❓ Final Review — your own questions

All 155 of your review questions, grouped into 18 topics. The answer is hidden until you tap the question, so you can test yourself; Show all answers turns it back into a study guide.

🚨 Neurovascular & compartment syndrome8🫁 Fat embolism5🦴 Fractures & healing13🩹 Casts, traction & fixation10🦴 Osteoporosis11🦵 Arthritis & joint replacement16🔬 Osteomyelitis, AVN & CRPS7🦿 Amputation & phantom limb pain7🩼 Assistive devices & mobility9🛏️ Immobility complications4🔍 Low back pain & diagnostics9💊 Pain assessment & management5🎗️ Skin cancer6🏥 Perioperative care4🫁 Respiratory & aspiration15💨 Asthma & COPD8⚗️ Acid–base & ABGs8💧 Fluids & electrolytes10

🚨 Neurovascular & compartment syndrome

What are the 6 Ps of neurovascular assessment?

Pain, Pallor, Pulselessness, Paresthesia (tingling/numbness), Paralysis, Poikilothermia (temp irregularity).

What are the earliest signs of compartment syndrome?

Severe pain, esp with passive stretching

What are the late signs of compartment syndrome?

Pulselessness

How do you manage compartment syndrome?

THIS IS AN EMERGENCY

A fasciotomy is an emergency surgical procedure in which the surgeon makes long incisions through the skin and fascia surrounding the affected muscle compartment.

What actions are taken post-fasciotomy?

The open wounds require sterile packing and dressing until secondary closure occurs. And when they do the secondary closure, they may need skin grafts and a negative pressure, la wound vac placed, just to keep that closed and reduce that edema.

T/F When a patient has compartment syndrome, you should elevate the effected area above the heart?

FALSE

In most orthopedic injuries, you elevate the extremity above the level of the heart to reduce swelling. Compartment syndrome is the exception.

The problem in compartment syndrome isn't just swelling—it's loss of blood flow (perfusion) to the muscles and nerves.

Elevating above the heart decreases blood flow = worse!

  • Keep the affected extremity at the level of the heart.
For a fracture patient, how often do you perform neurovascular assessments?

Hourly for the first 24hrs. 1-4 hours after that.

Check the 6 Ps - risk for compartment syndrome

Pain, sensation, skin temp, cap refill, pulses, movement.

What is the priority assessment after a cast application?

Distal neurovascular status (6 P's)

🫁 Fat embolism

What is the classic triad of a fat embolism?

Respiratory distress, neurological changes, petechia rash

Which complication is associated with long bone fractures 24-72 hours after injury?

Fat embolism syndrome

Usually 24-72 hrs after long bone fracture.

Classic Triad:

  • Respiratory distress
  • Neurologic changes
  • Petechiae

Priority:

  • Oxygen
  • Rapid provider notification
What are key differences between a fat embolism and a pulmonary embolism?
Fat embolismPulmonary embolism
Long bone fractureDVT
PetechiaeNo petechiae
Neuro changesUsually no neuro changes
24-72 hrs after breakAnytime
Why can a fat embolism cause petechiae?

Late sign of FE - cutaneous petechiae. They're pinpoint-sized subdermal hemorrhages that can occur, usually in the neck, chest, upper arms, and abdomen, because of blockage of the capillaries by fat globules.

A patient is being treated for a fat embolus after a fracture. Which data would the nurse evaluate as MOST favorable indication of resolution of the fat embolus? A. Clear mentation B. Mild dyspnea C. O2 sats 85% D. Petechiae to upper chest only

A. Clear mentation (normal mental status; Oriented x 4)

Fat embolus = dyspnea, respiratory distress, confusion because of lack of oxygen.

headache, and then ultimately a petechial rash

🦴 Fractures & healing

What surgery repairs an open fracture?

Open reduction Internal fixation (ORIF)

When the fracture has not healed within 6 months of the injury, what is this called?

Delayed union

It can be treated with electrical bone stimulation and bone grafting. Low intensity pulse ultrasound can promote healing.

When the fracture never heals or heals incorrectly, what is it called?

Never heals - nonunion

Heals incorrectly - Malunion

What is a transverse fracture?

Break straight across the entire bone

What is an oblique fracture?

Break at an angle across the bone

Which type of fracture occurs when the bone bends and cracks without breaking completely? One side breaks while the other side bends.

Greenstick - Most common in children because their bones are more flexible.

Think of trying to break a young green branch. It bends before it completely breaks—just like a child's bone.

Which type of fracture occurs when bone is shattered into three or more pieces? Usually caused by high-energy trauma.

