NR 324 Exam 1 Study Guide

Chapters 17, 26, 27, 28, 29, and ABG interpretation.

Fluid & Electrolyte

1. Potassium Chloride intravenous- care of patient, how much (meq/hr) is the infusion rate?(p.316)
Potassium Chloride intravenous can be administered to treat a patient with hypokalemia.
Except in severe deficiencies, KCL is never given unless there is urine output of at least
0.5ml/kg of body weight per hour
Safety Alert:
 KCL given intravenously must always be diluted.
 Never give KCL via IV push or in concentrated amounts.
 IV bags containing KCL should be inverted several times to ensure even distribution in the bag.
 Never add KCL to a hanging IV bag to prevent giving a bolus dose.
How much (meq/hr) is the infusion rate?
The preferred maximum concentration is 40 mEq/L; however, stronger concentrations may be given
for severe hypokalemia (up to 80mEq/L) with continuous cardiac monitoring.
The rate of IV administration of KCL should not exceed 10 to 20mEq per hour and should be
administered by infusion pump to ensure correct administration rate. Because KCL is
irritating to the vein, assess IV sites at least hourly for phlebitis and infiltration
o Infiltration can cause necrosis and sloughing of the surrounding tissue.
Central IV lines should be used when rapid correction of hypokalemia is necessary

2. ABG interpretation( do the practice questions that teacher gave& p324 & hesi 43,44)
An acid-base balance must be maintained in the body because alterations can result in alkalosis or
acidosis.
Maintain the acid –base balance involves 3 systems
 Chemical buffer
o The chemical buffer act immediately to prevent major change in the body fluid pH by
removing or releasing hydrogen ions.
 The main chemical buffer is the Bicarbonate-Carbonic acid (HCO3-
 H2CO30system.
 Normally there are 20parts of bicarbonate to 1 part of carbonic acid. If the
20:1 ratio is altered, the pH is changed( ratio is important not absolute
values)
 Carbonic acid (H2CO3) is form when carbon dioxide (CO2) combines
with water (H2O).
 Excess CO2 in the body alters the ratio and creates an imbalance. Other
buffer system involve:
o Monohydrogen-dihydrogen phosphate
o Intracellular and plasma protein
o Hemoglobin
 Respiratory system (lungs)
o The respiratory system responds in minutes and reaches maximum effectiveness in hours
 Control CO2 content through respirations (carbonic acid content)
 Control, to a small extent, water balance (CO2+H2O=H2CO3)
 Release excess CO2 by increasing respiratory rate.
 Retain CO2 by decreasing respiratory rate.
 The rate of the CO2 is control by the respiratory center in the medulla in the brainstem.
If the respiratory problem is the cause of an acid –base imbalance (e.g., respiratory failure), the
respiratory system loses its ability to correct a pH alteration.
 Renal system (kidney)
o The renal response takes 2 to 3 days to respond maximally, but the kidneys can maintain
balance indefinitely in chronic imbalance.
 Regulate bicarbonate levels by retaining and reabsorbing bicarbonate as needed.
 a very slow compensatory mechanism ( can require hour or days).
 Cannot help with compensation when metabolic acidosis is created by renal
failure
If the renal system is the cause of and acid-base imbalance (e.g., renal failure), it loses its ability
to correct a pH alteration.

Arterial Blood Gas (ABG) values provide valuable information about a patient’s acid-base status, the
underlying cause of the imbalance, the body’s ability to regulate pH, and the patient’s overall oxygen
status. (p. 324, shows the steps on how to diagnose acid disturbances and identification of compensatory
processes).

