NUR155 EXAM 2 2024-2025, Exams of Nursing

Download NUR155 EXAM 2 2024-2025 and more Exams Nursing in PDF only on Docsity! 1 | P a g e 1 | P a g e NUR155 EXAM 2 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND AND VERIFIED DETAILED ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS|ALREADY GRADED A+|NEWEST|GUARANTEED PASS |LATEST UPDATE What is fluid volume deficit? Dehydration in which the body's fluid intake is not sufficient to meet the body's fluid needs. S/S of fluid volume deficit low BP, less output, dry mucous membrane, brittle hair and nails, dehydration What is aldosterone? Increase water and sodium and puts back into bloodstream Normal urine output 30-80 mL/hr What is Anuria? absence of urine What is oliguria? low urine output What is polyuria? excessive urination What is normal level of BUN? 10-20 mg/dL What is the normal level of creatnine? 2 | P a g e 2 | P a g e Women 0.5-1.1 Men 0.6-1.3 What is stress incontinence? The loss or leaking of urine during exercise, sneezing, laughing, coughing, or when lifting something heavy. What is urge incontinence? overactive bladder/detrursor instability. sudden urge. frequent urination. What is mixed incontinence? combination of stress and urge incontinence What is functional incontinence? Occurs when the patient is unable to get to the bathrooom because of problems with immobility or other factors unrelated to bladder function What is overflow incontinence? cannot completely empty bladder What is temporary incontinence? caused by severe constipation, infection, or medication What is urinary retention? inability to empty the bladder What are factors that affect urinary elimination? Growth and development Disease conditions Sociocultural & Psychological - degree of privacy needed varies, anxiety, stress Fluid Balance Who are at risk for UTI? Elderly, immobile patient, women, foley What are some prevention of UTI? Underwear w/ cotton crotch, no tight clothes, drink 8-8oz water a day, hygiene What are the s/s of UTI? burning, frequency, fever, pain, elevated WBC, odor, and color of urine What are the different types of catheters? 5 | P a g e 5 | P a g e What is chronic illness? More than 6 months, requires ongoing long-term care What is social determinants of Health? Non-medical factors that influence health outcomes. Examples of social determinants of health? Age, gender, genetics and inherited traits, lifestyle, environment, attitudes and emotions, quality of education, and access to food What is the correct a patient should walk with a cane? Cane goes on the strong side, move cane out first, weak leg, and then strong leg Education for pt. with cane Cane should be at the level of hip, and arm should be bent, don't look at the ground What is the normal BMI? 18.5-24.9 What are Simple carbohydrates? fast acting sugar, starch and fiber. What are examples of simple carbohydrates? fruit, milk, table sugars, raisins What are complex carbohydrates? slow acting sugar, starch and fiber. What are examples of complex carbohydrates? pasta, bread, peas, lentil, grains What does pre-albumin and albumin indicate? mal-nutrition Iron green leafy vegetables and animal meat Calcium milk, mild product, tofu, soy products, green leafy vegetables Phosphorus dairy beans and meats 6 | P a g e 6 | P a g e Vitamin C citrus fruit, broccoli, brussel sprouts, tomatoes, Potassium bananas, avocado, sweet potatoes, white beans Proteins Lean meats, eggs, dairy, seeds and nuts, beans, and legumes and soy Vitamin A carrots, green leafy vegetables What are vegan at risk for? protein and calcium deficiency What places people at a higher risk for nutritional deficiency? Elderly patients, economic statues, religion, disease, diets, social factors, environment, mental health issues, dental issues, difficult swallowing or pain swallowing What is a full liquid diet? Foods liquid at room temperature or that melt at body temperature What is a clear liquid diet? any liquid you can see through What is a pureed diet? a modification of the soft diet; liquid may be added to the food, which is then blended to a semisolid consistency What is mechanical soft diet? Soft foods that you can chop up What are intervention for patient at risk for aspiration? Change diet, sit them up, have suction available