Comminuted fracture

Often requires ORIF (plates, screws, rods). Higher risk for delayed healing.

Comminuted = Crumbled

"C" = Crushed into many pieces.

Which fracture occurs when a twisting force causes the fracture to spiral around the bone?

Spiral - Often occurs during sports injuries. In children, unexplained spiral fractures may raise concern for abuse.

Which fracture occurs when a bone is crushed or collapses on itself?

Compression - Common in vertebrae due to osteoporosis. May cause sudden back pain and loss of height.

Which fracture occurs when one broken end of the bone is driven into the other?

Impacted - Often occurs with falls, especially hip fractures in older adults.

Impacted = In

One bone fragment is driven into the other.

Which type of fracture occurs when a bone breaks because it has been weakened by disease rather than trauma?

Pathologic - Common causes include osteoporosis, bone tumors, or metastatic cancer.

👵 Compression fractures are strongly associated with which disorder?

Osteoporosis

Which fractures presents the greatest infection risk, open or closed?

Open because of actual exposure through the compromised skin.

For open fractures: Prevent infection. Cover with a sterile dressing, administer IV antibiotics, assess tetanus status, and prepare for surgery.

🩹 Casts, traction & fixation

How should wet plaster casts be handled?

With the palms NOT the fingers (this is for plaster casts which take a long time to dry (24-72hrs) and fingers can leave indents.

Fiberglass is more common now - dries in 30min. More water proof (don't need as much water proofing)

What should you do to the casted body part to avoid edema?

Elevate!

T/F A cast is typically applied immediately to a fracture to ensure immobility?

False - allow for some swelling to go down to avoid compartment syndrome (swelling causes diminished blood flow = necrosis)

What is the main purpose of traction?

Prevent soft tissue injury; Maintain alignment, reduce muscle spasms, dec pain

Should traction weights ever be removed?

No

Only changed by a provider, NOT patient

What is skeletal traction and what are the benefits?

Screws are inserted into the bone

Can use heavier weights (15-30lbs) and longer traction times to realign bones.

Pin site care is key.

What are key rules for use of traction?
  • Never remove weights.
  • Weights hang freely.
  • Do not place weights on bed.
  • Maintain body alignment.
The primary purpose of skeletal traction is A. Maintain alignment B. Reduce pain C. Prevent infection

A. Maintain alignment - helps to heal.

Assess traction for proper weight alignment every shift.

Patient should use an incentive spirometer regularly to avoid atelectasis/pneumonia.

When a fracture is immobilized using percutaneous pins and wire attached to rigid external frame, what is this called?

External fixation

  • Clean pin sites with chlorhexidine, one swab per spot to avoid cross-contamination.
  • Inspect pins every 8 hours for signs of infection for first 48-72 hours, then daily.

Internal fixation uses plates, screws, pins, and rods inside the body (open reduction)

Nurse providing discharge teaching to a client after application of a leg cast. Which statement indicates that the client understands proper cast care? A. I will avoid getting the cast wet B. I will need to cover the casted leg with warm blankets C. I need to use my fingertips to lift and move my legs D. I need to use something like a padded coat hanger to scratch under the cast if it itches.

A. I will avoid getting the cast wet

🦴 Osteoporosis

What is the best diagnostic for osteoporosis?

DEXA scan

What T-score indicates osteoporosis?

<= -2.5

Normally, specialized cells called osteoclasts break down old bone (bone resorption). In osteoporosis, bone is broken down faster than it is rebuilt.

What are three common fracture sites for osteoporosis?

Hip, vertebra, wrist

What are the modifiable risks for Osteoporosis?

Low calcium and Vit D

Sedentary lifestyle

Smoking and excessive alc

Low body weight or eating d/o

Certain meds (corticosteroids, anticonvulsants)

What are the risk factors for osteoporosis?
  • Women (esp. postmenopause)
  • Smoking and Alcohol
  • Steroids use
  • Low calcium and Vitamin D deficiency
  • Thin body habitus
  • Older age
  • Asian and white Americans
  • Hyperthyroid, hyperparathyroid
What medications can be used to treat osteoporosis?

"Biscuits and Ale to Rise"

  • Bisphosphonates
  • Alendronate
  • Risedronate
What is alendronate used for and what are key teaching points?

Alendronate (Fosamax) is a bisphosphonate that is primarily used to prevent and treat osteoporosis by slowing the breakdown of bone.

Take in the morning on empty stomach

Full Glass of water (not coffee, tea)

Remain upright for 30-60 mins - Can cause severe esophageal irritation.

What does calcitonin do?

Decreases bone resorption

What is denosumab used for?

