Exam 2: NUR 210/ NUR210 Transition to Practice-Capstone| (NEW 2026/ 2027 Update) Questions and Answers| Grade A| 100% Correct (Accurate Solutions)- Fortis

Exam 2: NUR 210/ NUR210 Transition to Practice-Capstone| (NEW 2026/ 2027 Update) Questions and Answers| Grade A| 100% Correct (Accurate Solutions)- Fortis Q. What are the two systems of the ANS? ANSWERS sympathetic and parasympathetic Q. What response does the Sympathetic Nervous System stimulate? ANSWERS Fight or Flight response Q. What response does the Parasympathetic Nervous System stimulate? ANSWERS Rest and Digest Q. Andregenic Agents can also be known as _____________. ANSWERS symapthomometics Q. The Beta 1 receptor controls what body system? ANSWERS Cardiac (heart) Q. What response in the heart is caused by stimulation of the Beta 1 receptor? ANSWERS Makes it beat faster and stronger Q. The Beta 2 receptor controls what body system? ANSWERS respiratory (lungs) Q. What response in the lungs is caused by stimulation of the Beta 2 receptor? ANSWERS bronchodilation Q. Which ANS affecting medication deals with the Sympathetic nervous system? ANSWERS Adrenergic Agents Q. What responses are caused by the stimulation of the Alpha Receptors? ANSWERS vasodilation (perpheral vascular), pupilary dilation Q. Nervousness, insomnia, fine muscle tremors, palpitation, tachycardia, and hypertension are all side effects of what agent? ANSWERS Adrenergic Agents Q. What kind of medicine increases the effects of the Parasympathetic Nervous System? ANSWERS Cholinergic Agents Q. What affect do Andrenergic Agents in the cardiac system? ANSWERS Tachycardia Q. What affect do Andrenergic Agents cause in the respiratory system? ANSWERS Bronchodilation Q. What affect do Adrenergic Agents cause in the peripheral vascular system? ANSWERS vasoconstriction (causes increased BP) Q. What affect do Adrenergic Agents have on the eyes? ANSWERS pupillary dilation Q. What are side effects? ANSWERS Too much of a good thing Q. What is another name for Cholinergic Agents? ANSWERS Muscarinic Agonists Q. What affect do Cholinergic Agents have on the heart? ANSWERS slows the heart rate Q. What affect do Cholinergic Agents have on the colon? ANSWERS Stimulates peristalis (relaxes) Q. What affect do Cholinergic Agents have on the bladder? ANSWERS increases bladder tone (helps urination) Q. What affect do Cholinergic Agents on the eyes? ANSWERS pupillary constriction, decreased intraocular pressure Q. Diarrhea, frequent urination, and blurred distance vision are all side effects of which agent? ANSWERS Cholinergic Agents Q. What medicine blocks the Parasympathetic Nervous System and doesn't stimulate the Sympathetic Nervous System? (aka a Cholinergic Blocker) ANSWERS Anticholinergic Agents Q. Which ANS agent is used prior surgeries to dry out mucous membranes? ANSWERS Anticholinergic Agents Q. Another name for an Anticholinergic Agent is a _______. ANSWERS Cholinergic Antagonist Q. What affect do Anticholinergic Agents have on the cardiac system? ANSWERS mild increase in pulse rate Q. What affect do anticholinergic agents have on the respiratory system? ANSWERS mild bronchial dilator Q. T/F: Anticholinergic Agents are used as a treatment for conditions requiring total bronchodilation. ANSWERS False Q. What affect do Anticholinergic Agents have on the mucous membranes? ANSWERS decrease salivation (drys them out) Q. T/F: Prior to surgery Anticholinergic Agents are given to prevent aspiration during the procedure. ANSWERS True Q. What affect do Anticholinergic Agents have on the colon? ANSWERS decreases GI motility Q. What affect do Anticholinergic Agents have on the eyes? ANSWERS pupillary dilation Q. Decreased urination, decreased defecation, decreased saliva, and decreased (poor) vision are all side effects of which ANS agent? (can't pee, can't see, can't spit, can't shit) ANSWERS Anticholinergic Agents Q. Cholinergic Agents can also be known as ______________. ANSWERS Parasymathomimetics Q. Normal body flora are found where? ANSWERS Bowels, upper respiratory tract, skin, vaginal vault Q. _________ are the normal body flora found in the bowels. ANSWERS Probiotics Q. What WBC type increases within the 24 hours of infection? ANSWERS neutrophils Q. What WBC type is present with an allergic reaction? ANSWERS eosinophils Q. What WBC type appears during the healing process? ANSWERS basophils Q. What WBC type appears late in the inflammatory process and with chronic inflammation? ANSWERS lymphocytes Q. What WBC is known for digesting things? ANSWERS monocytes The nurse recieves paper charting that claims there was a "shift to the left" in the Complete Blood Count (CBC) w/ WBC differetial. The nurse knows this means: There has been an increase in neutrophils indicating an infection What is the purpose of bone marrow producing bands? Bands of WBCs are produced to create as many WBCs as possible to fight the infection The nurse notes redness, warmth, edema, and pain around a cut. The nurse knows this is an example of a ________ reaction. local reaction A reaction throughout an entire body system is known as a ___________. systemic reaction Leukocytosis (increased WBCs), fatigue, fever, enlarged lymphnodes, and confusion in elderly patients are all symptoms of a __________________________. systemic reaction A healthy (non-immunocompromised) individual presents symptoms of an infection following a procedure. The nurse knows most noscocomial infections in health individuals come from _____________. invasive procedures How can a health care asccoicated infection be transmitted through an antibiotic? incorrect or inappropriate administration A nursing student knows both _______ and ____________ populations can be compromised hosts due to age. newborn and elderly T/F: Nutritional deficiencies can lead to higher susceptiblilty of infection. True T/F: A healthcare providers failure to adhere to infection and prevetion control activities (PPE, infection control guidelines, etc.) can lead to patient infection. True T/F: An individuals exposure to the healthcare system doesn't make them a compromised host. False T/F: A patient who has chronic coexisting medical conditions is a compromised host. True T/F: Physiological Stress isn't a factor that leads to an individual becoming a compromised host. False Antibotics that kill only a few bugs are known as a ____________ antibiotic. narrow spectrum The antibiotic that kills everything, including normal body flora, is known as a _______________ antibiotic. broad spectrum The nurse knows a patient will need antibiotics but doesn't have the results from the culture yet. The nurse knows they should begin the patient on _________ spectrum antibiotics and then move to __________ spectrum when the results come back. Broad, Narrow A ________________ antibiotic kills bacteria by breaking open the cell wall of germs. baceriocidal A ___________ antibiotic limits the growth of bacteria so the body processes can eliminate them. bacteriostatic The nurse is giving antibiotics for gram-negative bugs. The nurse knows that killing gram-negative bugs is ______ than gram-positive due to an extra layer on the gram-negative cell wall. harder T/F: a culture should be obtained AFTER starting the antibiotic. False (obtaining a culture after antibiotic administration will result in the issue being masked) The nurse is administering antibiotics to a patient. The order states that the antibiotic should be given TID. The nurse knows that it is important to administer an antibiotic at regular intervals to ensure even distribution. This being said, the nurse should give it q ____ h. (this is allegedly a test question per Rayman) 8 When educating a patient about antibiotic use, it is important for the nurse to stress the importance of ________________ even after symptoms subside. Not doing so can lead to reinfection or antibiotic resistance. taking all of it When giving a broad spectrum antibiotic it's important to monitior for a __________ or a secondary infection. suprainfection T/F: The interaction between oral contraceptives and antibiotics can block the effectiveness of the contraceptive. True The nursing student knows that all forms of __________ because the end in the suffix -illin. penicillin T/F: Penicllin is baceriostatic. False (bactericidal) T/F: Penicillin is prone to bacterial resistance. True (it's been around for a long time) T/F: Penicillin has a high prevelance of allergic reactions. True T/F: Penicillin should be taken with food. False (patient should take on an empty stomach q 1 h ac) A patient has an allergic reaction featuring a red rash all over the body and possible breathing problems. The nurse knows this indicative of: Penicillin Allergic Reaction An immediate penicillin allergic reaction happens in ______. 2-30 minutes An accelerated penicillin allergic reaction happens in __________. 1-72 hours A late penicillin allergic reaction happens in _________. days or weeks A patient is having an allergic reaction R/T penicillin. The nurses first action should be: stop administration To decrease swelling after an allergic reaction to penicillin the nurse should give: epinephrine and antihistamines T/F: If penicllin is the best treatment for the bug, a physician could order benadryl to take with the penicillin to stop the allergic reaction. True A nursing student is identifying Cephalsporins, the student knows that all forms begin with the prefix _________. Cef- There are ______ generations of Cephalsporins. 4 The nurse knows that cephalsporins can penetrate the extra layer on a gram-negative bug, making them ____________. bactericidal Allergic reactions, bleeding, thrombophelbitis are all ADRs of which antibiotic? Cephalosporins The first generation cephalosporins combat gram-__________ bacteria, and are _________ spectrum. postive, broad Second genertion cephalosprins combat gram-_________ and some gram-______________ bacteria. They are _____________ spectrum. positive, negative, broad Cephalosporins can penetrate ___________ an extra envelope on gram-negative bacteria. beta-lactamase Third generation cephalosporins combat gram-___________ and some gram-_____________ bacteria. They are _________ spectrum. negative, positive, broad Fourth generation cephalosporins combat gram-___________ bacteria and are _____________ spectrum. negative, broad T/F: Third generation cephalosporins can enter the cerebrospinal fluid. True T/F: Fourth generation cephalosporins cannot enter the cerebrospinal fluid. False T/F: Cephalosporins are similar in structure to penicillins. True A patient has been prescribed tetracyclines, the nurse knows these are ___________ spectrum. broad T/F: Tetracyclines deal only with gram-negative bacteria. False (gram-positive AND gram-negative) The nurse is caring for a client with the following vital signs: temp 101.4F, pulse 105, pulse ox 99%, respiration rate 20, blood pressure 125/71. The nurse would suspect which of the following labs to be elevated? - Red Blood Cells - White Blood Cells - Platelets - Complete Blood Count White Blood Cells (increased when infection is present) The nurse is caring for a client who is receiving penicillin. For which of the following side effects should the nurse monitor? Select all that apply. - A decrease in WBCs and Platelets - Diarrhea - Constipation - Renal Failure - Allergic Reactions (rash and/or anaphylaxis) A decrease in WBCs and platelets, diarrhea, allergic reactions (rash and/or anaphylaxis) The nurse is administering a cephalosporin to a client following a sinus infection. Which of the following are side effects associated with this medication? Select all that apply. - vaginal cadidiasis - abdominal cramps - constipation - diarrhea - blood clotting tedencies vaginal cadidiasis, abdominal cramps, diarrhea T/F: Tetracyclines are bacteriostatic. True For the purpose of absorption, the nurse knows tetracyclines should be taken ___________. on an empty stomach Tetracyclines inhibit _____________. protein synthesis A client is being prescribed doxycylinen (tetracycline) and the nurse knows that which of the following would be a contraindication for this client? - pregnancy - history of headaches - renal failure - peptic ulcers pregnancy Calcium, iron, magnesium, aluminum, zinc, and all dairy products do not interact well with what antibiotic? tetracyclines The nurse knows due to ___________ or sensitivity to light/sun, patients should be educated on sun protection measures when taking tetracyclines. photosensitivity What population are tetracyclines contraindicated in? pregnant women, nursing women, and children under 8 years (remember the acronym PNC) Tetracylines can ___________ childrens permenant teeth. discolor Tetracyclines can _________ women's bones. weaken A patient taking tetracyclines also wears contact lenses. The patient tells the nurse that they are experiencing unusual colored vision. The nurse knows this is because tetracyclines: stain contact lenses A nursing student is identifying different types of tetracyclines. The student knows they can identify these by the suffix ____________. -cyclines A nursing student is identifying macrolides. They know all macrolides end in the suffix ______________. -thromycin Macrolides stop the growth of bugs so they can be killed by body processes. Therefore the nurse knows macrolides are _____________ bacteriostatic Macrolides are a ___________ spectrum antibiotic. broad T/F: Macrolides are often used on patients who are allergic to penicillins (or cephalosporins) True T/F: Penicillins cannot cross the Blood Brain Barrier false Erythromycin is the poster child of which antibiotic? macrolides A patient with liver injury is prescribed Macrolides. The nurse should call the physician because they know macrolides can cause _____________ in patients with liver injuries. kidney failure T/F: gastrointestinal issues are an ADR of macrolides. True A client comes to the office because of side effects of their prescription for tetracycline. The nurse would expect to see which of the following on assessment? - Additional teeth - Tooth loss - Discoloration of permanent teeth - Gingivitis discoloration of permenant teeth A nurse is giving a client education on tetracycline use and asks about other medications that the client takes. The nurse would be concerned by which of the following other medications being used with tetracyclines? Select all that apply. - iron - probiotics - antacids - tylenol - anticogulants iron, antacids, anticoagulants A client is being prescribed a tetracycline and asks the nurse about names of tetracycline medications. The nurse knows that which of the following medications is NOT a tetracycline? - Demeclocycline - Doxycycline - Minocycline - Oxytacyclone Oxytacyclone Peak and trough are used to monitor ___________ levels in the body. blood Peak should be drawn ____________ medication administration. 30 minutes after Trough should be drawn __________ medication administration. immediately before Aminoglycosides are a subset of which antibiotic? macrolides Aminoglycosides can be identified by the suffix __________. -mycin Due to poor oral absorption aminoglycosides are usually administered via _______. IV Aminoglycosides are used mostly for gram-_____________. negative (aerobic bacilli) Aminoglycosides are a ___________________ spectrum antibiotic. narrow Since they kill gram-negative bacteria, aminoglycosides are ____________. bacterilcidal Aminoglycosides must have __________ and ___________ drawn to gauge their therapeutic range due to their high toxicity peak and trough The ADRs of aminoglycosides are _______________ and ___________. neprotoxicity (kidney toxcity) and ototoxicity (hearing loss) A client receiving medication as an anti-infective starts showing signs of nephrotoxicity. The nurse knows that which of the following are signs of nephrotoxicity? - Low blood pressure - Hearing loss - Fluid retention - Decreased urine output - Increased urine output fluid retention, decreased urine output The nurse is caring for a client that is receiving aminoglycoside. The nurse knows to assess the client for which of the following adverse effects? - Vomiting - Ototoxicity - Nephrotoxicity - Fever - Heart burn nephrotoxicity, ototoxicity Sulfonamides always begins with the prefix _______________. sulf- Hypersensitivity, blood dyscrasias, and rash are all ADRs of which antibiotic? Sulfonamides and Trimethoprim Sulfonamides and trimethoprim treat _____________ caused by E. coli and community acquired ____________. UTIs, MRSA (CA-MRSA) A patient is receiving a sulfonamide for treatment of a UTI. The nurse knows this is a ____________ spectrum antibiotic. broad Because they suppress bacterial growth, sulfonamides and trimethoprim are considered ______________ antibiotics. bacteriostatic What do sulfonamides and trimethoprim inhibit? folic acid The nurse is administering antibiotics to a patient. The order states that the antibiotic should be given TID. The nurse knows that it is important to administer an antibiotic at regular intervals to ensure even distribution. This being said, the nurse should give it q ____ h. (this is allegedly a test question per Rayman) 8 Water moves from compartment to compartment ___________________ than electrolytes. differently What percent of the body is water? 50-80% 1 liter of fluid = ________ lbs 2.2 2.2 lbs = _________ L of fluid 1 T/F: the percentage of water in the body is age dependent. True T/F: Fat holds more water than muscle. False T/F: Men hold more water than women. True Why do men lose weight faster than women? Men have more muscle than women A nursing student is reading the chart for a balanced intake and output. The perfect total in mL of intakes and outputs is: 2500 A nursing student is measuring a patients outputs, the student knows proper kidney function is ____ mL per 1 kg per hour. 1 Intracellular fluid is ___________ of body fluid. 75% Extracellular Fluid is ___________ body fluid. 25% Of the extracellular fluid _______% is intravascular. 5 Of the extracellular fluid _______% is in the interstitial space (third space). 20 The nurse needs to obtain a fluid status on a patient. The nurse knows the only way to get this is through what? Blood Volume Which part of the brain is responsible for thirst? hypothalamus What are thirst receptors called? Osmoreceptors When plasma high in solutes move past osmoreceptors what is stimulated? thirst Water moves from _________ concentration of solutes to a ____________ concentration of solutes. low, high Water moves by ________________. osmosis Electrolytes move by ____________. diffusion Diffusion happens by moving from a _______________ concentration to a _______________ concentration. high, low _____________ run fluid control. kidneys Kidney function adjusts output by which two hormones? antidiuretic (ADH) and Aldosterone T/F: When kidneys don't have enough fluid, they secrete ADH to retain fluid (stop peeing). True T/F: Kidneys require 25% of hearts output. True A nursing student is discussing the two hormones that work with kidney function with a peer. The student knows that the hormone that does the following is ______. - works with fluid volume deficit - stimulates the posterior pituitary - releases "anti-urine" hormone - stimulates the kidneys to reabsorb water antidiuretic hormone (ADH) If the heart is not receiving 25% of the total cardiac output, which hormone is secreted? antidiuretic hormone (ADH) ______________ is the hormone that causes sodium conservation, therefore making the body conserve water. aldosterone ACE stands for what? angiotensin-converting enzyme Aldosterone does which of the following? - Is stimulated as the juxtaglomerular (JG) cells response to decreased blood pressure/volume - stimulates the renin angiotensin feedback loop - conserves sodium which then causes water conservation - all of the above all of the above The nurse has a patient who has lost a large amount of water. The nurse knows this patients renal perfusion will ___________ because of this decrease The nurse has a patient who has lost a large amount of water. The nurse knows this patients renal blood pressure will _______________ because of this. decrease The nurse has a patient who has lost a large amount of water. The nurse knows the patients glomerular filtration rate will____________ because of this. decrease A patient who presents with low fluid intake will have a(n) _________________ in ADH secretion. increase A patient's urine output will _____________ as a result of extreme fluid loss. decrease A patients aldosterone level will _________________ as result of extreme fluid loss. decrease When experiencing significant fluid loss a patients blood pressure will first ____________. After this the patients blood pressure will _________________. decrease, increase The best way to assess fluid balance and maintain it is by collecting ____________. daily weights 1 kg of weight = ________ L of fluid 2 1 lb = ________ mL of fluid 500 IV fluids, drips, drinks, and irrigation fluid are all examples of what? intake Urine, vomit, NG suction, diarrhea, and sweat are all examples of what? output The normal range of BUN is _______ mg/dl 8-20 The normal range of creatinine is ___________ mg/dl 0.6-1.3 The percentage of actual blood cells in the blood stream is the __________ level. hematocrit The more solutes present in the blood the _____________ the hematocrit level is. higher Fluid Volume Deficit is also known as __________. dehydration Decreased fluid volume is known as ______________. hypovolemia What two groups are most susceptible to dehydration? infants and elderly Loss of GI fluid, fever, increased respiratory rate, and diuretics are all factors that contribute to ____________. increased loss of fluid (leads to a fluid volume deficit) How much fluid is in your GI tract? 