skin color, pulse

6. Petechiae over the chest; conjunctival hemorrhages, patchy infiltrates on chest x-ray, usually
occurs within the first 36 hours of an injury.

7. Increased pressure in a limited space

8. Loosen the cast
9. a. We dont want to indent the cast
b. Could cause pressure sores under the cast
c. To prevent indentions
d. To allow heat to escape
e. To decrease indentations or damage to the cast
f. To monitor bleeding
g. Keep it clean
h. Monitor for circulation or nerve impairment (compartment syndrome)
i. Decrease edema

10.Lightweight, waterproof, stronger than plaster and provide for earlier weight bearing.
11.Neurovascular check
12.To realign bones; to decrease muscle spasms and to immobilize
13.If the weights are not hanging freely then the amount of traction being applied is not what
the doctor has ordered.

14.The skin has not been penetrated. Bucks traction and Russells traction are examples.
15.Skin assessment, because the skin is being pulled on.

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16.Prolonged traction using pins and wires. Steinmann Pins or a Halo Vest.
17.Use sterile technique; remove the crust.
18.a. Internal rotation or external rotation could dislocate the new hip
b. Could dislocate the hip
c. Extension minimizes hip dislocation
d. Keeps the balls of the hip in the socket

19.Assess the degree of flexion the machine is exerting; assess the clients pain level and
tolerance of the machine.

20.Isometric such as gluteal and quadriceps/squeezing; rocking in a rocking chair; walking and
swimming.

21.Bending over, sitting in a low chair, climbing stairs.

22.In case of hemorrhage
23.To decrease edema and bleeding
24.Extend the joint-prone position to extend the hip and knee.
25.Pain that is experienced in the amputated extremity. The pain is real to the client.
26.Diversional activity and pain meds are given.

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Maternity

1. a. Presumptive signs: amenorrhea, N/V, frequency, breast tenderness

b. Probable signs: positive pregnancy test, Goodells sign, Chadwicks sign. Hegars sign,
uterine enlargement, Braxton Hicks contractions, Pigmentation/changes of the skin: Linea
nigra, abdominal striae, facial chloasma, darkening of the areola
c. Positive signs: fetal heartbeat, fetal movement felt by experienced examiner, ultrasound

2. 140; because it decreases cardiac output and uterine perfusion.

3. Sudden gush of vaginal fluid, bleeding, persistent vomiting, severe headache, abdominal
pain, increase temps, edema, no fetal movement.

4. Regular contractions, contractions increase in frequency and duration, discomfort in back

radiating around the abdomen, pain level increases with a change in activity.

5. To fight hypotension
6. When the contractions are too often, when contractions last too long, fetal distress.
7. Hemorrhage
8. Massage it until firm to control bleeding and check for bladder distension.
9. Cleanse with warm water after each feeding; let air dry, support bra, ointment for soreness
or express some colostrum and let it dry, breast pads to absorb moisture, initiate breast
feeding ASA after birth, if breast feeding interrupted, mom can pump, increase calorie
intake by 500 calories, fluid/milk intake 8-10 eight ounce glasses/day.

10.Heart rate, respiration, muscle tone, reflex irritability, color; 1 and 5 minutes.

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Complications of Maternity

1. Pain
2. Manage fetus status and maternal shock
3. NPO for 48 hours, IVFs about 3000 mL for 1st 24 hours, antiemetic, vitamins, quiet

environment/not close to nurses lounge, oral hygiene, dont talk about food, keep emesis
basin out of sight, 6-8 small, dry feedings followed by clear liquids, should be icy cold or
steaming hot, well-ventilated room.

4. BP, proteinuria, edema after 20th week

5. The client is losing protein, and albumin is protein, fluid doesnt stay in vascular space, it
leaks into the tissues.

6. Checks for magnesium toxicity every 1-2 hours. BP, respirations, DTRs, and LOC, hourly
urinary output because that is how magnesium is excreted, serum magnesium checks
periodically.

7. Increased pulse and hyperactivity

8. To stimulate maturation of the babys lungs in case preterm birth occurs.
9. Prolapsed cord can occur when the presenting part is not engaged.
10.Cultured around 35-37 weeks and on admission to L&D.

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Neuro

1. LOC
2. Measures the degree of level of consciousness. It is used in a client that already has altered
level of consciousness or the potential of altered consciousness from trauma.

3. Eye Opening- What stimuli is required to get the client to open their eyes
Motor Response- How the client reacts to pain
Verbal Response- Can the client speak

4. When the bottom of the foot is stroked you watch to see what the toes are going to do. In a
child less than 1 yr. a positive Babinski is ok ---+ Babinski means toes fan out. Anyone
greater than 1 year of age, we want the toes to curl up. This would be a negative Babinski.

5. No
6. Yes
7. Claustrophobic
8. They will be in a closed space; need to lie still, they will hear a clanging sound; they can
talk to others while they are in the tube, no menal objects are allowed in the tube.

9. It is an x-ray of cerebral circulation using dye.

10.Usually femoral
11.Heart Catheterization
12.To help the client excrete the dye through the kidneys.
13.Post-procedure we will need to check the circulation in the extremity to make sure a clot did
not form distal to the puncture sight. So baseline data should be collected pre-procedure.)

