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CEIN Fundamentals Final 2021
Terms in this set (116)
DVT diagnostic tests include
Duplex venous ultrasonography
Duplex venous ultrasonography
- an imaging test that uses sound waves to look at the flow of blood in the veins
- looks for DVT
Hypercoagulability, Endothelial damage, venous stasis
DVT is characterized by
- leg pain
Clots that embolize most frequently travel to the
Elevated D Dimer indicates
An IVC filter prevents
clots to travel to lung
A dorsalis pedis pulse of only +1/4 may indicate
Assessing a patient with chronic PAD, which of the following findings should you expect
- decreased hair on lower extremities/toes
- Burning and pain in the legs during exercise
- Capillary refill of toes greater than 3 secs
A patient who has been on bedrest for 2 days is at risk for which of the following complications
- Weakness and dizzyness
Risk factors for developing a DVT
- Oral contraceptives
- Extended sitting (plane rides)
- lower extremity trauma
You would see the following in a patient with venous insuffiency:
- reddish brown discoloration
- thickened skin
Peripheral Arterial Disease
blockage of arteries carrying blood to the legs, arms, kidneys and other organs
Peripheral Arterial Disease Symptoms
Pallor with touch
Leg numbness or weakness
Nursing care for Peripheral Venous Disease:
- avoid crossing legs
- protect extremity from injury
- avoid direct heat to affected extremity
Patients with peripheral venous disease should be encouraged:
Decrease dependent time for the legs (don't dangle)
Patients with varicose veins will complain of:
Heavy feeling in the affected leg
Nursing care of the patient with varicose veins or PVD includes
- Wearing support hose
- Losing weight
- Avoiding prolonged standing
Signs and symptoms of chronic venous insufficiency in the legs includes
- heavy, dull aching pain in the calf and thigh
- thickening and hyper-pigmentation of the skin
Therapy for chronic venous insufficiency includes
Chronic Venous Insufficiency
a condition in which venous circulation is inadequate due to partial vein blockage or leakage of venous valves
The primary result of aging on the peripheral vessels is
Stiffening of vessel walls
A life or limb threatening event that requires immediate attention
Intermittent claudication is a classic sign of:
Peripheral Artery Disease
A serious complications of DVT is
The peripheral pulse has disappeared in a post-op patient with Peripheral Artery Disease. The nurse suspects it may be related to:
Signs of limb ischemia include:
Paleness over an area of reduced blood supply
This is associated with intermittent claudication
Determined by palpating for rate, quality, and rhythm
Impairment of motor function is called
A "pins and needles" sensation is known as:
Invasive procedure requiring dye to be injected into the vascular system
Preventive measures might be used before and after any procedure or event to prevent DVT
- Getting up out of bed as soon as possible.
- adequate hydration
Preventing DVT includes:
- Get up and move around every hour on a long flight.
- Using compression stockings
The nurse is planning the care of a client diagnosed with acute gastroenteritis. Which nursing problem is priority
Fluid and electrolyte imbalance
Reasons to Delegate:
- to get more work done efficiently and productively
- improve quality of care
- develop trust among staff
- empower staff
Types of Tasks Delegated:
repetitive tasks that are similar person to person, require little supervision, non-invasive, predictable, and with minimal risk
Nurse Practice Act
law established to regulate nursing practice
Tasks and Responsibilities that an LNP CANNOT do
- providing new education to patients
- IV meds
- Caring for patients in labor/delivery
What is the responsibility for an RN only?
care of an unstable patient
- Form of hyperventilation
- Deep and Labored Breathing Pattern
What type of lung sounds can be heard with pneumonia, atelectasis, and left-sided heart failure?
What are bronchovesicular breath sounds
equally, medium in loudness and pitch and can be heard in the 1st and 2nd intercostal space anteriorly
What is rhonchi?
low-pitched, continuous, snoring lung sounds heard during expiration caused by airflow obstruction from secretions
What is pleural friction?
abnormal breath sounds heard with the inflammation of pleural surfaces
What is the intraoperative period?
