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Physiological Adaptation and Reduction of Risk Potential 1. Describe different types of surgical dra ins and nursing interventions in maintaining them. 2. What are signs and symptoms of hypoglycemia and hyperglycemia? What should the nurse do if these are identified? Hypoglycemia S/S = hunger, shakiness, nervousness, sweating, dizziness or light headness, sleepiness, confusion, difficulty speaking, anxiety, weakness. If these sysmtoms are identified and pt. Bloodd sugar is below 70 give orange juice, 15 grams of carbohydrates, or 8 oz of milk for immediate tx. Absolutely med. Should be used on regular basis. Hyperglycemia S/S = polyuria, polyphagia, polydipsia, If these S/S are identified give insulin as prescribed, watch for their diet, lifestyle and have them do the exercise if it possible. 3. Identify interventions to improve brea thing and gas exchange. Put the pt. On high fowler or standing postion it helps promote breathing and gas exchange. You can also provide paper bag for breathing 4. A client is experiencing a seizure. What interventions should the nurse take during the seizure? What interventions should the nurse take after the seizure? During seizure have the pt. lie on side lying position. Do not put any restraint and oral airway should be cleared. Dont insert anything in the mouth and protect them from the head injury. After seizure put the pt. in comfortable and in relaxing position. Watch for any muscle pain, injury and confusion.

5. What is the difference between wound dehiscence and evisceration and what action should the nurse take if these occur?

Wound dehiscence is the part of the layers of a surgical wound and the evisceration removal
of the contents from an organ or an organ from its cavity.
6. Differentiate between signs and symptoms of a local infection as compared to a systemic infection. Local infection s/s = Redness, high temperature at the sight, sensitivity, opaque exudate, pain, lightly sawollen, red spots. Systemic infection S/S = fever, chills, aches, nausea, vomiting, weakness 7. What are nursing measures to prevent post -operative complications? Tell the pt. to take prescribed meds as it ordered. Report any sign of infection or discoloration of the skin.

8. Differentiate between a colostomy, ileostomy, urostomy. What are potential complications that can occur with these different types of ostomies? 1) Colostomy = has the surgical opening from colon transverse or either descending colon. Water gets secreted by the colon and stool comes out hard. 2) Ileostomy = has the surgical opening throu gh ileum. It has the watery stool that comes out from the ostomy. 3) Urostomy= has the surgical opening from the bladder. Urine flow out from the bladder throw stoma with catheter. 9. Describe physiologic changes that occur during hemorrhage. How do these changes affect vital signs?

Bleeding can occur internally, where blood leaks from blood vessels inside ... There is typically no change in vital signs and fluid resuscitation is not usually necessary.
10. What are steps to ensure safety for clients with a tracheostomy?

A. Use medical aseptic technique when performing tracheostomy care B. Change tracheostomy ties each time tracheostomy care is given C. Keep cuff pressure between 14 to 20 mm Hg D. Clean stoma site with antibiotic solution

11. What are complications of fractures? Pain and/or reduced movement Crepitus: A grating sound created by the rubbing of bone fragments Deformity: May observe internal rotation of extremity, shortened extremity, visible bone with open fracture Muscle spasms: Occur from the pulling forces of the bone when not aligned Edema and ecchymosi

12. List the steps for mixing a short acting and a long acting insulin in the same syringe. =draw up the regular first, then nph (clear then cloudy)

13. What are signs and symptoms of DKA?

Excessive thirst Frequent urination

Nausea and vomiting Abdominal pain Loss of appetite Weakness or fatigue Shortness of breath Fruity-scented breath Confusion

14. What are the symptoms of angina pectoris? Angina is a symptom of what disease process? How is it treated? How is it prevented? =chest pain, symptom of myocardial ischemia caused by arterial stenosis or blockage, uncontrolled blood pressure, or cardiomyopathy. Avoid smoking, Rest after meals, Give nitroglycerin every 5 min * 3 call 911 15. The nurse is reinforcing dietary education for a client with Crohns disease. The nurse knows that the client understands instructions when he says (please complete). = fatty diarrheal stool is common with crohn disea 16. List 3 disease processes/situations that could cause a client to experience respiratory alkalosis. What should the nurse do if respiratory alkalosis occurs? Cause: hyperventilation, decreased oxygen, elevated body temp Have pt. breathe into paper bag. Provid oxygen. 17. Explain the manifestations of glomerulonephritis. What are the dietary restrictions that a client with glomerulonephritis would need to follow? What are a few of the medications that are used to treat this disorder? =manifestation: hematuria, edema, hypertention, anemia, abdominal pain, pallor, chills, N/V. =reduce diatery protein and sodium: increace calories =meds: pencillin,corticosteroids, hypertensives.