What is enteral nutrition? nutrition goes directly into the stomach via some devise PEG tube or NGT. What are NG tubes used for short term or long term? Short term What are PEG tube used for short term or long term? 7 | P a g e 7 | P a g e Long term What is the most reliable way to check for nasogastric tube placement? X-ray Enteral feeding tubes are used for working or not working GI? Working GI Total parenteral nutrition is used for working or not working GI? Not working Gi Normal levels of Sodium 135-145 mEq/L What systems does sodium affect? Brain and muscle S/S of hyponatremia confusion, lethargy, weakness, muscle cramping, seizures, anorexia, nausea, vomiting, serum osmolality <290 Treatment of hyponatremia administer IV fluid with NA, eat foods with na, monitor vitals, I&O, labs, admin hypertonic IV saline solutions as ordered S/S of hypernatremia Thirst, dry sticky mucous membranes, weakness, elevated temp., osmolality >290 Treatment of hypernatremia Monitor vitals, LOC, labs, increase water intake, Na restricted diet, admin hypotonic IV solutions as ordered Normal levels of potassium 3.5-5.0 mEq/L What systems does potassium affect? Muscle, heart, GI S/S of hypokalemia weak, irregular pulse, fatigue, lethargy, anorexia, nausea, vomiting, muscle weakness/cramping, decreased peristalsis, hypoactive bowel sounds, paresthesia, cardiac dysrhythmias Treatment of hypokalemia 10 | P a g e 10 | P a g e 1. Assessing 2.Diagnosing 3. planning 4. implementing 5. evaluating what care plan do we mainly use as nurses? individualized care plan Initial planning you have your data, and then you begin your assessment. Macronutrients include what? water, carbs, proteins, fat, and vitamins. All macronutrients all measured in what? grams Micronutrients include what? some vitamins and minerals. Micronutrients measured in? milligrams and micrograms Monosaccharides include what? glucose, fructose, and galactose. absorbed in small intestines. Carb metabolism breaks it down and turns it into energy Glucose stored and use as glycogen Proteins amino acids, and helps and aids in tissue repair, building muscle, will give protein supplements if not getting enough protein Protein digestion beings? Mouth by pepsin Pancreas does what? secretes 11 | P a g e 11 | P a g e water soluble vitamins can not be stored. they need replaced daily. They are Vitamin C & B complex Fat soluble vitamins can be stored. vitamins a,d,e,k Macro minerals calcium phosphorus sodium magnesium sulfur Micro minearls iron zinc iodine floridine copper advance as tolerated allowed to increase diet to soft food, etc. as long as tolerated. do not have to call dr Clear liquid diet short. usually lasts 24-36 hours. ex: water, tea, jello, broth Soft diet easily chewed and digested. good for people who have trouble swallowing Full liquid diet liquids or foods that can turn into liquid by body temps. milk, ice cream, butter, eggs PEJ tube inserted in jejunum PEG tube inserted in stomach NG tube inserted in nose 1/4 cup of almonds will help ? 12 | P a g e 12 | P a g e cholesterol Older adults need? need protein, higher chloric diet, and higher calorie . metabolism slows down. water is _____% of body weight? 60 it is important to remove what from body? waste Extracellular fluid fluid outside the body. 1/3 of adult body fluid Intracellular fluid fluid inside the body. 2/3 of adult body fluid Diffusion separated by semipermeable membrane osmosis water moves across cell membrane from less concentration to more Normal urination per hour? 60 ml. less than 30 ml may show decreased blood flow to the kidneys Filtration build by hydrostatic pressure normal bowel movement daily? 100-200 ml How much ml is normal for output daily? 1500 ml Ascites fluid in the abdomen Normal sodium level? 