Used to treat osteoporosis and reduce fracture risk.

  • Given as a subcutaneous injection every 6 months.
  • Monitor for hypocalcemia

Watch for osteonecrosis of the jaw and advise good dental care.

For a patient with suspected osteoporosis, what education can you provide to assist with slowing the progression of pain?

Weight-bearing exercises

Also Vitamin D with calcium supplementation

Monitor bone mineral density (stop calcium before test) and ability to perform ADLs.

What are key differences b/w osteoporosis and osteoarthritis?
OsteoporosisOsteoarthritis
Bone density lossCartilage degeneration
Usually painless 'til fractureJoint pain
DEXA diagnosisX-ray
FracturesStiffness

🦵 Arthritis & joint replacement

What causes osteoarthritis?

Degeneration of articular cartilage (wear and tear) on weight-bearing joints

Diagnostics: X-ray

Treatment: Exercise, weight loss, heat, NSAIDs, arthroplasty/replacement if severe

Knobby Joints

What are the manifestations of OA?

Pain worse with activity

Morning stiffness <30 minutes

Crepitus (cracking, popping in joints)

Limited ROM

What are meds for OA?

Analgesics, like Tylenol, topicals, lidocaine patches, NSAIDs (ibuprofen, naproxen) for pain relief

Opioids - tramadol is a weak opioid that can be used.

Hot/heating pads - but not too hot.

Cold packs

What therapeutic procedures can be used for OA?

Intra-articular injections of glucocorticoids (localized inflammation) or hyaluronic acid replacement.

Total joint arthroplasty/replacement

The surgical removal of a diseased joint due to OA, osteonecrosis, RA, trauma or congenital anomalies is called…

Arthroplasty (partial or total joint replacement)

What is Rheumatoid arthritis?

RA is a chronic autoimmune disease that causes symmetrical inflammation of the synovial joints, resulting in progressive joint damage, pain, stiffness, and loss of function.

  • occurs at any age
  • Inflammatory
  • Morning stiffness lasts >1 hour
  • Improves with gentle movement
How does RA differ from OA?
Rheumatoid arthritisOsteoarthritis
AutoimmuneWear and tear
Any ageUsually older age
Morning stiffness >1 hour, improves with movementWorse with movement
Starts in small jointsWeight-bearing joints
Usually bilateral / symmetricalAsymmetrical
Can cause deformitiesTypically doesn't
Systemic symptomsLocalized
Which type of osteo pain worsens with activity?

Osteoarthritis

After a hip replacement, what is the max flexion a PT should do?

Maximum of 90 degrees. Don't bend over to the ground.

When and why do you use an abduction pillow?

After hip surgery to prevent hip dislocation.

What are three signs of a prosthetic joint infection?

Fever, redness, drainage

What are the differences in post surgery for a knee vs hip replacement?
KneeHip
Early ROMNo flexion > 90
CPM machineNo crossing legs
Knee exercisesAbduction pillow (avoid dislocation)
What are key nursing considerations for a hip arthroplasty?

Prevent dislocation of that new joint.

  • We don't want that to pop out because they're bending over too far, or trying to put on their own shoes and socks
  • Place a pillow or abduction device between the legs when turning to the unaffected side.
  • We don't want to turn to the operative side.
  • Use raised toilet seats, straight-back chairs with arms.
  • Assistive items to prevent strain on that prosthetic; avoid flexion greater than 90 degrees.
  • We don't want them crossing their legs
What is the highest-priority complication to monitor for after arthroplasty during the first postoperative days?

Neurovascular compromise

DVT/PE

Infection

Bleeding

A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in teaching? SATA A. Clean the incision daily with soap and water B. Turn toes inward when sitting or lying C. Sit in a straight-backed chair D. Bend at the waist when putting on socks E. Use a raised toilet seat.

A. Clean the incision daily with soap and water

C. Sit in a straight-backed chair

E. Use a raised toilet seat. (Don't excessively bend at hip)

A nurse is providing information to a client who has osteoarthritis of the hips and knees. Which of the following information should the nurse include? SATA 1. Apply heat to the joints to alleviate pain. 2. Ice inflamed joints for 60 minutes (in 20 minute intervals) following any activity. C. Reduce the amount of exercise done on days you have increased pain D. Prop the knees with a pillow while on the bed E. Active range of motion is more effective than passive.
  • Apply heat to the joints to alleviate pain (but not too hot - don't burn).
  • Ice inflamed joints for 60 minutes (in 20-minute intervals) following any activity.

C. Reduce the amount of exercise done on days you have increased pain (Don't stop exercises, just reduce # of reps)

E. Active range of motion is more effective than passive.

🔬 Osteomyelitis, AVN & CRPS

What are key SSX of osteomyelitis?