6-8 L T/F: decreased intake from factors such as nausea, anorexia, inability to swallow, and confusion can contribute to a Fluid Volume Deficit. True When more than 2% of the body weight has been lost in fluids ____________ symptoms occur. dehydration Paleness, skin turgor, increased HR, decreased BP, respiratory rate, sunken eyes and cheeks, dry mouth and tongue, dizziness, muscle weakness and tired ness are all symptoms of what condition? dehydration When fluid loss reaches ______% hypovolemic shock occurs. 20 T/F: confusion and extremely high vitals are examples of hypovolemic shock. True Acute weight gain of 5% is a sign of what? Hypovolemia T/F: When considering risk factors for Fluid Volume Excess, renal failure and decreased cardiac output will increase urinary output. False (decrease) Jugular venous distension, congestive heart failure, pulmonary edema, full bounding pulses, High BP, weight gain, peripheral edema are all signs of what condition? Fluid Volume Excess (caused by fluid retention) The nurse has a patient who presents with signs of fluid volume overload, without edema. How is this possible. The patient has fluid in the third space A student nurse hears a nurse tell another nurse during report the patient is "dry on the inside, but wet on the outside." The student knows this means their is fluid in the ___________ of the body. interstital space (third space) T/F: third spacing occurs because fluid doesn't correctly transfer between the vascular space and the cells causing it to sit in the space between. True A decrease in colloid pressure is a lack of _____________ in the blood vessels. protein A nursing student is looking at a care plan for a patient with insufficient albumin levels. The student knows this will cause fluid to do what? leak into the interstitial (third) space A balance of fluid and electrolytes between the vascular space and the cells is ____________. isotonic When there is more water than solutes present in the vascular space it is considered ______________. hypotonic An isotonic saline solution is ________%. 0.9 The patient has a hypotonic concentration in the vascular space, the nurse should give a ___________% saline. 0.45 When there is high solutes in the vascular space this is considered _______________. hypertonic The patient has a hypertonic concentration in the vascular space. The nurse knows they should give a ______% saline to balance this out. 3 Potassium lives where in the body? cells Since we can't check cell levels we must check ___________ levels for potassium concentration. blood Potassium is a major intracellular ______________. cation For potassium, the range of normal intravascular concentration is _________ mEq. 3.5-5 If you don't have potassium, _________ can't be moved into the cells. solutes Potassium excess is known as ___________. hyperkalemia IV replacement therapy, multiple blood transfusions, and taking a potassium supplement without a need for it can cause _________ intake of potassium. This contributes to hyperkalemia. excess T/F: Decreased loss of potassium is caused by potassium-sparing diuretics and renal failure. Due to this, hyperkalemia can occur. True In the gastrointestinal system, _________,____________, __________ and ___________ are symptoms of hyperkalemia. nausea, vomiting, diarrhea, hyperactive bowel sounds In the CNS ____________ and _________ are signs and symptoms of hyperkalemia. This is often described as a feeling of "pins and needles". numbness, paraesthesia _____________ makes muscles contract. In addition the muscles are irritable and produce hyperactive reflexes during this condition. hyperkalemia In the cardiac system ______________ causes ventricular fibrillation, which causes extreme muscle contraction therefore cardiac arrest. hyperkalemia _________ is a symptom of hyperkalemia as it relates to the kidneys. oliguria T/F: Monitoring blood levels and signs and symptoms is not a nursing intervention for hyperkalemia. False (it is) A nursing intervention for decreased kidney function due to hyperkalemia is insulin & dextrose infusion. While this doesn't fix the problem, it hides potassium ___________ to prevent it from affecting the heart. inside the cells The nurse gives an Ion Exchange Resin Enema. The nurse knows this will cause what to happen to potassium? gets sucked into stool for excretion T/F: dialysis cannot be used as an intervention for hyperkalemia. False Hypokalemia means what? potassium deficiency The provider orders an electrolyte replacement on a client with a potassium of 2.4. The nurse knows that this potassium level could be caused by which of the following? (select all that apply) - dehydration - vomiting - diarrhea - excess potassium intake - loop