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NUR 3524Acute Care Final Exam Focused Review Updated 2022
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Acute Care Final Exam Focused Review.Chapter 1
• Safety – 9 key areas where nursing practice should be improved
o Medication Administration
o Clearly communicating patient data and clinical assessments
o Attentiveness/surveillance
o Clinical reasoning or judgment
o Prevention of errors or complications
o Intervention (carrying out nursing actions in an appropriate and timely manner)
o Interpretation of authorized provider orders
o Professional responsibility and patient advocacy
o Mandatory reporting
• Delegation – Know the 5 rights
o As a nursing leader, you will delegate certain nursing tasks and activities to
unlicensed assistive personnel (UAP), such as patient care technicians (PCTs) or
patient care assistants (PCAs).
o Delegation is the process of transferring to a competent person the authority to perform
a selected nursing task or activity in a selected patient care situation. This process
requires precise and accurate communication.
o The nurse is always accountable for the task or activity that is delegated!
o An important process that is sometimes not consistently performed by busy
medical- surgical nurses is supervision of the UAP to whom the task or activity has
been delegated.
▪ Supervision is guidance or direction, evaluation, and follow-up by the nurse to
ensure that the task or activity is performed appropriately.
▪ Examples of delegated tasks are turning and positioning, vital signs, and
intake and output measurements.
o Be sure to follow these five rights when you delegate and supervise a nursing task or
activity to a UAP:
▪ Right task: The task is within the UAP's scope of practice and competence.
▪ Right circumstances: The patient care setting and resources are appropriate
for the delegation.
▪ Right person: The UAP is competent to perform the delegated task or activity.
▪ Right communication: The nurse provides a clear and concise explanation of
the task or activity, including limits and expectations.
▪ Right supervision: The nurse appropriately monitors, evaluates, intervenes, and
provides feedback on the delegation process as needed.
o Other activities or patient care responsibilities may be assigned by a registered
nurse (RN) to another RN or to a licensed practical or vocational nurse (LPN/LVN).
o Each state designates which tasks may be safely delegated and assigned to nursing team
members.
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,Acute Care Final Exam Focused Review.
Chapter 11 – Fluid and Electrolyte imbalances
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,Acute Care Final Exam Focused Review.
Know the assessment findings for the following electrolyte imbalances (hyper and hypo): Sodium,
potassium, and calcium. You may be given a set of symptoms and will need to pair that up with the
appropriate imbalance. Hint: know what effect the imbalance will have on the ECG readings for both
potassium and calcium (textbook pp. 160-169)
SODIUM 136-145
• Hyponatremia (sodium below 136)
o Sodium imbalances often occur with a fluid imbalance because the same
hormones regulate both sodium and water balance.
▪ The problems caused by hyponatremia occur from two changes—reduced
excitable membrane depolarization and cellular swelling.
• Excitable cell membrane depolarization depends on high
extracellular fluid (ECF) levels of sodium being available to cross
cell membranes and move into cells in response to a stimulus.
Hyponatremia makes depolarization slower so that excitable
membranes are less excitable.
▪ With hyponatremia, the osmolarity of the ECF is lower than that of the
intracellular fluid (ICF). As a result, water moves into the cell, causing
swelling.
• Even a small amount of swelling can reduce cell function.
• Larger amounts of swelling can make the cell burst (lysis) and die.
▪ Many conditions and drugs can lead to hyponatremia (Table 11-5).
▪ A common cause of low sodium levels is the prolonged use and overuse of
diuretics, especially in older adults.
▪ When these drugs are used to manage fluid overload, sodium is lost along
with the extra water.
▪ Hyponatremia can result from the loss of total body sodium, the
movement of sodium from the blood to other fluid spaces, or the dilution
of serum sodium from excessive water in the plasma.
Actual Sodium Deficits Relative Sodium Deficits (Dilution)
Excessive diaphoresis Excessive ingestion of hypotonic
fluids
Diuretics (high-ceiling diurectics) Psychogenic polydipsia
Decreased secretion of aldosterone Freshwater submersion accident
Hyperlipidemia Kidney failure (nephrotic syndrome)
Kidney disese (scarred distal Irrigation with hypotonic fluids
convoluted tubule)
Nothing by mouth (NPO) Syndrome of inappropriate
antidiurectics hormone secretion
Low-salt diet Syndrome of inappropriate
antidiuretic secretion
Cerebral salt-wasting sydndrome Heart failure
Hyperglycemia
o Assessment
▪ The manifestations of hyponatremia are caused by its effects on excitable
cellular activity. The cells especially affected are those involved in
cerebral, neuromuscular, intestinal smooth muscle, and cardiovascular
functions.
▪ Cerebral changes are the most obvious problems of hyponatremia.
Page 3 of 49
, Acute Care Final Exam Focused Review.
• Behavioral changes result from cerebral edema and
increased intracranial pressure.
• Closely observe and document the patient's behavior, level of
consciousness, and mental status.
• A sudden onset of acute confusion or increased confusion is often
seen in older adults who have low serum sodium levels.
• When sodium levels become very low, seizures, coma, and death may
occur (McGraw, 2012).
▪ Neuromuscular changes are seen as general muscle weakness.
• Assess the patient's neuromuscular status during each nursing shift
for changes from baseline.
• Deep tendon reflexes diminish, and muscle weakness is worse in the
legs and arms.
• Test arm muscle strength by having the patient squeeze your hand.
• Another way to test arm muscle strength is to have the patient flex
his or her arms against the chest and keep them flexed while you
attempt to pull them away from the chest.
• Test leg muscle strength by having the patient push both feet against a
flat surface (like a box or a board) while you apply resistance to the
opposite side of the flat surface.
• If muscle weakness is present, immediately check respiratory
effectiveness because ventilation depends on adequate strength of
respiratory muscles.
▪ Intestinal changes include increased motility, causing nausea, diarrhea,
and abdominal cramping.
• Assess the GI system by listening to bowel sounds and observing stools.
• Bowel sounds are hyperactive, with rushes and gurgles over the
splenic flexure and in the lower left quadrant.
• Bowel movements are frequent and watery.
▪ Cardiovascular changes are seen as changes in cardiac output.
• The cardiac responses to hyponatremia with hypovolemia
(decreased plasma volume) include a rapid, weak, thready pulse.
• Peripheral pulses are difficult to palpate and are easily blocked with light
pressure.
• Blood pressure is decreased, and the patient may have severe
orthostatic hypotension, leading to light-headedness or
dizziness.
• The central venous pressure is low.
▪ When hyponatremia occurs with hypervolemia (fluid overload), cardiac changes
include a full or bounding pulse with normal or high blood pressure. Peripheral
pulses are full and difficult to block; however, they may not be palpable if
edema is present.
o Interventions
▪ The specific cause of the low sodium level is determined to plan the
most appropriate management.
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