 Uncompensated respiratory Alkalosis with hypoxemia(Kidney clearance)

 Uncompensated Respiratory Acidosis with Hypoxemia
 Partially compensated Respiratory Acidosis
 Partially compensated Metabollic Alkalosis(Kidney and lungs are helping each other)
 Fully compensated Respiratory Alkalosis(Good prognosis)

Page44 hesi
Acid-base condition pH Pco2 HCO3
(mm Hg) (mEq/L)
Normal 7.34-7.45 35-45 22-26
Respiratory ↓ ↑ Normal
Acidosis
Respiratory ↑ ↓ Normal
Alkalosis
Metabolic ↓ Normal ↓
Acidosis
Metabolic ↑ Normal ↑
Alkalosis

 Respiratory
 Opposite
 Metabolic
 Equal
A. pH 7.50, pco2 30,HC03 26
B. PH 7.30, Pco2 42,HC03 20
C. pH 7.48, Pco2 42, HCO3 32
D. pH 7.29, Pco2, 55, HCO3 26 (Refer to Hesi page 46 for Answers)

3. Fluid volume deficit- assessment findings- which is most important?(p. 309 & hesi p.39)
Fluid deficit occurs when the body loses water and electrolytes isotonically, that is in the same
proportion as exists in the normal body fluid

Causes:
  Vomiting
 Diarrhea
 GI suctioning
 Sweating
 Inadequate fluid intake
 Massive Edema, as in initial stage of major burns
 Ascites
 Elderly forgetting to drink
 Diabetic insipidus
Assessment findings:
 Weight loss (1 pint of fluid loss=1pound of weight loss)
 Decreased skin turgor
 Oliguria (concentrated Urine)
 Dry and sticky mucous membranes
 Postural hypotension or weak, rapid pulse
Labs findings:
 Elevated BUN and creatinine
 Increased serum osmolarity
 Elevated hemoglobin and hematocrit
Treatment
 Strict I&O
 Replacement of fluids isotonically, preferably orally
Page 309 for mor info

4. Fluid Deficit- post burn- greatest concern

After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes
(success p.420)

5. Low serum protein level- implications

( I think of the Edema because you won’t have enough albumin to pull that water from the interstitial
space)

6. Hyponatremia- signs and symptoms, most important assessment findings and monitoring, care of
patient (p. 313hesi p.40)
 The normal sodium is 135-145
 Sodium is the main cation of the ECF
 Play a major role in maintaining the concentration and volume of the ECF.
o Therefore, sodium is the primary determinant of ECF osmolality. Sodium affects the
water distribution between ECF and ICF.
 Sodium is also important in the generation and transmission of nerve impulse and the regulation
of acid-base balance.
 The GI tract absorbs sodium from food.
 Sodium leaves the body through urine, sweat, and feces.
 The Kidneys are the primary regulator of sodium balance.
o The kidney regulates the ECF concentration of sodium by excreting or retaining water
under the influence of ADH.
  Aldosterone also plays a big role in sodium regulation by promoting sodium reabsorption from
the renal tubules.
o Aldosterone (p.1206): is a potent mineralocorticoid that maintains extracellular fluid
volume. It acts at the renal tubules to promote renal reabsorption of sodium (Na+) and
excretion of potassium (K+) and hydrogen ions (H+).
 Changes in the serum of sodium level may reflect a primary water imbalance, a primary sodium
imbalance, or a combination of the two. Sodium imbalances are typically associated with
imbalances in ECF volume.

Hyponatremia

 Patho:
 Causes:
o may result from loss of sodium-containing fluids
o from water excess(dilutional hyponatremia)
o or combination of both
 Nursing implementation or treatment:
o Restrict fluid
o Hypertonic saline solution(3%NaC) can be given to restore the serum sodium level( if
severe symptoms like seizures develop)
o

Hesi p. 40

Abnormality and common Signs and symptoms or Treatment or intervention

causes assessment findings
Hyponatremia(↓Na)
 Diuretics  Anorexia, nausea, vomiting  Restrict fluid(safer)
 GI fluid loss  Weakness  If IV saline solution
 Hypotonic tube feeding  Lethargy prescribed administer very
 D5W or hypotonic IV  Confusion slow.
fluids  Muscle cramps, twitching
 Diaphoresis  Seizures
 Na<135mEq/L

7. Diuretic therapy- hypokalemia- interaction with what other drug?(p.315)

Patient taking Digoxin, Digitalis experience increased digoxin toxicity if their serum potassium level is
low. Skeletal muscle weakness and paralysis may occur with hypokalemia.
*Severe hypokalemia can cause weakness and paralysis of respiratory muscles, leading to shallow
respirations and respiratory arrest.

8. Hypercalcemia- plan of care(p.317)

Two thirds of hypercalemia cases are caused by hyperparathyroidism and one third are caused by
malignancy, especially from breast cancer, lung cancer, and multiple myeloma.
Hypercalcemia is also associated with vitamin D overdose.
Excess calcium leads to reduced excitability of both muscles and nerves.
Plan of care for hypercalcemia:
  The basic treatment of hypercalcemia is promotion of excretion of calcium in urine by
administration of a loop diuretic (ex. Furosemide [Lasix]), and hydration of the patient with
isotonic saline infusions.
 In hypercalcemia, the patient must drink 3000 to 4000ml of fluid daily to promote the renal
excretion of calcium and to decrease the possibility of kidney stone formation.
 Synthetic calcitonin can also be administered to lower serum calcium levels. A diet low in
calcium may be prescribed.
 Mobilization with weight-bearing activity is encouraged to enhance bone mineralization.
Plicamycin (Mithrancin), a cytotoxic antibiotic, inhibits bone resorption and thus lowers the
serum level. In hypercalcemia related to malignancy the drug of choice is paramidronate
(Aredia), which inhibits the activity of osteoclasts(cells that break down bone and result in
calcium release)
o Paramidronate is preferred over plimacamycin because it does not have cytotoxic side
effects and it inhibits bone resorption without inhibit bone formation and mineralization.

9. PICC- D50 dextrose- Why?(p.327)

Peripheral Inserted Central Catheters (PICCs) are central catheters inserted into a vein in the arm rather
than a vein in the neck or chest. They are single- or multiple-lumen, nontunneled catheters that are up to
60cm in length with gauges just above the antecubital fossa (usually cephalic or basilic vein) and
advanced to a position with the tip ending in the distal one third of the superior vena cava.
The PICC lines are intended for patients who need vascular access for 1 week to 6 months but can be in
place for longer period of time.
Advantages of PICC line:
 Lower infection rate
 Fewer insertion-related complications
 Decreased cost
 Insertion at the bedside or outpatient area
Complications of PICC lines include:
 Catheter occlusion and phlebitis
o If phlebitis occurs it usually appears within 7to 10 days fallowing insertion.
o The line in which the PICC line in place should not be used for blood pressure
readings or blood drawing.

Solutions containing 10% dextrose or less may be administered through the peripheral IV line. Solution
with concentrations greater than 10% must be administered through a central line so that there is
adequate dilution to prevent shrinkage of RBCs
 Normal Blood sugar=70-110mg/dl
 Hypoglycemia(low blood sugar)

10. CVAD- plan of care(p.328-331)

a. Nursing management of CVADs includes assessment, dressing change and cleansing, injection
cap changes, and flushing. Catheter and insertion site assessment includes inspection of the site
for redness, edema, warmth, drainage, and tenderness or pain.
b. Dressing change and cleansing of the catheter insertion site using sterile technique. (For infection
control –prevent sepsis). (a Dacron cuff on the catheter serves to stabilize the catheter and may
decrease the incidence of infection by impeding bacteria migration along the catheter beyond the
cuff).
c. Injection caps must be changed at regular intervals using strict sterile technique according to
institution policy or when they are damaged from excessive punctures. Teach the patient to turn
 the head to the opposite side of the CVAD insertion site during cap change. If the catheter can’t
be clamped, instruct the patient to lie flat in bed and perform the valsalva maneuver whenever
the catheter is open to air to prevent air embolism.
d. Flushing is one of the most effective ways to maintain lumen patency and to prevent occlusion of
the CVAD. It also keeps incompatible drugs or fluids from mixing. Use the push-pause
technique, instilling 1-2 ml with each push of normal saline solution.
e. Removal of CVADs- remove the sutures if present and gently withdrawing the catheter while
instructing the patient to perform the Valsalva maneuver as the last 5-10 cm of the catheter is
withdrawn. Pressure should be immediately applied to the site to prevent air from entering and to
control bleeding. Patient should be in trendelenburg position.
i. Infusion of IV solutions through a PICC line allows rapid dilation of 5% dextrose in
0.45% saline.

11. Electrolyte laboratory normal and abnormal values- interpretation(p.309, hesi p.39)

Electrolyte normal lab values

Sodium (Na+) 135-145 mEq/L
Potassium ( K+) 3.5-5 mEq/L
Calcium (Ca) Ionized 4.4-5.3 mg/dl and total 8.9-10.1
mg/dl
Phosphate(PO3^4) 2.5- 4.5 mg/dl or 1.8-2.6 mEq/L

Magnesium(Mg2+) 1.5-2.5 mEq/L

Chloride(Cl-) 98-108mEq/L

12. NGT- low suction. Patient NPO- priority assessment to report to HCP

13. Increased Extracellular Fluid Osmolality- priority assessment(p.305 hesi39)

14. Hpo/hypercalcemia- priority of care(p.317,318)

15. Post thyroidectomy- plan of care, signs and symptoms to watch for.(p.318)(1268,9)

16. Hypo/Hypermagnesemia- assessment findings- which is most important, diet, plan of

care(p.319,320)

17. Hypovolemia- assessment

Respiratory
18. Asthma- asthma guidelines, nursing interventions, signs and symptoms, patient med teachings
Pg.588-608, Nclex pg. 69&169
Asthma is a chronic inflammatory disorder of the airways. The airways become edematous, the airways
become congested with mucous, the smooth muscles of the bronchioles constrict, and air trapping occurs
in the alveoli.

Clinical Manifestations: wheezing, breathlessness, chest tightness, cough, dyspnea, particularly at

night or in the early morning. Condition is reversible spontaneously or with treatment. The person with
asthma tries to sit upright or slightly bent forward using the accessory muscle of respiration to try to get
 enough air. You may see hypoxia, increase pulse and blood pressure, pulses paradoxus, difficulty
speaking, diminished breath sounds often referred to as the “silent chest” which means severe
obstruction and impending respiratory failure. Life-threatening situation may require mechanical
ventilation.

Nursing interventions:
 Monitor carefully for increasing respiratory distress
 Administer rapid-acting bronchodilators and steroids for acute attacks.
 Maintain hydration (oral fluids or IV)and humidification
 Monitor blood gas values for signs of respiratory acidosis
 Administer oxygen nebulizer therapy as prescribed. Monitor pulse oximetry

Teach home care programs: (I think this is the guidelines as well)

Identify precipitating factors, reduce allergens in the home, use metered-dose inhalers , monitor peak
respiratory flow rate at home, do breathing exercises, monitor drug actions, dosages, and side effects,
managing acute episode and when to seek emergency care.
Precipitating Factors:
Mucosal edema
Increased work of breathing
Beta-blockers
Respiratory infections
Allergic reactions
Emotional stress
Exercise
Environmental or occupational exposure
Reflux esophagitis (GERD)

How to use metered-dose inhaler correctly: Table 29-7

When you use your inhaler the wrong way, less medicine gets into your lungs

Guidelines for Pursed Lip breathing (PLB): Table 29-14

How to use your Peak Flow Meter: Table 29-15

Extra Info:
*Risk Factors include:
 Male gender in children (not in adults)
 Obesity, genetics, environment
People with asthma have what’s called the asthma triad, which you’ll most likely see nasal polyps, asthma, and
sensitivity to aspirin and NSAIDS (wheezing will develop in any of these triads)
- GERD can trigger asthma because reflux of stomach acid into the esophagus can be aspirated into the
lungs, causing reflux vagal stimulation and broncho-constriction. (diagnose and manage asthma using a
spirometer)
19. TB- precautions and care of patient

20. Pulmonary Function Test- plan of care, patient teachings

21. Tracheostomy care- cuffed or uncuffed
22. Tracheostomy dislodgement- action plan
23. Tracheotomy- check for aspiration, post op care
24. Respiratory signs and symptoms- priority of care
25. Post thoracotomy- priority plan of care
26. COPD- position, nursing diagnosis, diagnostic test, exercise recommendation, when to take
bronchodilator?
27. Bronchitis-Advair Diskus – purpose of the drug, nursing diagnosis
28. Serevent administration patient teaching, evaluation of effectiveness of interventions(p.599)
29. Total laryngectomy- care post op, nursing diagnosis
30. Influenza- signs and symptoms
31. Nosebleeding- management(p.520,521)
To manage epistaxis (nosebleed) the nurse would use simple first aid measures:
 Keep the patient quiet
 Place the patient in a sitting position
 Apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes
 Partially insert a gauze pad into the bleeding nostril.
 Apply digital pressure if bleeding continues
 Obtain medical assistant if bleeding does not stop.
If first aid is not effective:
Medical management involves identification of the bleeding site and application of a vasoconstrictive
agent, cauterization, or anterior packing by a health care provider. Plagets (nasal tampon) impregnated
with anesthetic solution and/or vasoconstrictive agents such as lidocaine or cocaine are placed into the
nasal cavity. Allow patient to remain in place for 10 to 15 minutes. Silver nitrate may be used to
cauterize after bleeding has stopped.
If bleeding does not stop:
Packing may be used, it consists of traditional Vaseline ribbon gauze, a prefabricated nasal sponge
( Merocel), or an epistaxis balloon (Rhino)
 Refer to page 521 for instructions on how to insert the gauze.
The nasal packing may alter the respiratory status, especially in older adults. Therefore, the nurse should
close monitor the RR, HR and rhythm, O2 Sat and level of consciousness and also observe for sign of
aspiration. Because of the risk of complication the patient may be admitted to a monitored unit to permit
closer observation.
The nasal packing predisposes patients to infection from bacteria (e.g. S. aureus) present in the nasal
cavity. The patient should receive mild opioid analgesic for pain (e.g. acetaminophen with codeine) and
antibiotic effective against staphylococci to protect against infection.
The nasal packing may be left in place for few days.
Before removal: the nurse should medicate the patient for pain (because this procedure is very
uncomfortable).
After Removal: cleanse the nares gently and lubricate them with water-soluble jelly

32. Pneumonia- evaluation of effectiveness of treatment(p.552)

 Maintain adequate alveolar oxygen-carbon dioxide exchange
 Clear lungs of fluids and exudates
33. Pneumococcal pneumonia- assessment findings, patient teachings, nursing diagnosis
34. Aspiration pneumonia- prevention measures(p. 548)
Aspiration pneumonia refers to the condition that occurs from abnormal entry of secretions or
substances into the lower airway.
It usually fallows aspiration of material from the mouth or the stomach into the trachea and subsequently
the lungs.
Conditions that increase the risk of aspiration pneumonia are:
 Seizure, Anesthesia, head injury, stroke or alcohol intake
 Difficulty swallowing
 Nasogastric intubation or tube feeding
 Loss of consciousness (because the gag reflex are depressed.
The aspirated material includes:
  Food, water, vomitus, or oral contains
Prevention measures: (Hesi 65)
 Comatose and immobile person: Elevation of head of bed to feed and for 2hours after feeding;
frequently turning
 Aspiration pneumonia can be prevented by positioning unconscious patient with the head
elevated 15 to 30 degree and turned to the side
 By paying careful attention to the maintenance of enteral feeding therapy and an adequate
airway.

35. Pleuritic chest pain- management, signs and symptoms, priority of care(p.576)

36. TB- multidrug therapy- what assessment findings to report to HCP, effectiveness of treatment
37. Chest tube monitoring
38. TB- skin test, history taking- most important to ask (p.555)
The tuberculin Skin test (TST) AKA Mantoux test using purified protein derivative (PPD) is widely
used to determine if a person is infected with Mycobacterium tuberculosis.
The test is administered by injecting 0.1 ml of PDD intradermally on the on the dorsal surface of the
forarm. The test is read by inspection and papation 48 to 72 hours later for the presence or absence of
induration.
The indurated area (if present):
 Is measured and recorded in millimeters with 0 for no induration.
The induration (not redness) at the injection site means
 At the injection sites mean: the person has been exposed to TB and has develop antibodies. The
reaction occurs
39. TB test positive- action plan
40. When to d/c airborne prec for TB patient

41. Peak flow- normal values- management of abnormals

 Used to check your asthma the way the blood pressure cuffs are used to check blood pressure. PFM
is a device that measures how well air moves out of your lungs. Steps to use it: - move indicator to
the bottom of the numbered scale – stand up – take a deep breath, filling your lungs completely –
place the mouthpiece in your mouth and close your lips around it do not put your tongue inside the
hole – blow out as hard and fast a you can in a single blow.
 Best peak flow# is the highest peak flow number u can achieved over a 2 week period when your
asthma is under good control. It is recommended that patients check peak flows when asthma
symptoms or attacks occur to compare the peak flow with the baseline. Increased doses of rapidly
acting 2-agonists are indicated for peak flows in the red zone. Peak flows should be checked every
morning before using medications. Peak flows are assessed during rapid exhalation.
 Peak flows of 80% or greater indicate that the asthma is well controlled. Corticosteroids are long-
acting, prophylactic therapy for asthma and are not used to treat acute dyspnea. Because asthma is an
acute and intermittent process, home oxygen is not used. The patient who has effective treatment
should sleep throughout the night without waking up with dyspnea.
 It is recommended that patients check peak flows when asthma symptoms or attacks occur to
compare the peak flow with the baseline. Increased doses of rapidly acting 2-agonists are indicated
for peak flows in the red zone. Peak flows should be checked every morning before using
medications. Peak flows are assessed during rapid exhalation.

42. Acute asthma attacks- priority interventions

43. Xolair- most important to report to HCP(p.598-600)
Anti-IgE. Omalizumab (Xolair)
44. Pre-op thoracentesis care-pg. 514
 Purpose: Thoracentesis used to obtain specimen for pleural fluid for diagnosis, to remove pleural fluid,
or to instill medication. Chest x-rays is always obtained after procedure to check for pneumothorax
 Nursing responsibility: Explain procedure to patient and obtain signed permit before procedure, which
is usually performed in patient’s room. Position the patient upright with elbows on an overbed table and
feet supported. Instruct the patient not to talk or cough, and assist during procedure. Observe signs of
hypoxia and pneumothorax and verify breath sounds in all fields after procedure. Encourage deep
breaths to expand lungs. Send labeled specimens to lab.
 Pg. 516 (Look also at the figure 26-14)-
Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to
obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural
space. The patient is positioned sitting upright with elbows on an overbed table and feet supported. The
skin is cleansed and a local anesthetic (Xylocaine) is instilled subcutaneously. A chest tube may be
inserted to permit further drainage of fluid.
 Pg.568-
Treatment of pneumothorax (hemothorax or chylothorax) depends on the severity and the nature of the
underlying disease. If the patient is stable, and the amount of air and/or fluid accumulated in the
intrapleural space is minimal, no treatment may be necessary as the condition may resolve
spontaneously. If the amount of air or fluid is minimal, the pleural space also can be aspirated with a
large-bore needle. This procedure is called a thoracentesis. The most definitive and common form of
treatment of pneumothorax and hemothorax is to insert a chest tube and connect it to water-seal
drainage. Repeated spontaneous pneumothorax may need to be treated surgically by a partial
pleurectomy, stapling, or pleurodesis to promote adherence of the pleurae to one another.
 Pg. 576-
Thoracentesis is aspiration of intrapleural fluid for diagnostic and therapeutic purposes. For a
thoracentesis, the patient sits on the edge of a bed and leans forward over a bedside table. Chest x-ray
with determine the puncture site, and percussion of the chest will assess the maximum degree of
dullness. The skin is cleansed with an antiseptic solution and the area is anesthetized. Thoracentesis
needle is inserted into the intercostal space. Fluid is aspirated with a syringe, or tubing is connected to
allow fluid to drain into a sterile container. After fluid is removed, the needle is withdrawn; a bandage is
applied over the insertion site.
Usually only 1000 to 1200ml of pleural fluid is removed at one time. Rapid removal of a large
volume can result in hypotension, hypoxemia, or pulmonary edema. A follow-up chest x-ray will detect
a possible pneumothorax that could have been induced by perforation of the visceral pleura. During and
after the procedure, monitor vital signs and pulse oximetry and observe the patient for any
manifestations of respiratory distress.

45. Chest tube- bubbling- action plan

 Pg. 572 Table 28-23 Drainage System-
1. Keep all tubing loosely coiled below chest level. Tubing should drop straight from bed or
chair to drainage unit. Do not let it be compressed.
2. Keep all connections between chest tubes, drainage tubing, and the drainage collector tight
and tape at connections
3. Observe for air fluctuations (tidaling) and bubbling in the water-seal chamber.
~If no tidaling is observed (rising with inspiration and falling with expiration
46. Post thoracentesis- assessment findings most important to report to HCP
o Thoracentesis is aspiration of intrapleural fluid for diagnostic and therapeutic purposes. For a
thoracentesis, the patient sits on the edge of a bed and leans forward over a bedside table.
o Chest x-ray will determine the puncture site, and percussion of the chest will assess the
maximum degree of dullness
 o The skin is cleansed with an antiseptic solution and the area is anesthetized. The thoracentesis
needle is inserted into the intercostals space. Fluid is aspirated with a syringe, or tubing is
connected to allow fluid to drain into a sterile container. After the fluid is removed, the needle is
withdrawn, and a bandage is applied over the insertion site.
o Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large
volume can result in hypotension, hypoxemia, or pulmonary edema.
A follow up chest x-ray will detect a possible pneumothorax that could have been induced by
perforation of the visceral pleura. During and after the procedure, monitor vital signs and pulse oximetry
and observe the patient for any manifestations of respiratory distress
47. Rhinplasty- nursing interventions
48. Allergic Rhinitis- management of care
49. URI patient teachings
50. Post thoracostomy- position
51. Psot thoracostomy drainage- normal and abnormal amount
52. Pulmonary embolism- assessment, diagnosis, management, tests
53. Pulmary HTN- assessment, +diagnosis, management, tests
54. Metabolic acidosis- signs and symptoms
55. Assessment of Respiratory- breath sounds, tactile fremitus
56. Broncgoscopy- post op
 Bronchoscopy is a test to view the airways and diagnose lung disease. It may also be used during
the treatment of some lung conditions. The doctor will spray a numbing drug (anesthetic) in your
mouth and throat. If the bronchoscopy is done through the nose, numbing jelly will be placed on
one nostril. 
 Inserting the bronchoscope will make you cough at first. The coughing will stop as the numbing
drug begins to work. There is a risk of choking if anything (including water) is swallowed before
the numbing medicine wears off. You will not be allowed to eat or drink anything until your gag
reflex has returned.

57. Delegation (UAP, LPN, NAP)

58. Prioritization of Care

59. Medication Calculation Exam

60. Foods rich in Calcium, phosphate, magnesium, potassium, sodium

 Potassium: Bananas, oranges, cantaloupes, avocados, spinach, potatoes, peanut butter and fish.
 Magnesium: green leafy vegetables, whole grains, tea, and fruit.
 Calcium: Milk, cheese, dark green vegetables, dried figs, soy and legumes.
 Phosphorus: Milk, liver, legumes, fish, soy, anchovies.
 Sodium: tomato juice, canned vegetables, pickles, table salt, bacon, baking powder, soups, soy
sauce, peanut butter, corned beef, cheeses.