18. A client is experiencing an adrenal crisis. What symptoms should the nurse anticipate? What hormone is missing? Hypsecreation of adrenal cortex horman.( insufficiency of cortisol, aldosterone and androgens) 19. Explain the clinical manifestations of Guillain Barre Syndrome and nursing actions for the client with these symptoms. Manifestation: an infection is respiratory or gastrointestinal. Tingling of leg that may progress to upper extremities, ascending paralysis. Nurse action: support airway, monitor bp, mange bowel and bladder problem.

20. Explain the clinical manifestations of meningitis and nursing actions to care for the client with meningitis including isolation measures.

21. Explain nursing interventions for the client with esophageal varices. What is an emergent complication of this disease process and what are the priority nursing actions if it occurs?

22. A client is receiving radiation therapy for treatment of c ancer. What are nursing care activities that will help minimize side effects to the integumentary, GI, hematologic, and immune systems. 1 2 3 4 5 6 change in bowel or bladder habits a sore that does not heal unusual bleeding or discharge thickening or lumps in breast obvious change in wart or mole nagging cough or horseness

= administer meds: steroids, urinary antiseptics, aesthetics.

23. A client has been diagnosed with SLE (lupus). What are priority nursing tasks for this client? Manifestation: butterfly rash on both cheeks and across the bridge of the nose. Treat: avoid smoking, wear sunscreen and protective clothing, Identify triggers: stress, oral, contraceptives, sunlight, foods, pregnancy. 1 symtomatic 2. salicylates, steroids, dialysis 3. NSAIDS 24. What should be monitor in a client with anemia? DECREASED HGB, HCT, RBC LEVELS Shortness of breath, weakness, dizziness, pallor

25. What teaching should the nurse reinforce to the client with CHF about prevention of CHF exacerbations? = client teaching: assess pulse, report sigs of toxicity, keep lab appointments, st.johns wort and licorice increase the risk of toxicity: low so dium/ high potassium diet

26. A client has been diagnosed with liver cancer. Explain which lab values are expected to be abnormal and what actions the nurse should take to help this client experience minimal complications. Bleeding tendencies: decreased vitmin-k, prothrombin, anemia, clay colored stools, bile in urine. = fat soluble vitmin supplements and folic acid may need to be given IV. 27. A client has the medical diagnosis of COPD. What labs and diagnostic tests are important to monitor? 1. BRONCODILATOR MEDS VIA NEBULIZATION. 2. CHEST PHYSIOTHERPY. 3. CHECKING THE BREATH SOUND AND PULSE OXIMETRY. 28. A client has just undergone a cardiac catheterization. What is the priority focus? =measure oxygen contration, saturation, tension, and pressure in various chambers of the heart. =determine cardiac output and pulmonary blood flow. 29. A client is receiving Digoxin. What is important to monitor and why? Monitoring pulse is important because if the pulse is below 60 it could even drop down more. This can cause cardiac arrest.

30. What is essential to prevent infection with urinary catheter insertion? Because it can cause UTI. If sterility is not maintaind. 31. What is involved with neurovascular checks?
It includes:

1) 2) 3) 4) 5) 6) 7) 8)

Date and time Extremity Sensation Temperature Movement Capillary refill Pulses color

32. What are teaching points for clients regarding foot care and diabetes? Clean your feet in a shower or bath tub Wear socks that fit smoothly and are not tight Sit with both feet on the floor Wear walking shoes that fit well and are comfortable Cut nails after taking shower or soaking feet in tub or bowl

33. pH 7.36 PaCO2 67

PaO2 47 HCO3 37 What is this? Respiratory acidosis. What could have caused it? PH , PaO2 level is going down. PaCO2 and HCO3 is going up 34. pH 7.18 PaCO2 38 PaO2 70 HCO3 15 What is this? It is metabolic acidosis What could have caused it? Ph , HCO3, PaO2 is going down

35. pH 7.60 PaCO2 30 PaO2 60 HCO3 22 What is this? Respiratory Alkalosis

What could have caused it? PH is high, PaO2 and PaCO2 is low 36. pH 7.58

PaCO2 35 PaO2 75 HCO3 50 What is this?

Metabolic alkalosis