14.The dye causes a flushed feeling.

15.Iodine is used and I am worried about an anaphylaxic reaction

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16.Same care as for a heart catheterization client-check peripheral circulation and keep
extremity still. Were checking to see if a clot is forming and we want to decrease
movement of the extremity to decrease the chance of hemorrhage.

17.Because a clot could form and go to the brain. Were looking for a change in LOC or any
motor or sensory deficits and one-sided weakness or paralysis.

18.Electroencephalogram
19.Hold sedatives, no caffeine, do not make client NPO
20.They will be asked to lie quietly, first; then they may be asked to do such things as
hyperventilate during the procedure.

21.To check for blood, to measure pressures, and to obtain a specimen.

22.Left side in the fetal position or propped up over the bedside table.
23.We want arch to the back to increase the space in between the discs and to thin out the
meninges.

24.Clear and colorless

25.We want the client to be on bed rest and lie flat so a seal can form at the puncture sight.
Client should drink many fluids. We should check the dressing to make sure it is not wet.

26.Headache
27.Bed rest, fluids, pain medications, a blood patch may need to be done.
28.Herniation
29.Change in LOC, slurred or slowed speech, delay in response, increase in drowsiness,
restlessness, confusion

30.Result of pressure on the brain stem. Systolic hypertension with widening pulse pressure,
irregular respirations, slow, full bounding pulse.

31.Decorticate posturing = arms flexed inward. toward the core

Decerebrate posturing = all 4 extremities in rigid extension
Decerebrate indicates more serious brain damage

32. Increases
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33. To pull fluid off the brain. Osmotic diuretics pull fluid off of the brain into the vascular
system and the excess fluid is excreted through the kidneys.

34.Heart and kidneys

35.To decrease cerebral edema
36.ICP would go up
37.Every time you do something to a head injury client, ICP goes up.
38.To decrease cerebral metabolism therefore decreasing ICP.
39.Too many fluids will increase ICP.
40.Decrease because not as much blood would be pumped out by the left ventricle; therefore
not as much blood would make it to the brain.

41.The higher the blood pressure is, cardiac output goes down; therefore, cerebral perfusion
would decrease.

42.Infection
43.To decrease chance for infection.
44. Meningitis is inflammation of the spinal cord or brain. It can be viral or bacterial. Bacterial
is transmitted through the respiratory system, viral is transmitted through the feces. S/S
include fever, chills, severe headache, nausea, vomiting, nuchal rigidity, and photophobia.

45. Bacterial droplet. Viral contact.

46. A seizure is a symptom of an underlying disorder rather than a disease. In a partial seizure,
only a portion of the brain is involved. In a generalized seizure, the entire brain is affected.

47. Status epilepticus indicates that the client is having continuous seizures with no return of
conscious between the seizures.

48. A long acting is phenytoin. Rapid acting is diazepam.

49. The meninges have been broken and there is direct entry into the brain
50. The meninges have not been broken
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51. Open
52. Base of the skull
53. Bruising on the mastoid, indicates basal skull fracture
54. Bruises around the eyes
55. Leakage of CSF from the nose
56. It will test positive for glucose and form a halo on a sheet or pillowcase
57. May become unconscious for a couple of seconds or may just get dizzy for a couple of
seconds or just see spots

58. Be aware of s/s such as difficulty awakening or speaking, confusion, severe headaches,
vomiting, pulse changes, unequal pupils or one sided weakness.

59. No
60. Client loses consciousness, then wakes up after going through a recovery period; but then
as the bleeding in the head increases, the client starts having neuro changes and possibly will
pass out again.

61. Burr holes and remove the clot. Control the ICP.
62. Immediate craniotomy, remove clot, control ICP.
63. To decrease stimuli which could initiate seizures.
64. A neurological emergency in clients with spinal cord injury above T6, characterized by
severe hypertension, headache, bradycardia, nasal stuffiness, flushing, sweating, blurred
vision and anxiety.

65. Sit the client up to lower BP. Treat the cause.

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Pediatrics

1. Least invasive first; observe before touching or even talking with them. Resp. rate, heart rate,
blood pressure, temp

2. Toddler
3. Use of gestures, writing boards, head nods, eye blinks
4. Constricts edematous blood vessels
5. It is important to know the onset S/S because the disease will becomes worse at day 2-3.
S/S can range from mild to severe; can go from cough, runny nose with copious amounts of
mucous, to severe respiratory distress.

6. The child is losing sodium on their skin.

7. Crying increases the workload on the heart, and eating tires the client with HF.
8. Because they swallow a lot of air that puts them at risk for abdominal distention, which
puts them at risk for vomiting and aspiration.

9. To help prevent aspiration.

10.Helps relieve pain.

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Management and Delegation

1. Because you have to look at every client situation and make a judgment call based on medsurg knowledge.

2. Because these activities do not require nursing judgments.

3. RN to RN
4. To help delegate to the right personnel and improve client care.
5. Teach
6. Because evaluation involves assessment, and we never delegate assessment.
7. Because a new admit is always considered unstable.

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