diuretics vomiting, diarrhea, loop diuretics When treating hypokalemia or hyperkalemia the top priority during treatment is protecting the __________. heart When treating hyponatremia or hypernatremia the top priority during treatment is protecting the __________. brain A client with hypotension is in the emergency department being evaluated. The client's sodium level has come back at 148 mmol/L. What interventions by the nurse would be most appropriate? Select all that apply. - Administer hypertonic solution IV as ordered - Perform neurological assessments at least every 4 hours - Limit oral intake of sodium - Encourage water intake perform neurological exam at least every four hours, limit oral intake of sodium, encourage water intake When presenting with hypokalemia a patients kidneys are not good at what? conserving potassium Hypokalemia can be causes by decreased intake, the two main examples of this are: failure to replace losses (of potassium) and decreased food and fluid intake Hypokalemia can be caused by increased loss. These loses can come from: vomiting, diarrhea, potassium losing diuretics, long-term steroid use T/F: Oliguria is present only in hyperkalemia and not hypokalemia. False (presents as a cause or symptom in both) Affects of hypokalemia on the ___________ system are caused by anorexia, nausea, and paralytic ileus. gastrointestinal Affects of hypokalemia on the __________ include lethargy, confusion, and diminished deep tendon reflexes. CNS T/F: Hypokalemia's affect on the muscles include weakness and paralysis. True The nurse is reading the EKG of a patient with a K+ level of 2.4. The nurse knows dysrhythmias and T-waves appearing like a flattened "U" wave. The nurse knows this is an indication of ___________. hypokalemia Decreased capacity to concentrate urine from hypokalemia causes ________ damage. renal The key to reversing hypokalemia is ____________ potassium. replacing Angi/o vessel stasis to stop cyte cell Hem/o, -emia blood Hypoxemia (low oxygen), hematosalpinx (blood in the uterine tubes) Atherosclerosis hardening of the arteries myocardial infarction An infarction is blockage of blood flow resulting in death of muscle tissue. heart attack. Arrhythmia/dysrhythmia Abnormal heart rhythm Ischemia Lack of blood supply to the heart Hematologist a physician specializing in diseases of the blood Electrocardiogram (ECG/EKG) - a printout recording of the electrical activity of the heart. A frequently used instrument in the hands of a cardiologist. Echocardiography using ultra high frequency sound waves (beyond human hearing), similar to "sonar," to form an image of the inside of the heart. This procedure can demonstrate valve damage, congenital (before birth) defects and other abnormalities. Cardiac catherization a long hollow tube, a catheter, can be threaded into an artery up into the heart. Then material opaque to X-rays can be released into the blood flow through the heart imaging the details of coronary arteries. Typically used to identify a blockage and location in the coronary circulation. Phlebotomist/venipuncturist the specially trained nurse or technician draws blood for lab tests and may also start IV's (intravenous fluids). The Greek and Latin versions of "cutting into a vein." Previous stenosis narrowing of a heart valve passageway ADPIE Assess, Diagnose, Plan, Implement, Evaluate does patient have issues with ABC? Airway, Breathing, Circulation Maslow's Hierarchy of Needs (level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization Tanner's Clinical Judgement Model Noticing Interpreting Responding Reflecting Subjective Data things a person tells you about that you cannot observe through your senses; symptoms Objective data vital signs Cognitive perceptual pattern questions date, year, who is the president biographical data age, gender, marital status, occupation, address,type of healthcare Back Channeling includes active listening prompts such as "all right", "go on", or ""uh-huh". Closed Ended Questions Can be answered with Yes or No what is the nursing actions needed for a 50 y/o M pt who is 2 days post surgery for a gallbladder removal, reporting pain and oozing noted from the surgical site? 1. Gather information about the problem 2. identify the exact problem 3. plan appropriate nursing action 4. perform the required nursing action 5. evaluate the outcome Setting the stage patient centered interview - greet with patients full name - introduce themselves - shutting doors or closing curtains - explain reasoning for conducting the interview R/T Related to AEB as evidenced by Nursing Diagnosis Problem R/T excessive secretions AEB Evidence "Risk for" nursing diagnosis always last Concept Map Nursing diagnosis, goal, intervention Encephal/o inside the head (brain) Mening/o Membranes surrounding the brain and spinal cord Myel/o Spinal Cord Neur/o Nerve Dys Difficult, painful, abnormal -cele Hernia, abnormal protrusion of structure out of normal anatomical position -pathy Disease, abnormality -plasia Development, formation, growth -plegia Paralysis Cerebrovascular accident (CVA) stroke Aphasia loss of speech Neurologist a physician who treats physical disorders of the nervous system Electroencephalography (EEG image of the brains electrical activity Meningitis refers to inflammation of the