Nur 3000 Questions With Complete Solutions

1. What is a CK cardiac test? - ANSWER measures the amount of an enzyme called creatine kinase (CK) in your blood. 2. T/F: the muscles in the body need CK to function? - ANSWER True 3. What is CK-MB useful for? - ANSWER Measures troponin levels in the blood to determine MI and cardiac damage 4. What is CK-MB, what is it used to Dx and when is it present - ANSWER Acute MI 5. What are invasive cardiovascular diagnostic tests? - ANSWER - Cardiac catheterization - Coronary angiography - Electrophysiology study - Intracoronary ultrasound - Blood flow and pressure measurement 6. What are the 4 heart valves? - ANSWER - tricuspid, - pulmonary, - mitral, - aortic 7. What is the purpose of the heart valve? - ANSWER to prevent regurge 8. What is valve stenosis? - ANSWER narrowing of a valve d/t thickened and stenotic valve leaflets 9. What causes valve stenosis? - ANSWER - Rheumatic fever - Congenital factors - Calcification 10. What are the 2 types of valve stenosis? - ANSWER - Mitral valve stenosis - Aortic valve stenosis 11. What is mitral valve stenosis? - ANSWER Narrowing of the mitral valve (left atrium to ventricle) 12. What does mitral stenosis cause? - ANSWER - Tachycardia - Decreased filling time - increased left atrium pressure and dilation - Change in refractory period - decreased CO - precipitate AFib 13. Define the trans nasal route - ANSWER - Rapid action of medication - Direct absorption via nasal mucosa 14. Define the transdermal route - ANSWER - Non - invasive - Delivers relatively stable plasma drug levels 15. Define the rectal route - ANSWER - Effective route for those with nausea, vomiting 16. Define the intraspinal route - ANSWER - Epidural or intrathecal - Superior analgesia medication use 17. What are some non-pharmacological pain management - ANSWER - Heat/ice - Acupuncture - Massage - Reposition 18. What is the composition of body fluids? - ANSWER - Water (primarily) - Electrolytes - Glucose - Urea - Creatinine 19. What are the 2 main mechanisms for regulating body water homeostasis? - ANSWER 1. Thirst 2. Excretion 20. What is the CNS regulation of body water homeostasis? - ANSWER - Hypothalamus - Baroreceptors 21. What is the endocrine regulation response to decreased blood vol? - ANSWER ACTH release ADH release RAAS activation 22. What is ACTH and what does it do for fluid regulation? - ANSWER - Aldosterone - Sodium reabsorption 23. What is ADH and what does it do for fluid regulation? - ANSWER - Antidiuretic hormone - Water reabsorption in renal tubules/collecting ducts 24. What is the RAAS and what does it do for fluid regulation? - ANSWER - Renin Angiotensin Aldosterone System - Converts angiotensin 1 to angiotensin 2 (ACE) causing vasoconstriction and aldosterone release 25. What is hypovolemia? - ANSWER A state of decreased fluid vol 26. What are nursing diagnosis for hypovolemia? - ANSWER - Fluid vol deficit - Ineffective tissue perfusion - Risk for injury - Decreased cardiac output 27. What are nursing interventions for hypovolemia? - ANSWER - Identify the problem and treat it - decrease vomiting, bleeding, diarrhea - increase fluid intake, PIV access - Administer IV solutions - Monitor fluid and electrolytes 28. 29. what is ECF vol deficits? - ANSWER - Hypovolemia - Abnormally low vol of body fluid - Produces extracellular dehydration - Leads to intracellular dehydration - Can occur slowly or rapidly What is the first fluid space? - ANSWER Normal distribution of fluid in ICF and ECF 30. What is the second fluid space? - ANSWER Abnormal accumulation of interstitial fluid 31. What is the third fluid space? - ANSWER Fluid accumulation in part of body where it is not easily exchanged with ECF - transcellular space 32. What is the primary goals of treatment related to hypovolemia? - ANSWER - Identify and control source of fluid loss - Correct fluid vol deficit by replacing fluids 33. T/F: we must replace the fluid one puts out to avoid fluid and electrolyte imbalance? - ANSWER True 34. What are the three types of solutions? - ANSWER isotonic, hypotonic, hypertonic 35. What are crystalloids and colloids? - ANSWER - Solutions of small molecules that can transport across cell membrane - Vol expanders as molecules remain in intravascular space - Often used for patients who can't have normal fluids 36. What is a isotonic solution? - ANSWER The concentration of solutes is equal inside and outside the cell so water moves across the membrane in both directions maintaining cell size 37. What is a hypotonic solution? - ANSWER the solution has a lower solute concentration than the cell so water moves into the cell 38. What is a hypertonic solution? - ANSWER The solution has a higher solute concentration than the cell so water moves out of the cell and into the solution 39. What is ECF vol excess? - ANSWER - Overhydration in the intravascular compartment - Excess fluid in the interstitial compartments - Water and sodium retained - Fewer contributing factors than for fluid vol deficit 40. What are clinical manifestations of overhydration? - ANSWER - Abnormally high vol of body fluid - Produces extracellular overhydration - Leads to intracellular overhydration - Can occur slowly or rapidly 41. True 42. T/F: Renal failure causes fluid vol excess - ANSWER What are physical nursing assessments for overhydration? - ANSWER - Mental status - Weight gain - Distended neck veins - Periorbital edema - Adventitious lung sounds - SOB - Generalized edema 43. What are the vital signs of a patient who is overhydration? - ANSWER - Elevated BP - Increased CVP and pulmonary artery pressures - Increased cardiac output 44. What are the lab values of patients who are overhydrated? - ANSWER - decreased hematocrit - Low serum osmolality - Low urine specific gravity 45. What is the treatment for overhydration? - ANSWER - Correct underlying cause - Restrict intake - Administer diuretics - Hemodialysis (if pt. is in renal failure) 46. How do diuretics help with overhydration? - ANSWER - Inhibits sodium and water absorption - increases urine output - monitor potassium levels 47. Why is it important to monitor potassium levels? - ANSWER Because high amounts can damage the heart What are nursing diagnosis for overhydration? - ANSWER - Fluid vol excess - Risk for for impaired skin integrity - Risk for impaired gas exchange What are cations? - ANSWER ions positively charged What are anions? - ANSWER negatively charged ions What are the 3 major extracellular electrolytes? - ANSWER - Sodium (Na+) - Chloride (Cl-) - Calcium (Ca+) What are the 3 major intracellular fluids? - ANSWER - Potassium (K+) - Magnesium (Mg+) - Phosphorus (PO4) What is the normal sodium range in the body? - ANSWER 135 145mEq/L