135-145 normal potassium level 3.5-5 15 | P a g e 15 | P a g e Collect and compare data related to outcomes, relate nurse actions to client goats/outcomes, draw conclusion about problem status, continue/modify/terminate client care plan. Initial nursing assessment performed after admission to obtain baseline data All RN's are responsible for the initial admission assessment/vitals to give a base line Problem focused assessment Focus on 1 body system, the thing they are complaining of. IF they come into the ER with abdominal problems you wouldn't assess neurology Time lapsed reassessment Assessment done several months from the first assessment to check progress Roys adaptation model using data collection Gordons functional health pattern frame work assess and sees whether they are able to function or not, their ADL's. Orem's self-care model 8 universal health care needs Hyponatremia Loss of to much sodium, you want to take a patient down slowly. o Signs: Tired, confusion, muscle twitching, abdominal cramps, anorexia, N/V, HA, Seizures, coma. o Nursing interventions: Monitor I&O, lab data, encourage food and fluids high in sodium if possible Hypernatremia Gain of to much sodium o Signs: Thirst, decreased urine output/retaining, color change of urine, dry sticky mucosa membranes aka dry lips, tongue red dry and swollen, weakness. Would see Edema and Seizures big one. Early signs disorientation, fatigue and tired. Hypokalemia loss of potassium . o Signs: Muscle weakness, tired, weak/threaded pulse, N/V/D, decreased GI motility, cardiac dysrhythmias, depressed deep tendon reflexes Hyperkalemia 16 | P a g e 16 | P a g e too much potassium increased HR and cardiac changes. Anything over 5.5 can cause cardiac changes. o Signs: Paralyzed skeletal muscles, cardiac issues including dysrhythmias or arrest, cramping, muscle twitching, irritable, anxiety, Faster GI hyperactivity N/V/D, confusion o Nursing interventions: Monitor Cardiac status and ECG, administer diuretics, holt potassium supplements, monitor K levels and watch for a rapid drop. Hypocalcemia too little calcium. Can happen when the parathyroid gland is removed o Signs: look out for twitching in the check bone area this is called Positive Chvostek' and carpal spasm in response to inflating a BP cuff on o Nursing interventions = Monitor respiratory and cardiac status, admin oral calcium supplements, recommended for 1000-15000 mg per day. normal creatnine level in man 0.6-1.2 mg/dl male sperm can cause urine to look? cloudy concentrated urine is ________ gravity? higher specific gravity Urinary incontinence Involuntary leak or urine or loss of bladder control Stress incontinence - Weak pelvic floor muscle or urethral hypermobility; urine leak due to cough, sneeze, laugh, childbearing women, weight gain and sports injury. Embarrassing and uncontrolled. Urge incontinence need to urinate and inability to stop, triggered by sound of running water or nothing at all, can leak large amounts, have to urinate even when bladder not at capacity, over active muscle spasms of bladder. Struck with desperate need to go. Can be triggered by running water. PT has a chance of leaking large amounts of urine. Overactive bladder may have urge to go but may be able to hold it. They key with this is that your able to hold it but can interrupt your daily routine. Think of the gotta go gotta go commercial. Deficient fluid volume 17 | P a g e 17 | P a g e Dehydration or water loss alone without change in sodium Excess fluid volume increased fluid retention Risk for imbalanced fluid volume Refers to body fluid loss, gain or both Risk of deficient fluid volume N/V/D Impaired gas exchange Excess or deficit in oxygenation and/or CO2 elimination Impaired oral mucosa membrane fluid volume deficit Impaired skin integrity dehydration and edema Decreased cardiac output related to hypovolemia and/or cardiac dysrhythmias secondary to fluid imbalance. Ineffective tissue perfusion decreased cardia output secondary to fluid volume deficit or edema. Fluid volume deficit = Hypovolemia = Tinting/turgor If it doesn't come back down. Dry skin, pale, sunken eyes, dry oral cavity, lips are dry and cracked, delay in cap refills, decrease in bowl Fluid Volume excess =hypervolemia = edema, weight gain, crackles, distended abdomen, strong sounds from bowels b/c of so much excess fluid, increased BP, pulse bounding, over hydration. What are some things that affect flulid volume/electrolytes in older adults? 1. Decrease thirst 2. Decrease in fluids 3. Increased immobility 4. Increased diuretics 5. Medications (especially that cause constipation) a. Push fluids to help with constipation 6. All of these you need to encourage fluids! What things should be done before administering food and afterwards. through tubes: