ADVANCED CLINICAL CONCEPTS

RESPIRATORY FAILURE:

1. What PO2 value indicates hypoxemia?

- Below 50 mmHg

2. What blood value indicates hypercapnia?

- PCO2 above 45 mmHg

3. Identify the condition that exists when the PO2 is less than 50 mmHg and FiO2
is greater than 60%.
- Hypoxemia

4. List 3 symptoms of respiratory failure in the adult.

- Dyspnea/tachypnea, intercostal retractions, cyanosis.

5. List 4 common causes of respiratory failure in children.

- Congenital heart disease, infection or sepsis. Respiratory distress syndrome,
aspiration, fluid overload or dehydration.

6. What percentage of O2 should a child in severe respiratory distress receive?

- 100% O2

SHOCK/DIC (DISSEMINATED INTRAVASCULAR CLOTTING):

1. Define shock.
- Widespread, serious reduction of tissue perfusion which leads to generalized
impairment of cellular function.

2. What is the most common cause of shock?

- Hypovolemia

3. What cause septic shock?

- Release of endotoxins from bacteria which act on nerves in vascular space in
periphery, causing vascular pooling, reduced venous return, and decreased cardiac
output, resulting in poor systemic perfusion.

4. What is the goal of treatment for hypovolemic shock?

- Quick restoration of cardiac output and tissue perfusion

5. What intervention is used to restore cardiac output when hypovolemic shock

exists?
- Rapid infusion of volume-expanding fluids
6. It is important to differentiate between hypovolemic and cardiogenic shock.
How might the nurse determine the existence of cardiogenic shock?
- History of MI with left ventricular failure or possible cardiomyopathy, with
symptoms of pulmonary edema.

7. If a client is in cardiogenic shock, what might result from administration of

volume expanding fluids, and what intervention can the nurse expect to perform
in the event of such an occurrence?
- Pulmonary edema, administer cardiotonic drugs such as digitalis preparations

8. List 5 assessment findings found in most shock victims.

- Tachycardia. Tachypnea. Hypotension. Cool clammy skin. Decrease in urinary
output.

9. What is the normal central venous pressure for an adult?

- 4 to 10 cm of H2O

10. Once circulating volume is restored, vasopressors may be prescribed to increase

venous return. List the main drugs that are used.
- Epinephrine (Bronkaid). Dopamine (Dopram). Dobutamine (Dobutrex).
Norepinephrine (Levophed). Isoproterenol (Isuprel).

11. What is the established minimum renal output per hour?

- 30 cc/hr

12. List 4 measurable criteria that are the major expected outcomes of a shock
crisis.
- BP mean of 80 to 90 mmHg. PO2 >50 mmHg. CVP above 6 cm of H2O. Urine
output at least 30 cc/hr.

13. Define DIC.

- A coagulation disorder in which there is paradoxical thrombosis and hemorrhage

14. What is the effect of DIC on PT, PTT, platelets, FSPs (FDPs)?
- PT: prolonged. PTT: prolonged. Platelets: decreased. Fribin split products:
increased.

15. What drug is used in the treatment of DIC?

- Heparin

16. Name 4 nursing interventions to prevent injury in clients with DIC.

- Gently provide oral care with mouth swabs. Minimize needle sticks and use the
smallest gauge needle possible when injections are necessary. Eliminate pressure by
turning the client frequently. Minimize the number of BPs taken by cuff. Use gentle
suction to prevent trauma to mucosa. Apply pressure to any oozing site.
RESUSCITATION:

1. What is the first priority when a client with an unwitnessed cardiac arrest is
found?
- Begin CPR

2. Define myocardial infarction.

- Necrosis of the heart muscle due to poor perfusion of the heart.

3. What criteria should alert a client with known angina who takes nitroglycerin
tablets sublingually to call the EMS?
- Unrelieved chest pain after 3 nitroglycerin tabs in 15 minutes.

4. After calling out for help and asking someone to dial for emergency services,
what is the next action in CPR?
- According to American Heart Association guidelines published September 2000, you
should call for help first for unresponsive adults and then begin the ABC’s of CPR.
For unresponsive infants & children, CPR should be performed for 1 minute before
placing a 911 call for help.

5. True or False: In feeling of presence of a carotid pulse, no more than 5 seconds

should be used.
- FALSE: palpate for at least 5 to 10 seconds, recognizing that arrythmias or
bradycardia could be occurring.

6. During one-rescuer CPR, what is the ratio of compressions to ventilations for an

adult? During one-rescuer CPR, what is the ratio of compressions to
ventialations for a child?
- 15:2 X 4 cycles for adult. 5:1 for a child and neonate.

7. What is the FIRST drug most likely to be used for an in-hospital cardiac arrest?
- Epinephrine

8. A client in cardiac arrest is noted on bedside monitor to be in pulseless

ventricular tachycardia. What is the first action that should be taken?
- Defibrillation with 200 to 360 joules.

9. True or False: A precordial thump is routine activity for an in-hospital cardiac

arrest.
- FALSE: only indicated in pulseless VT or VF or when ventricular asystole on
monitor responds to a thump with a QRS complex.

10. How would the nurse assess the adequacy of compressions during CPR? How
would the nurse assess for adequacy of ventilations during CPR?
- Check for a pulse. Watch for chest excursion and auscultate bilaterally for breath
sounds.

11. If a person is choking, when should the rescuer intervene?

- When the person points to his/her throat and can no longer cough, talk, or make
sounds.

12. One should NEVER make blind sweeps into the mouth of a choking child or
infant. Why?
- Because the object might be pushed further down into the throat.

13. Why do ACLS guidelines recommend a decreased reliance on the use of

bicarbonate during adult CPR?
- Because acidosis should be relieved with improved ventilation. Bicarbonate
administration can actually contribute to increased CO2.

FLUID AND ELECTROLYTE BALANCE:

1. List 4 common caused of fluid volume deficit.

- GI causes: vomiting, diarrhea, GI suctioning. Decrease in fluid intake. Increase in
fluid output such as sweating. Massive edema. Ascites.

2. List 4 common causes of fluid volume overload.

- CHF, renal failure; cirrhosis; excess ingestion of table salt or over-hydration with
sodium-containing fluids.

3. Identify 2 examples of isotonic fluids.

- Ringer’s lactate. Normal saline.

4. List 3 systems which maintain acid-base balance.

- Lungs. Kidneys. Chemical buffers.

5. Cite the ABG normals for the following: pH, pCO2, HCO3.
- pH: 7.35-7.45. pCO2: 35 to 45 mmHg. HCO3: 22-26 mEq/L

6. Determine the following acid-base disorders:

A. pH- 7.50, pCO2 – 30, HCO3 – 26 = Respiratory alkalosis
B. pH- 7.30, pCO2 – 42, HCO3 – 20 = Metabolic acidosis
C. pH- 7.48, pCO2 – 42, HCO3 – 32 = Metabolic alkalosis
D. pH- 7.29, pCO2 – 55, HCO3 – 26 = Respiratory acidosis

PERIOPERATIVE CARE:

1. List 5 variables that increase surgical risk.

- Age: very young and very old, obesity and malnutrition, preoperative
dehydration/hypovolemia, preoperative infection, use of anticoagulants preoperative
(aspirin)

2. Why is a client with liver disease at increased risk for operative complications?
- Impairs ability to detoxify medications used during surgery. Impairs ability to
produce prothrombin to reduce hemorrhage.

3. Preoperative teaching should include demonstration and explanation of expected

postoperative client activities. What activities should be included?
- Respiratory activities: breathing, use of spirometer. Exercises: range of motion, leg
exercises, turning. Pain management: medications, splinting. Dietary restrictions:
NPO to progressive diet. Dressings and drains. Orientation to recovery room
environment.

4. What items should the nurse assist the client in removing before surgery?
- Contact lenses, glasses, dentures, partial plates, wigs, jewelry, prosthesis, make-up
and nail polish.

5. How and why is the client positioned in the immediate postoperative period?
- Usually on the side or with head to side in order to prevent aspiration of any emesis.

6. List 3 nursing actions to prevent postoperative wound dehiscence/evisceration.

- Splint incision when coughing, encourage coughing/deep breathing in EARLY
postoperative period when sutures are STRONG. Monitor for signs of infection,
malnutrition, and dehydration. Encourage high-protein diet.

7. Identify 3 nursing interventions to prevent postoperative urinary tract

infections.
- Avoid postoperative catheterization. Increase oral fluid intake. Empty bladder q4 to
6 hours, early ambulation.

8. Identify nursing/medical interventions to prevent postoperative paralytic ileus.

- Early ambulation. Limit use of narcotic analgesics. NG tube decompression.

9. List 4 nursing interventions to prevent postoperative thrombophlebitis.

- Perform in-bed leg exercises. Early ambulation. Apply antiembolus stockings.
Avoid positions/pressure which obstruct venous flow.

10. During the intraoperative period, what activities should the operating room
nurse do to ensure safety during surgery?
- Ascertain correct sponge, needle, and instrument count. Position client to avoid
injury. Apply ground during electrocautery use. Strict use of surgical asepsis.

HIV INFECTION:
1. Identify the way HIV is transmitted.
- Transmitted through blood and body fluids, e.g., unprotected sexual contact with an
affected person, sharing needles among drug abusing persons, infected blood products
(rare), maternal to fetus transmission through breast milk, or breaks in universal
precautions (needle sticks or similar occurrences).

2. Vertical transmission (from mother to fetus) occurs how often if mother is

treated during pregnancy?
- Vertical transmission occurs 30 to 50% of the time.

3. Describe universal precautions.

- Protection from blood and body fluids is the goal of standard precautions. Standard
precautions initiate barrier protection between caregiver and client through: Hand
washing, use gloves, use gown and masks, eye protection as indicated, depending on
activity of care and the likelihood of exposure. Prevent needle sticks by not capping
needles.

4. What are the side effects of Amphotericin B?

- Side effects of amphotericin B (can be quite severe) include: Anorexia, Chills,
Cramping, Muscle and joint pain, Circulatory problems.

5. What does the CD4 T cell count describe?

- CD4 T cell count describes the number of infection-fighting lymphocytes the person
has.

6. Why does the CD4 T cell count drop in HIV infections?

- CD4 T cell count drops because the virus destroys CD4 T cells as it invades them and
replicates.

7. Describe the ways a pediatric client might acquire HIV infection.

- Through infected blood products. Through sexual abuse. Through breast milk.

PAIN:

1. What modalities are associated with the Gate control pain theory?
- Massage, heat and cold, acupuncture, TENS.

2. How does past experiences with pain influence current pain experience?
- The more pain experienced in childhood, the greater the perception of pain in
adulthood or with current pain experience.

3. What modalities are thought to increase the production of endogenous opiates?

- Acupuncture, administration of placebos, TENS.

4. What 6 factors should the nurse include when assessing the pain experience?
- Location, intensity, comfort measures, quality, chronology and subjective view of
pain.

5. What mechanism is involved in the reduction of pain through the administration

of NSAIDs meds?
- NSAIDs act by a peripheral mechanism at the level of damaged tissue by inhibiting
prostaglandin synthesis and other chemical mediators involved in pain transmission.

6. If narcotic agonist/antagonist drugs are administered to a client already taking

narcotic drugs, what may be the result?
- Initiation of withdrawal symptoms

7. List 4 side effects of narcotic medications.

- Nausea/vomiting. Constipation. CNS depression. Respiratory depression.

8. What is the antidote for narcotic-induced respiratory depression?

- Narcan (Naloxone).

9. What is the 1st sign of tolerance to pain analgesics?

- Decreased duration of drug effectiveness

10. Which route of administration for pain medications has the quickest onset and
the shortest duration?
- IV push or bolus.

11. List the 6 modalities that are considered non-invasive, non-pharmacologic pain
relief measures.
- Heat and cold applications. Transcutaneous electrical nerve stimulation (TENS).
Massage. Distraction. Relaxation techniques. Biofeedback techniques.

DEATH AND GRIEF:

1. Identify the 5 stages of death and dying.

- Denial. Anger. Bargaining. Depression. Acceptance.

2. A client has been told of a positive breast biopsy report. She asks no questions
and leaves the healthcare provider’s office. She is overheard telling her
husband, :the doctor didn’t find a thing.” What coping style is operating at this
stage of grief?
- Denial

3. Your client, an incest survivor, is speaking of her deceased father, the

perpetrator. “He was a wonderful man, so good and kind. Everyone thought
so.” What would be the most useful intervention at this time?
- Gently point out both the positive and negative aspects of her relationship wit her
father. Try to minimize the idealization of the deceased.
4. Your client feels responsible for his sister’s death because he took her to the hospital
where she died. “If I hadn’t taken her there, they couldn’t have killed her.” It has
been one month since her death. Is this response indicative of a normal or
complicated grief reaction?
- This is a normal expression of anger and guilt, which occurs. Try to minimize the
rumination of these thoughts.

5. Mrs. Green lost her husband 3 years ago. She has not disturbed any of his
belongings and continues to set a place at the table for him nightly. Is this
response indicative of a normal or complicated grief reaction?
- This is a dysfunctional grief reaction. Mrs. Green has never moved out of the denial
stage of her grief work.

ELECTROCARDIOGRAM:

1. Identify the waveforms found in a normal EKG?

- P wave, QRS complex, T wave, ST segment, PR interval

2. In an EKG reading, which wave represents depolarization of the atrium?

- P wave

3. In an EKG reading, what complex represents depolarization of the ventricle?

- QRS complex

4. What does the PR interval represent?

- The time rquired for the impulse to travel from the atria through the A-V node

5. If the U wave is most prominent, what condition might the nurse suspect?
- Hypokalemia
6. Describe the calculation of the heart rate using an EKG rhythm strip.
- Count the number of the R-R intervals in the 30 large squares and multiply by 10

7. What is the most important assessment data for the nurse to obtain on a client
with arrythmia?
- Ability of the client to tolerate the arrhythmia

8. Calculate the rate of this rhythm strip.

- 90 to 100 depending on which set of 6 squares you use.
GERONTOLOGICAL NURSING:

1. What are normal memory changes that occur as one ages?

- Short-term memory declines while long-term memory undergoes minimal change.

2. What symptoms might the nurse expect to see in an older person who has had an
overload of changes as well as a respiratory infection?
- Confusion.

3. Why can the BP of older adults be expected to increase?

- Heart work increases in response to increased peripheral resistance.

4. What is the major cause of respiratory disability in the elderly?

- COPD

5. List 5 nursing interventions to promote adequate bowel functioning for older

persons.
- Determine what is normal GI functioning for each individual, increase fiber and bulk
in the diet, provide adequate hydration, encourage regular exercise, and encourage
eating, small, frequent meals.

6. How can a female nurse increase the older client’s ability to hear her speak?
- Lower the pitch or tone of her voice.

7. What is the most common visual problem occurring in the elderly?

- Cataracts.

8. Describe the following conditions which occur in the elderly: Presbyopia, Arcus
senilis, Presbycusis.
- Presbyopia – decreased ability of the eye to accommodate for close work.
- Arcus senilis – glossy white ring encircling the periphery of the cornea
- Presbycusis – decrease in hearing acuity, auditory threshold, pitch and tone
discrimination, and speech intelligibility.

9. Describe the onset of Alzheimer’s disease.

- Slow, insidious onset with progressive downward course.

10. What is the purpose of a reality orientation group?

- To keep the client oriented to time, place, and person.

11. What are the 2 factors that cause decrease in excretion of drugs by the kidneys?
- Decrease in glomerular filtration and slowed organ functioning.