Chương 7 / 721% của kỳ thi
Physiological Adaptation and Reduction of Risk
Physiological Adaptation is the largest physiological content area, covering the care of clients with acute, chronic, and life-threatening conditions. The nurse interprets laboratory values, manages fluid and electrolyte and acid-base balance, and recognizes complications requiring urgent intervention.
Laboratory Value Interpretation
The nurse interprets common laboratory values to detect and respond to physiological changes. Recognizing abnormal values guides priority action.
Know normal potassium
Normal serum potassium is about 3.5 to 5.0 mEq/L; values above or below signal danger.
Interpret cardiac markers
Troponin is the most specific marker for myocardial injury and rises within hours.
Assess coagulation
An INR of 5.0 indicates a high bleeding risk; normal is near 1.0 without anticoagulation.
Recognize anemia
A low hemoglobin causes fatigue, pallor, and compensatory tachycardia.
Fluid and Electrolyte Balance
The nurse identifies and manages fluid volume and electrolyte disturbances, which can be life-threatening. Assessment findings distinguish overload from deficit.
Recognize fluid overload
Rapid weight gain and lung crackles suggest fluid volume overload.
Recognize dehydration
Poor skin turgor and concentrated urine indicate fluid volume deficit.
Prioritize hyperkalemia
Peaked T waves with high potassium require immediate intervention.
Interpret hypocalcemia
Positive Trousseau and Chvostek signs reflect increased neuromuscular excitability.
Acid-Base Balance
The nurse interprets arterial blood gases to identify respiratory and metabolic disturbances. Systematic analysis of pH, PaCO2, and bicarbonate guides interpretation.
Identify respiratory acidosis
A low pH with an elevated PaCO2 reflects hypoventilation.
Identify respiratory alkalosis
A high pH with a low PaCO2 reflects hyperventilation.
Identify metabolic acidosis
Diabetic ketoacidosis lowers pH and bicarbonate and triggers Kussmaul respirations.
Identify metabolic alkalosis
Loss of gastric acid through suction causes alkalosis with hypokalemia.
Recognizing Life-Threatening Complications
The nurse detects emergencies such as stroke, pulmonary embolism, shock, and increased intracranial pressure and intervenes rapidly. Time-sensitive recognition saves lives.
Act fast in stroke
Facial droop, slurred speech, and weakness require immediate stroke protocol activation and onset time documentation.
Suspect pulmonary embolism
Sudden dyspnea, chest pain, and tachycardia after surgery signal a possible embolism.
Detect early increased ICP
A change in level of consciousness is the earliest sign of increased intracranial pressure.
Recognize compensated shock
Tachycardia and cool, clammy skin appear as the body compensates for hypovolemia.
Managing Chronic and Endocrine Conditions
The nurse manages chronic conditions such as diabetes, thyroid and adrenal disorders, and organ failure, teaching self-care and preventing crises. Understanding pathophysiology guides intervention.
Treat hypoglycemia promptly
Give about 15 grams of fast-acting carbohydrate to a conscious client, then recheck glucose.
Recognize thyroid patterns
Hypothyroidism causes fatigue, cold intolerance, and bradycardia; hyperthyroidism causes the opposite.
Prevent adrenal crisis
Severe hypotension and hyperkalemia in Addison's disease require immediate fluids and hydrocortisone.
Support organ failure
Lower ammonia in hepatic encephalopathy and implement bleeding precautions in liver failure.
Kiểm tra kiến thức của bạn
Câu hỏi luyện tập về Physiological Adaptation and Reduction of Risk