membranes around the brain Neuropathy is a term describing a noninflammatory disease of nerves A meningomyelocele describes herniation of both protective membranes and spinal cord Which of the following procedures involves injecting a radioactive element into a patient’s vein that may mark the presence of a tumor? brain scan anencephaly baby born without a brain A patient may have a brain tumor, and the physician decides to use a procedure that will give the highest resolution of imaging soft tissues. He gives orders for MRI magnetic Resonance imagine A tumor of the protective membranes surrounding the brain and spinal cord is called a/an meningioma A patient suddenly has difficulty speaking and her right arm feels stiff and weak. After four hours, she has complete return of normal speech and movement. This patient most likely suffered a/an transient ischemic attack Cognitive Skills a skill that a nurse has, understands what they are doing, and understand rationale of why they are doing it. also understands the response from the patient, abnormal or normal. Ex. Doctor orders blood. Does the nurse know how to start blood, why they are getting blood, and an abnormal/ normal response. Interpersonal skills Theraputic Communication. Building a relationship with the patient. Communication skills. Psychomotor skills Hands on skills Ex. Hanging the blood Instrumental ADL activities to support daily life. Chores, shopping, managing financing, etc. ADL talking, brushing teeth, getting dressed, brushing hair, etc. You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? A. The patient will eat 80% of all meals. B. The nursing assistant will set the patient up for abath every day. C. The patient will have improved airway clearance by June 5. D. The patient will identify the need to increase dietary intake of fiber by June D The patient will... specific timing measurable Your patient has met the goals set for improvement of ambulatory status. You would now: A. modify the care plan. B. discontinue the care plan. C. create a new nursing diagnosis that states goals have been met. D. reassess the patient's response to care and evaluate theimplementation step of the nursing process. B because now that the patient has met the goal, you can discontinue and set a new goal. You have finished with several nursing interventions. To evaluate interventions, you need to examine the: A. appropriateness of the interventions and the correct application of the implementation process. B. nursing diagnoses to ensure that they are not medical diagnoses. C. care planning process for errors in other health care team members' judgments. D. interventions of each nurse to enable the nurse manager to correctly evaluate performance. A was the intervention relatable, good enough to achieve goal, etc. inference A conclusion reached on the basis of evidence and reasoning Consultation occurs most often during which phase planning data collection assessment dependent intervention you need an order Collaborative intervention ex. consult with dietitian on initial foods to offer patient independent nursing intervention education, assisting patient in taking a bed bath, repositioning a patient for relief of pain anything the nurse can do independently w/o orders interventions that require an order starting IV normal saline Xray administrating antibiotics NIC model domains, classes, and interventions 3 categories of nursing interventions 1. Nurse-initiated interventions (independent) 2. Physician-initiated interventions (dependent) 3. Collaborative interventions intermediate priority non life-threatening nursing sensitive patient outcome example of quality health care incidence of pressure injuries number of patient falls primary prevention administrating vaccine to infant education secondary prevention clinic nurse screening patient for diabetes interpersonal skills effective communication teritary prevention people who already have the disorder (prevents worsening or rolls back symptoms) what action does the nurse take right before implementing interventions REASSESS the PATIENT Self evaluation- reflect model R- recall the events, review the facts about a situation and describe what happened E-Examine your responses. Thoughts and actions at the time of a situation. F- Acknowledge feelings. Feelings you had during situation. L-Learn from the experience. Review and highlight what you learned from the experience E-Explore options- think about options for similar events in the future. C- create a plan of action- create a plan of action for similar situations in the future. T-set a time- set a time by which your plan of action will be completed. Concept map visual representation of patient problems and interventions that shows their relationships to one another Critical thinking Reasoning process by which you cognitively apply and analyze your thoughts, actions and knowledge to make sound clinical judgements. back channeling includes active listening prompts such as "all right", "go on", or ""uh-huh". Probing Open ended questions "What else is bothering you?" direct closed ended questions yes or no open ended questions Approach that does not lead to a specific answer Leading question a question worded to lead a respondent to give a desired answer Data clusters Organizing data elements