Severe Localized Bone Pain ⭐ pulsating, worse with movement.

  • fever, elevated WBC count, drainage, and pain.
  • Typically requires long-term IV antibiotics.
  • usually caused by bacteria (most commonly Staphylococcus aureus).
  • The infection causes inflammation, swelling, decreased blood flow, and eventually bone destruction if left untreated.
  • Older patient may have confusion before fever.
How does someone typically get osteomyelitis?

Open fracture

Orthopedic Surgery

Diabetic Foot Ulcers

Bloodstream Infection

What are common orders for a patient with osteomyelitis?

Bed rest/immobilization

Weight-bearing is avoided (weak bones)

Elevate the injured area

  • Decrease risks of immobility (DVTs, pressure wounds, atelectasis).
The nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include? A. Antibiotic therapy should continue for 3 months B. Relief of pain indicates the infection is gone C. Airborne precautions are used during wound care D. Expect paresthesia distal to the wound.

A. Antibiotic therapy should continue for 3 months - these are hard to heal.

When blood flow to a fracture site is disrupted, it results in ischemia and necrosis, which is called?

Avascular Necrosis

  • Hip most often affected
  • Risk factors are trauma, long-term corticosteroid use, sickle cell disease, and radiation therapy.
  • Manifestations are pain and loss of function, often require surgical intervention, like joint replacement or bone grafting.
What are the early manifestations of complex regional pain syndrome (CRPS)?

Severe chronic pain that usually follows a musculoskeletal trauma.

It's more common in the feet and in the hands.

It can develop if acute pain is not well managed.

  • Motor changes, muscle spasms, autonomic nervous system changes, like temperature sensitivity, diaphoresis, and sensory changes can happen.
What syndrome can be characterized by untraceable, burning sensations?

CRPS

Avoid taking blood pressures, IV starts, blood draws in that affected extremity because we don't want to cause more pain

🦿 Amputation & phantom limb pain

What is phantom limb pain?

It is a real thing - pain perceived in an amputated limb.

  • pin and needle, or deep and burning, cramping, shooting, or aching pain that they'll experience.
  • Treat with neuropathic pain relievers like gabapentin.
  • Calcitonin during the first week after having the amputation can decrease that limb pain.
What meds can be taken to reduce phantom limb pain?
  • Antiepileptics like Gabapentin
  • Calcitonin during the first week after having the amputation can decrease that limb pain. Calcitonin may reduce the pain transmission by the nervous system by reducing the release of pro-inflammatory cytokines from the injured nerves.
  • Beta blockers, like propranolol, can relieve the continual dull, burning sensation associated with the amputated limb.
  • Opioids are about 50% effective for these patients.
How can you treat phantom limb pain?

Pain meds (Gaba)

Mirror therapy

Desensitization

T/F A patient with a new below-knee amputation should lie in the prone 30 minutes, several times a day?

True - Prone positioning prevents amputation contractures.

They should also avoid prolonged knee flexion.

T/F The nurse should place a pillow under an above-knee amputation stump?

False

What limb care is done to get ready for an amputation?
  • Figure 8 pattern wrap to bring up blood flow and reduce edema.
  • Shrinks swelling to allow for prosthetic
What steps should you take for traumatic amputation?
  • Activate EMS
  • Apply direct pressure using gauze or clean cloth
  • Elevate extremity above the heart
  • Wrap severed extremity in dry sterile gauze or clean cloth and place in sealed bag
  • Submerge bag in ice water (one part ice, 3 parts water) and send with client.

🩼 Assistive devices & mobility

What side should a cane be held on?

The strong side

What is the cane walking sequence?

Cane - weak leg - strong leg

What is the walker walking sequence?

Walker - weak leg - strong leg

What is the proper technique with a walker?
  • Push walker forward.
  • Step with weak leg.
  • Step with strong leg.

** Never pull walker toward body.

Where should the body weight be supported with crutches?

On the hands, not the axillae (armpits)

What is the proper fit for crutches?

2-3 finger width below axilla

Weight in hands, not armpits

What gait is used for non-weight-bearing on one leg?

Three point gait

Move:

Both crutches + injured leg

Then good leg

What is the most stable gait?

4-point

Slowest, most stable, both legs bear weight.

How can you remember using stairs with assisted devices?

Up with the good, down with the bad

Up:

Good leg - Crutches - Bad leg

Down:

Crutches - Bad leg - Good leg

🛏️ Immobility complications

What are 3 cardiovascular complications of immobility?

