Med Surg Final Exam ivy tech Study Guide Solutions

Med Surg Final Exam ivy tech Study Guide Solutions Modifiable risk factors - Ans:-Choices that can be altered to better health such as: weight, tobacco use, alcohol use, corticosteroid use and sedentary lifestyle Assess the airway - Ans:-When a patient is deteriorating, this will be the nurse's number one priority. Systemic infection - Ans:-An infection located throughout the body such as: fever, nausea and vomiting, swollen lymph nodes, fatigue and rapid pulse/breathing Localized infection - Ans:-An infection located in a localized area only such as: pain, erythema, swelling, warmth and drainage Standard precaution - Ans:-The believe that all body excretions, secretions and moist membranes and tissues excluding perspiration are potentially infectious. Requires use of hand hygiene and gloves Contact precaution - Ans:-A precautionary measure requiring the use of a gown and gloves for patients who typically have: C. diff, MRSA/VRE, pediculosis, respiratory syncytial virus and scabies Droplet precaution - Ans:-A precautionary measure requiring the use of a gown, gloves and mask for patients who typically have: diphtheria, streptococcal pharyngitis, pneumonia, influenza, rubella, mumps and pertussis ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 2/46 Airborne precaution - Ans:-A precautionary measure requiring the use of a gown, gloves and N95 mask for patients who typically have: tuberculosis, measles, varicella Peripheral arterial disease - Ans:-The most appropriate position for a patient to relieve pain is in the dependent position for this disease Patient should not wear compression stockings if this condition is present Magnetic resonance angiography - Ans:-A diagnostic test for PVD that is commonly used to assess blood flow in the peripheral arteries with use of contrast medium to help visualize blood flow through arteries Doppler probe - Ans:-A diagnostic test for PVD that is a segmental systolic blood pressure measurement of lower extremities at the thigh, calf and ankle Blood pressure readings in thigh and calf are normally higher than readings on the upper extremities. If pressures are lower than the brachial pressure, arterial disease may be present Ankle-brachial index (ABI) - Ans:-A diagnostic test for PVD that is a comparison of ankle and brachial pressure. A reading of less than 0.90 in either leg is diagnostic of PAD. Patients with diabetes are known to have a falsely elevated reading ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 3/46 Plethysmography - Ans:-A diagnostic test for PVD used to evaluate arterial flow in the lower extremities. If an occlusion is present, the waveforms are decreased to flattened, depending upon degree of occlusion Peripheral venous disease - Ans:-The patient with this condition can wear compression stockings and must be educated to wear above the bend of the knee to avoid deterring circulation Heparin and warfarin - Ans:-Anticoagulants often given concurrently because warfarin depresses synthesis of clotting factors, but does not have an effect on clotting factors currently present Takes 3-4 days before the clotting factors that are present decay and the therapeutic effects of warfarin occur Fluid volume deficit - Ans:-Too little fluid leading to dehydration and hypovolemia Fluid volume overload - Ans:-Too much fluid leading to water intoxication and hypervolemia Fluid volume deficit: Cardiovascular - Ans:-When reference fluid volume, this condition present as: • Increased HR to help maintain BP with less blood volume • Weak peripheral pulses ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 4/46 • Orthostatic hypotension • Flattened hand and neck veins Fluid volume deficit: Respiratory - Ans:-When referencing fluid volume, this condition present as: • Increased respirations due to decreased blood volume reducing perfusion and gas exchange Fluid volume deficit: Skin - Ans:-When referencing fluid volume, this condition present as: • Poor skin turgor • Dry and scaly Fluid volume deficit: Neurologic - Ans:-When referencing fluid volume, this condition present as: • Mental status change Fluid volume deficit: Kidneys - Ans:-When referencing fluid volume, this condition present as: ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 5/46 • Decreased urine output • Increased specific gravity (concentration) Fluid volume overload: Cardiovascular - Ans:-When referencing fluid volume, this condition present as: • Increased pulse rate with bounding pulse quality • Elevated BP with decreased pulse pressure • Elevated central venous pressure • Distended neck/hand veins and engorged varicose veins • Weight gain Fluid volume overload: Respiratory - Ans:-When referencing fluid volume, this condition present as: • Increased respiratory rate • Shallow respirations • Shortness of breath ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 6/46 • Moist crackles present on auscultation Fluid volume overload: Skin - Ans:-When referencing fluid volume, this condition present as: • Pitting edema in dependent areas • Skin pale and cool to touch Fluid volume overload: Neuromuscular - Ans:-When referencing fluid volume, this condition present as: • Altered LOC • Headache • Visual disturbances • Skeletal muscle weakness • Paresthesias Fluid volume overload: Gastrointestinal - Ans:-When referencing fluid volume, this condition present as: ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 7/46 • Increased motility • Enlarged liver Low potassium (Hypokalemia) - Ans:-This electrolyte presents as: • Respiratory: weak muscles, decreased respiratory effort and hypoxia • Muscular: weak • Cardiovascular: weak and slow • Neurological: altered mental status and confusion • Intestinal: weak, N/V, peristalsis and hypoactive bowel sounds High potassium (Hyperkalemia) - Ans:-This electrolyte presents as: • Respiratory: nothing until lethal levels • Muscular: twitching leading to weakness/flaccid ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 8/46 • Cardiovascular: decreased HR and BP • Intestinal: increased motility and diarrhea Complete heart block - Ans:-A type of rhythm seen in an EKG effecting the heart drastically leading to asystole (flat line) Na+ - Ans:-When an NG is used for suctioning, this electrolyte is the biggest concern. Nurse should monitor for signs of this electrolyte shortage: LOC changes, mental status changes, weakness, lethargy, GI motility, N/V/D, decreased BP and blood volu