about a patient into meaningful patterns. data interpretation Analyzing data to extract meaningful insights. The first step to treatment of hypokalemia is ___________ the reason the patient is losing potassium. stop When dealing with any sort of electrolyte (especially when imbalances are present) the nurse should ALWAYS: monitor the patients blood levels and signs and symptoms Two ways to replace potassium are ____________ and _____________. potassium-rich foods, oral potassium T/F: oral potassium should be taken without food. False (should be taken with food, it can cause GI bleeds) When administering potassium intravenously, is it safe to do an IV push? No (it can stop the heart) ___________ is an excess of Na+ in the body. hypernatremia The range of sodium in the body is ____________ mEq/L. 135-145 Increased water output such as diarrhea, diaphoresis, fever with increased respiration (water vapor), diabetes insipidus causes what electrolyte imbalance? hypernatremia T/F: too much intake of a 0.9% NaCl solution intravenously can cause hypernatremia. True In the gastrointestinal tract intense ________ can be present as a sign of hypernatremia. thirst T/F: red dry tongue, flush skin, non-elastic skin turgor, "sticky" membranes are symptoms of hyponatremia presented in the skin and mucous membranes. False (hypernatremia) A nurse is caring for a patient with hypernatremia. What can the nurse expect the patients attitude/demeanor will be like? agitated T/F: Anuria (failure to produce urine from the kidneys) and oliguria (minimal urine production) are affects of hypernatremia. True When treating hypernatremia the nurse knows they can give a hypotonic ________% solution of NaCl via IV. 0.45 T/F: oral intake will of fluids will not decrease the sodium level associated with hypernatremia. False (it will) Loss of Na+ without loss of water causes what electrolyte deficiency? hyponatremia Increased water intake such as Na+ free IV fluids and tap water enemas cause what condition? hyponatremia T/F: renal disease (failure) is the most common cause of hyponatremia. True Vomiting and irrigating and NG tube with water can cause increased _____+ loss, which causes hyponatremia. Na T/F: low sodium diets cause hypernatremia. False (hyponatremia) Finger printing on the sternum is an edema unique to which electrolyte imbalance? hyponatremia T/F: Disorientation, headaches, fatigue, absence of thirst, and abdominal cramping are all signs and symptoms of hypokalemia. False (hyponatreima) When treating a patient for hyponatremia the nurse knows _________ intake should be eliminated and replaced by a high ____________ intake. water, sodium A patient is on __________ precautions. They are placed in a room with negative airflow, staff must rare a N95 mask when in this room. airborne A patient on _________ precautions may infect others with their large _________ expelled 3 ft from the patient. Staff should wear a mask, gloves and perform hand hygiene. droplet, droplets Patients on ____________ precautions may infect others who come into contact with their infected fluids, or surfaces in the room that are contaminated. Staff wear gown and gloves. contact A room with positive airflow is known as a _______________ environment. protective __________ assumes all blood and body fluids are infectious. standard precautions T/F: medical asepsis is a STERILE technique. False (it's a clean technique) An area free of microorganisms and prepared to receive sterile items is a ________________. streile field A patient presents with a pressure ulcer that has intact skin and non-blanchable redness. The nurse should grade this what? Stage 1 The nurse assesses a patients pressure ulcer. The ulcer has partial thickness skin loss, epidermis and dermis, as well as blistering. The nurse should grade this: Stage 2 A nurse assesses a patients pressure ulcer. There is full thickness loss, the subcut fat is visible, but there isn't any bone or muscle showing. This is an example of what stage? Stage 3 A nurse is assessing a patient's pressure ulcer. There is full loss with bone showing. (also can present muscle or tendon) What grade pressure ulcer is this? Stage 4 When determining the size gauge necessary, the nurse knows the _________ the number on the gauge the ______________ it is. smaller, bigger When administering an intramuscular injection to the ventrogluteal site, what is the range for needle size? 1-1.5 inches The vastus lateralis, ventrogluteal, and deltoid are all sites for ____________ injections. intramuscular The outer posterior aspect of the upper arm, abdomen, anterior aspect of the thigh, scapular area of the upper back, and the upper ventral or dorsal gluteal areas are landmarks for __________ injections. subcutaneous An insulin syringe should have a gauge between ________ and a needle length of _______ inch. 25-31, 5/16-1/2 A intramuscular injection will utilize a 3 mL syringe. The gauge should be ________ and the needle should be _______ inch. 18-23, 1-1.5 For a subcutaneous injection the nurse will use a 1 mL syringe. The gauge should be between _________ and the needle should be ________ inch. 25-27, 3/8-5/8 For an intradermal skin injection the nurse will use a 1 mL syringe. The gauge should be ___________ and the needle should be _________ inch. 25-27, 3/8-5/8