DVT, venous stasis, orthostatic hypotension

What are three respiratory complications with immobility?

Atelectasis, pneumonia, retained secretions

What are 3 MSK complications with immobility?

Muscle atrophy, contractures, bone loss

Most important nursing intervention to prevent pressure injuries?

Reposition every 2 hours

🔍 Low back pain & diagnostics

What are the red flags for low back pain requiring immediate evaluation?

Bowel/bladder dysfunction

Saddle Anesthesia

Progressive weakness

Fever or Hx of cancer

What is saddle anesthesia?

Saddle anesthesia is a loss or decrease of sensation (numbness) in the areas of the body that would touch a saddle if you were sitting on a horse.

This includes the:

Perineum

Inner thighs

Buttocks

Genital area

Think of the area that contacts a bicycle or horse saddle.

What is an Arthrocentesis (Joint Aspiration) used to diagnose?

It is when a needle removes synovial fluid.

Used to diagnose:

  • Gout
  • Septic arthritis
  • Rheumatoid arthritis
What is the best imaging for ligaments and tendons?

MRI

What is an MRI used to diagnose?

Ligaments, Tendons, Cartilage, Spinal cord, Meniscus

Can't use with: Pacemakers, cochlear implants, certain aneurysm clips, metal frags

What are CT scans often used for?

Complex fractures

Joint and spine injuries

May use contrast - confirm iodine allergy, kidney function (BUN/Creatinine) - hydrate after

What is an arthroscopy used for?

Small camera inserted into the joint to diagnose:

Torn meniscus

ACL injury

Cartilage damage

Post-op:

· Ice

· Elevation

· Neurovascular checks

Watch for infection

What is electromyography (EMG) used for?

Measures muscle electrical activity.

Used for:

· ALS

· Muscular dystrophy

· Peripheral neuropathy

Before test - Avoid caffeine.

After - Temporary soreness expected.

What is a bone biopsy used for and what are the main complications?

Used to diagnose:

Osteomyelitis

Bone tumors

Complications: Bleeding and infection.

*** Check PT/INR and platelets before procedure for bleeding risks

💊 Pain assessment & management

What would be included in a pain assessment?

O - Onset - when did it start

L - Location - where is the pain

D - Duration - how long does it last, constant/intermittent

C - Characteristics - What does it feel like (sharp, dull, burn)

A - Aggravating/alleviating factors

R - Radiation - does it travel anywhere

T - Timing - Does it occur at certain times? Has it changed over time

S - Severity - 0-10

What would be TX options for acute pain?

NSAIDs + OTCs

Opioids

hot/cold

Tylenol (Not biliary, liver d/s)

Lidocaine

Who should avoid taking NSAIDs?

Kidney disease/Fluid Volume issues

Heart failure = retaining fluids

Respiratory issues = fluid worsens lung issues

GI bleeds/Ulcers

What would be TX options for Chronic pain?

Opioids/Morphine (assess respiratory first)

A post-op client has a PCA pump but has inadequate pain relief despite frequent use of PCA. What should the nurse do first? 1. Assess PT pain level, PCA setting, and med delivery Hx 2. Increase PCA med dosage 3. Encourage client to use the PCA more frequently 4. Replace PCA pump with oral meds
  • Assess PT pain level, PCA setting, and med delivery Hx

Need more info before doing the other things.

🎗️ Skin cancer

What are the three types of skin cancers?

"Best Sort-of Malignant"

Basal Cell Carcinoma - low chance of metastasizing.

Squamous Cell Carcinoma - Mid-risk. Can become Melanoma

Malignant Melanoma - High risk of metastasizing

What characteristics do you look at to assess a skin lesion?

A - Asymmetry

B - Border - jagged, scalloped, notched

C - Color - Multiple or uneven pigment

D - Diameter (>6mm, pencil eraser)

E - Evolution - changes over time

Which of the following characteristics is MOST suggestive of malignant melanoma? 1. A pearly, raised nodule w/ visible blood vessels 2. A firm, red nodule w/ crusted surface 3. An irregularly shaped mole with variegated color and diameter >6 4. Flat lesion with well-defined borders and scaling.
  • An irregularly shaped mole with variegated color and diameter >6
A client is diagnosed with basal cell carcinoma. What is the nurse's priority teaching? A. This cancer spreads quickly to internal organs B. You will need aggressive chemo and radiation C. This cancer rarely metastasizes but requires complete removal D. No treatment is needed unless symptoms worsen.