Period which begins when the patient is transferred to the OR bed until transfer to the PACU
What is a key role for the nurse in caring for a patient in the perioperative period
adovcate for the safety of the patient
When should patients be taught about incentive spirometry?
What are (American Society of Anesthesiologists) ASA Risk Factors?
Coronary Artery Disease
End-Stage Renal Disease
What is Atelectasis?
complete or partial lung collapse that is a complication after surgery resulting from a blocked airway due to decreased respiration, poor gas exchange, retained secretions
What is the Aldrete Score?
a tool used to determine patient readiness in which you assess the patients activity, respiratory, circulation, consciousness, and O2 saturation
What is the frequency of time to conduct postoperative assessments and interventions?
Every 10-15 mins
What are four signs and symptoms of Pulmonary Embolism?
- acute onset of dyspnea
- followed by chest pain, cough, tachycardia
- cool/clammy skin
- decreased O2 saturation that doesn't respond to O2
- Possibly Cyanosis
What is neuropathic pain?
type of pain where the nerve fivers themselves may be damaged, dysfunctional, or injured
What are consequences of untreated pain?
- Impaired sleep
- Depression, Anxiety, Confusion (in older adults)
- Nutritional Deficits
- Decline in ADLs
- Decreased Quality of Life
- Decreased Socialization/Loss of Relationships
What are five non-pharmacologic pain interventions?
- Relaxation. distraction, imagery, hypnosis, meditation, deep breathing, acupressure
- Heat/Cold, Massage, Therapeutic Touch
- Music, Humor
- Tai Chi, Yoga, Animal-Facilitated Therapy
What is the FLACC Scale?
Assess: Face, Legs, Crying, and Consolability
What are the names of the pain assessment tools?
• Beyer Oucher Pain Scale
• CRIES pain scale
• 1-10 Rating Scale
What is a priority intervention for a patient who skin is blue, dusky and not breathing?
Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw
What is splinting?
• includes pressing on incision with both hands
• pressing on a pillow placed over incision, or wrapping a bath blanket around the client (sometimes to facilitate coughing)
What are risks for a perioperative positioning injury?
• Prolonged procedures
• Diminsihed ability to communicate
• Decreased reflexes
What is a priority assessment for a client with a recent diagnosis of Deep Vein Thrombosis with a sudden onset of shortness of breath and chest pain that increases with a deep breath?
Assess O2 Saturation
What is a response to a clinician who asks an RN to obtain the informed consent signature from a patient?
explain that the it is not the RNs responsible to obtain the signature on the document
What are the five rights of delegation?
• Right task
• Right circumstance
• Right person
• Right direction or communication
• Right supervision and evaluation
Which nursing interventions would be the most effective in assessing for hypovolemia after a paracentesis?
Taking vital signs every 4 hr
The pain of a gastric ulcer begins
30-60 minutes after a meal, and does not occur at night.
• occurs in stomach
• small intestine
After a scope procedure, the client is difficult to arouse. An important nursing action for the nurse to perform at this time is to
open the client's airway
What test would you use to see the presence of H. Pylori?
Urea Breath Test
How is the stoma suppose to look?
moist & red
What classification of medications help with GERD?
• Proton Pump Inhibitors
• H2 Antagonists
What is the difference between emphysema and chronic bronchitis?
• chronic bronchitis and emphysema often occur together and make up COPD
• smoking is a leading cause of both conditions
• no cure for either condition, but treatment can help a person manage the symptoms
• chronic bronchitis produces a frequent cough with mucus. The main symptom of emphysema is shortness of breath
• emphysema isn't reversible, but you can lower the odds of chronic bronchitis
What is COPD?
• Chronic Obstructive Pulmonary Disease
• Irreversible decrease in the ability to force air out of the lungs
• Emphysema and chronic bronchitis are the most common conditions that make up COPD
a disease of the airways and is defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years
Emphysema is a pathologic term
that describes an abnormal distention of airspaces beyond the terminal bronchioles and destruction of the walls of the alveoli
Clinical Manifestations of COPD:
• chronic cough
• sputum production
• dyspnea at rest/exertion
• weight loss
• barrel chest
a chronic condition in which the heart is unable to pump out all of the blood that it receives
Arterial Blood Gases
clinical test on arterial blood to identify the levels of oxygen and carbon dioxide
a serious electrolyte disorder characterized by an imbalance in the body's acid-base balance
Metabolic Acidosis Labs
What is the primary disturbance in metabolic acidosis/alkadosis?
too low in metabolic acidosis
too high in metabolic alkadosis
What is basic on the pH scale?
7 to 14
What is acidic on the pH scale?
What is acute coronary syndrome?
a term used to describe a range of conditions associated with sudden, reduced blood flow to the heart
What are examples of acute coronary syndrome?
- unstable angina
- myocardial infarction (NSTEMI, STEMI)
What is NSTEMI?
- Non-ST Segment Elevation Myocardial Infarction
measurement of the volume percentage of left ventricular contents ejected with each contraction
What test is used for heart failure?
- BNP and pro-BNP
- Blood levels of both of these substances become elevated in patients with congestive heart failure
What labs should you look at for heart failure?
What are kidney function tests?
How is hypertension diagnosed?
when blood pressure consistently measures >130 mmHg systolic and >80 mmHg diastolic
What does a EKG measure?
electrical activity of the heart
Concerning Symptoms related to the Peripheral Vascular System:
Pain in the arms or legs
Cold, numbness, or pallor in the legs; hair loss
Swelling in the calves, legs, or feet
Swelling with redness or tenderness
In Peripheral Arterial Disease what arteries are most often affected?
The 5 P's of Arterial Insufficiency:
Clinical Manifestations of Arterial Insufficiency:
- Intermittent Claudication
- Pain is distal to the obstruction
- Pain disappears after stopping activity
- Tightening pressure in calves or buttocks
- Hip or leg "giving out"
- Sharp cramp or burning sensation (During walking/Disappears with rest)
- The affected artery is usually 70% blocked before symptoms occur
- Decreased capillary refill
- Coolness of skin
- Hairlessness of extremity
- Weak or absent pulses
- Dependent rubor (dark purple red color)
- Pallor with elevation of leg
- pain and discomfort in calf muscles while walking
- a condition seen in peripheral arterial disease
Normal Potassium Level
Normal Sodium Levels
Complications Post Operation:
DVT Risk Factors:
Disease process (ex: CHF, MI)
Pressure - Obesity, pregnancy, tumor
Trauma - Fractures, Venipuncture
Smoking, Dehydration, Advanced
What is a Foley catheter used for?
- meant for longer term use by patients who are unable to use the toilet themselves
- assist bladder emptying
- relieve bladder retention; bypass obstruction
- irrigate bladder or introduce drugs
- relieve incontinence
What is an indwelling catheter used for?
- drains urine from your bladder into a bag outside your body
formation of blood cells within the red marrow cavities of certain bones
What is a D-Dimer test?
-If elevated D-dimer it means the blood is reacting to clots
- Important in patients with DVT, PE.
- D-Dimer is produced by thrombin, which helps with clotting, so it indicates presence of clots
**If too low, your body is not responding to clots or not clotting and at risk for bleeding
- Low Molecular weight heparin (enoxaparin)
- Thrombolytic Therapy (tPa/Streptase)
- Oral Anticoagulants
What is the normal GFR?
90 to 120
What is a normal BUN?
What medication is given to reduce high K levels?
- Sodium polystyrene
- loop diuertic
Urinary output of less than 400 mL/day is
Clinical Manifestations of Hyperkalemia
Clinical Manifestations of Hypokalemia
- Muscle weakness, leg cramps
- Nausea, vomiting, paralytic ileus
- Soft, flabby muscles
- Paresthesias, decreased reflexes
- Weak, irregular pulse
Clinical Manifestations of Hypernatremia
- excessive thirst
- dry mucous membranes
- muscle twitching
complete thrombotic blockage in a coronary artery
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