C. This cancer rarely metastasizes but requires complete removal

The nurse is planning a health fair focused on cancer prevention. Which of the following actions best promotes primary prevention of skin cancer? A. Teaching clients to perform monthly skin self-exams B. Referring clients with suspicious moles to derm C. Offering free full-body skin screenings D. Distributing free sunscreen samples with application instructions.

D. Distributing free sunscreen samples with application instructions. PRIMARY PREVENTION

A, B, and C are all Secondary - finding/screening/reducing effects of existing issues.

Tertiary is dealing with folks who have had something and want to avoid it again or lessen impact of ongoing issues.

The nurse is teaching a client about proper cleaning techniques for an excisional biopsy site to prevent infection. Which method should the nurse emphasize? 1. Use hydrogen peroxide directly on the wound 2x a day 2. Clean the wound gently with mild soap and water, then pat dry with sterile cloth 3. Apply rubbing alcohol to the wound and cover with a dry bandage. 4. Scrub wound vigorously to ensure all the debris is removed, then rinse with sterile saline.
  • Clean the wound gently with mild soap and water, then pat dry with sterile cloth
  • We never want to recommend to people to use hydrogen peroxide, use rubbing alcohol, or, more importantly, to scrub vigorously.

🏥 Perioperative care

When do you begin discharge planning?

During admission

What typically kicks off the inter-operative phase?

Timeout

Right operation, right patient, right location.

Circulating nurse advocates for the patient during the operation.

In the post-op phase, after those ABCs, what are the things that we are primarily concerned about?

Bleeding, atelectasis, pain control, DVTs, infection control (incision), GI motility (early ambulation)

What is the primary role of the circulating nurse in an OR during a surgical procedure? A. Ensure overall client safety and act as client advocate B. Manage sterile aspects of OR C. Document the time the client arrived in the pre-op holding area D. Obtain informed consent for surgery

A. Ensure overall client safety and act as client advocate

🫁 Respiratory & aspiration

What are the risk factors for the development of aspiration pneumonia?
  • Dysphagia
  • Intubated (NG, PEGs, Trach)
  • Parkinsons, TBI, MS
  • Dementia/ALZ, delirium
  • Stroke
  • GERD, Esophageal strictures
How do we prevent aspiration pneumonia?
  • Raise HOB
  • Swallow study (within 24hrs)
  • Speech Therapist
  • Dietary changes (thick liquids)
What is food pocketing?

When a patient has dysphagia (trouble swallowing) they will often hold/store food in their mouths, which ends up in the pockets of their cheeks.

What is it called when PaO2 drops below 60?

Acute respiratory failure (ARF)

T/F The diagnosis of pneumonia may be missed in the older adult because they may not develop a fever.

True

A patient may have a cough, pleuritic-type chest pain, and dyspnea, whereas somebody who is older may have the initial clinical manifestation of confusion.

What are the most important interventions to prevent atelectasis and alveolar collapse?

Deep breathing, incentive spirometry

A client admitted with status asthmaticus requires endotracheal intubation and mechanical ventilation. Which intervention decreases the client's risk for ventilator-associated pneumonia? A. Providing a sedation vacation every 8 hours B. Administering daily oral care with hydrogen peroxide C. Lowering the head of the patient's bed 15 to 25 degrees D. Suctioning PRN using a specialized endotracheal suction tube

D. Suctioning PRN using a specialized endotracheal suction tube

  • Sedation vacation daily to assess readiness for extubation but doesn't prevent VAP
  • Oral care more than daily and NOT with HP
  • Do NOT lower HOB, minimum 30deg
Which manifestations may suggest a pneumothorax following an injury? SATA A. Tachycardia B. Tachypnea C. Pleuritic chest pain D. Tracheal deviation E. Expiratory wheezing

A. Tachycardia = inc HR to compensate for low O2

B. Tachypnea

C. Pleuritic chest pain = sharp, worsens with inspiration, usually on affected side

D. Tracheal deviation (esp with tension pneumo)

  • A pneumothorax occurs when air enters the pleural space, causing the lung to partially or completely collapse.
  • With a pneumothorax, we would auscultate nothing, either diminished or absent breath sounds on that side.
Select the clients at risk of developing a pulmonary embolism: 1. BMI of 20 2. Post-menopausal 3. Fractured tibia 4. Hormone birth control meds 5. Tamoxifen
  • Fractured tibia - immobility = DVT/Venous stasis
  • Hormone birth control meds
  • Tamoxifen - a selective estrogen-receptor modulator

Obesity >29 BMI (not 20)

Estrogen = PE (post-meno doesn't have estrogen unless on HRT).

Select the clients at risk for developing ARDS 1. Severe burn injury 2. Post coronary artery bypass surgery 3. Near drowning 4. Sepsis 5. Iron-deficiency anemia

ARDS = diffuse alveolar injury (ventilation issue) direct or indirect lung injury.

  • Severe burn injury
  • Post-coronary artery bypass surgery (triggers inflammatory response)
  • Near drowning (Direct damage)
  • Sepsis (#1 cause - damaged alveolar cap membrane = fluid in the lung)
Select the appropriate actions/interventions for ARDS
  • Treat cause of ARDS
  • Provide oxygen therapy (often mechanical/vent)
  • Provide nutritional support - supports immune and healing
  • Place the client in prone position (alleviates pressure on lungs)
  • Intubate and mechanically vent
What are the nursing goals of care of a TB patient?
  • Prevent transmission - airborne precautions (N95, negative pressure, gloves)
  • Airway patency - clear secretions

Education: Explain the why behind the isolation, how long it will last (3 negative sputum cultures)

  • Close contacts need to be tested
  • May need future chest x-rays to confirm TX is working.
  • Will always be positive on a TB skin test in the future.
What does TB treatment entail?

Lasts at least 6-12 months

Must adhere and complete all med cycles

Many TB drugs are hepatotoxic.

What are the meds used to treat active TB?

R - Rifampin - Orange-red body fluids, hepatotoxicity

I - Isoniazid (INH) - Peripheral neuropathy, hepatotoxicity

P - Pyrazinamide - Hepatotoxicity, hyperuricemia (gout)

E - Ethambutol - Optic neuritis (vision changes)

What are the most common clinical manifestations and treatments for Obstructive Sleep Apnea?

Loud snoring, daytime sleepiness

TX: CPAP

💨 Asthma & COPD

What are the side effects of albuterol?

Tremors (jittery, shaky)

Palpitations

Agitation

Tachycardia, restlessness, nervousness

How is albuterol commonly administered?

Using a Metered-dose inhaler.

Tiotropium is a long-acting anticholinergic medication. It is typically administered by dry powder inhaler, not metered dose inhaler.

What is the #1 thing you can do to avoid an asthma attack/exacerbation?

Avoid triggers - pollen (stay indoors during high pollen days); smoke

Using a rescue inhaler before exercising can prevent an exercise-induced bronchospasm, but it is not a comprehensive strategy for preventing overall asthma exacerbations.

A client with asthma is showing manifestations of an exacerbation. Select the correct findings in worsening asthma. (Select all that apply) A. SpO₂ 90% B. Inspiratory crackles C. Bilateral wheezing D. Tachypnea E. Accessory muscle use F. Confusion G. Bloody sputum

A. SpO₂ 90% - Hypoxemia is a key indicator

C. Bilateral wheezing - classic sound

D. Tachypnea - Increase R/R to compensate

E. Accessory muscle use

F. Confusion - Altered mental status (restlessness, confusion, or lethargy) is a late and serious sign

A nurse is teaching a client with COPD about the use of bronchodilators. Which statement indicates that the patient understands the teaching? A. "I should use my long-acting bronchodilator only when I have symptoms." B. "I will use my short-acting bronchodilator before engaging in physical activity." C. "I can stop using my bronchodilator if I feel better." D. "I should take my bronchodilator after using my corticosteroid inhaler."

B. "I will use my short-acting bronchodilator before engaging in physical activity."

SABAs such as albuterol are used both as rescue medication for acute symptoms and prophylactically before exercise or other activities that may trigger dyspnea.

  • LABAs are maintenance medications and must be taken regularly on a schedule. Don't stop when feeling better.

Take bronchodilators FIRST, before corticosteroids to allow for better absorption.

A nurse is caring for a client with COPD who requires supplemental oxygen. Which oxygen delivery method is most appropriate to prevent carbon dioxide retention? A. Simple face mask at 10 L/min B. Non-rebreather mask at 15 L/min C. Nasal cannula at 2 L/min D. Venturi mask at 50% FiO₂

The Venturi mask is actually the preferred device when a precise oxygen concentration is needed for COPD patients.

The nurse should teach a COPD client to ___ because high flow oxygen can ___

Avoid high-flow oxygen - it can depress respiratory drive

What would be the priority of interventions for a COPD patient in respiratory acidosis?
  • Semi Fowlers
  • Apply prescribed O2 and titrate as ordered
  • Pursed-lip breathing (release trapped air)
  • Prepare for BiPAP

⚗️ Acid–base & ABGs

What are common causes of respiratory acidosis?

Hypoventilation = CO2 retention = Low pH

  • COPD
  • Opioid or sedative o/d
  • Pneumonia
  • Atelectasis
  • Severe asthma

(The more I hold my breath, the more acidic I become)

What are common causes of respiratory alkalosis?

Hyperventilation → CO₂ loss → ↑ pH

Think: "Blowing off too much CO₂."

Anxiety/panic attack

Pain & Fever (inc r/r)

Early sepsis

PE

Respiratory Alkalosis = "Breathing Too Fast."

What are common causes of metabolic acidosis?

"The body is making acid or losing base."

  • DKA
  • Lactic acidosis (tissue hypoxia)
  • Renal Failure (can't excrete acids)
  • Severe diarrhea (Loss of bicarb)
  • Shock, starvation, salicylate o/d

** Kussmaul respirations (deep, rapid)

Metabolic Acidosis = "Diarrhea and DKA."

What are common causes of metabolic alkalosis?

Too much bicarbonate OR loss of stomach acid

  • Vomiting - lose hydrochloric acid
  • NG suction
  • Excess antacids
  • Diuretics (loop, thiazides - hydrogen ion loss)
Excessive use of antacids can cause which ABG imbalance?

Metabolic Alkalosis (loss of too much acid)

What are the expected clinical manifestations of respiratory acidosis?

Respiratory Acidosis = "Not Breathing"

😴 Sleepy

🧠 Confused

🤕 Headache

🌬️ Breathing too little

📈 High CO₂

High CO₂ = CNS Depression

A patient with COPD is experiencing increased SOB. Their ABGs indicate partially compensated respiratory acidosis. What is the primary cause of the imbalance, and what compensatory mechanisms would the body initiate to level out the pH?

Resp Acidosis caused by hypoventilation (holding onto CO2)

Compensation = increased renal retention of bicarb (inc HCO3 to up the base, up the pH).

How do Kussmaul breaths compensate for metabolic acidosis?

Kussmaul respirations are deep, rapid, labored breathing that occurs as the body tries to compensate for metabolic acidosis.

The patient is trying to blow off CO₂ to reduce the acidity of the blood.

Seen a lot in clients with DKA (high ketones = high acid)

💧 Fluids & electrolytes

Hyponatremia is most commonly associated with what symptoms?

Confusion and seizures - neurological systems

Hyperkalemia is most commonly associated with what symptoms?

Tall peaked T-waves, muscle cramps

Potassium = heart and muscles

Hypocalcemia is most commonly associated with what symptoms?

Tetany and positive Chvostek's sign

  • neuromuscular irritability
Hypermagnesemia is most commonly associated with what symptoms?

Depressed tendon reflexes

(Think - you take Mg to go to sleep and to poop b/c it relaxes your muscles. So too much = too much relaxation.)

What fluids would I give a patient with a Na level of 112?

Hypertonic (high Na) = > 0.9% saline

So 3% normal saline would work.

They need more salt, give them hypertonic.

However, this does NOT cure FVD. Only to fix the electrolyte issue b/c it pulls water from cells.

Hypotonic turns your cells into hippos - fat cells = rehydration. Na is high (170). Give them 0.45% saline.

When a patient needs resuscitative fluids, what do you give them?

Isotonic solutions.

0.9% saline or Lactated Ringers

Ex: low blood pressure due to fluid volume deficits

I have a patient whose Na is 110. What nursing interventions should I anticipate?
  • Fall precautions (due to confusion)
  • Seizure precautions (low Na)
  • Prepare for hypertonic fluids
What is a key factor of spironolactone?

It's a Potassium-sparing diuretic - so look for hyperkalemia (muscle cramps, peaked T-waves, widened QRS intervals)

Loop diuretics (Furosemide) and Thiazides do NOT spare K+, so look for hypoK.

What is a key factor in using ACE inhibitors?

Lisinopril - PRILs

ACE inhibitors → Hold on to potassium → Risk of hyperkalemia.

So when you see Lisinopril + spironolactone = Hyperkalemia risk.

They block the RAAS system so no aldosterone (which normally causes retention of water and Na, and excretion of K+). No RAAS, no aldosterone, no K+ excretion.

A client with chronic renal failure presents to the ER after missing 2 dialyses. Client reports chest pain, dyspnea, crackles in lungs and peripheral edema. Which electrolyte abnormality should the nurse MOST anticipate?

Hyperkalemia - kidneys can't excrete

Peaked T-waves

Fluid volume overload (crackles, edema)

TX: Diuretics (loop), Calcium gluconate IV to stabilize cardiac membrane, IV regular insulin and D50 (drive K+ back into cells), or sodium polystyrene sulfonate (pulls K+ into bowels)

Nothing matched that. Try a shorter word — “traction”, “gain”, “tic”.
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