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NCLEX > Basic Care and Comfort > Flashcards

Basic Care and Comfort Flashcards

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1
Q

diabetic diet

A

decreasing serum lipid levels

accurate carbs counting

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2
Q

DASH diet

A

limit sodium to 2300 mg/day

lower DASH diet = 1500 mg/day of sodium

low in saturated fat, cholesterol and total fat

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3
Q

low tyramine

A

avoid foods high in tyramine:

  • aged cheese
  • cured, processed or smoked heats
  • beer
  • pickled or fermented foods
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4
Q

low purine diet

A

used for clients with gout

restrict
- glandular meats
- chicken
- ducks
- fowl foods
anchovies
- beer and wine
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5
Q

low calcium

A

limit to 400 mg/day

restrcits:

  • dried fruits and vegetables
  • shellfish
  • cheese
  • nuts
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6
Q

enteral nutrition

A

breast milk can be given to newborns or infants through a feeding tube

types of feeding tubes:
NG tube, oro tube
- used for short term nutirtional supports
- usually less than 4 weeks

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7
Q

enteral nutrition interventiosn

A

HOB 30-45 degreee
monitor character and frequency bowel movements
pH less than 6

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8
Q

administration of enteral nutrition feedings

A

may be continuous or intermittent

hang for 8 hours or less
change tubing every 24 hours

administer at room temp

receive “free water” or water boluses

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9
Q

gastric residual monitoring

A

evaluate gastric residual every 4-6 hours for conitnuous feeding or prior to intermittent feedings

if gastric residual is greater than volume given over 2 hours

  • may be necessary to reduce the heart rate of feeding
  • or temporarily hold the feeding

DO NOT discard the aspirated residual
- return the entire residual amount to the stomach

flush tube with approc 30 mL at room temp every 4 hours after feeding is complete and before and after meds

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10
Q

hypercalcemia causes and findgins

A

causes:
- hyperparathyroidism
- metasis of cancer
- prolonged immbolization
- Pagets disease

findings:

  • weakness
  • paralysis
  • decreased deep tendon reflexes
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11
Q

hypocalcemia causes and findings

A

causes:

  • vit D deficiency
  • renal failure
  • pancreatitis
  • hypoparathyroisim

findings:

  • mscle tingline
  • twitching
  • tetany
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12
Q

magnesium is used for

A 
normal muscle and nerve function
heart rhythm
immune system
blood sugar regulation
BP
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13
Q

hypermagenesemia causes and findings

A

causes:

  • chronic renal disease
  • overused of mangesium-containing antacids like Maalox and Mylants
  • Addison’s disease
  • uncontrolled diabetes mellitus

signs and symptoms will be the opposite of “hyper” so all the findings will be slow or low

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14
Q

hypomagnesemia causes and findgins

A

causes:
- malnutrition
- malabsorption
- alcoholism
- diabetic acidosis

signs and symptoms will be the opposite of “hypo” so all the findings will be high or erratic

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15
Q

phosphate is used for

A

aids in cellular energy absorption
combines with calcium in one

assistsin structure of genetic maternal
normal: 2.8 - 4.5

balanced by parathyroid gland, along with calcium

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16
Q

potassium is used for

A

regulated by kidneys

hyperkalemia and hypokalemia:
high or low findings can results ina fast or slow and irregular heart rhythm, changes in ECG and muscle function
- like leg cramps

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17
Q

sodium is used for

A

regulated by slat intake, aldosterone and urianry output

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18
Q

hyponatremia

A

fluid overload

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19
Q

hypernatremia

A

dehydration

hypertension
generalized edema or anasarca

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20
Q

pressure ulcers

A

turn and reposition at least every 2 hours
use heel and elbow protectors

use alternating pressure mattrees or other pressure-reducing bed surface

avoid massaging any reddned areas and potentially damaging any skin tissue

limit sitting in chair for no longer than 2-4 hours
- shift weight at least every 30-60 minutes

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21
Q

mobility for respiratory system

A

instruct client to cough and deep breathe every hour

perofrm incentive spirometry every hour
turn immobile client every 2 hours

oropharyngeal suctioning if needed

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22
Q

mobility for urinary renal system

A

ensure that client drinks at least 2000 to 3000 mL (2-3L) of water per day

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23
Q

orthostatic hypotension

A

put the client at risk for falls

instruct to change positions slowly, progressing from lying down to sitting up and then standing

highest risk of falling is while moving from supine to standing position

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24
Q

increased cardiac workload

A

avoid bearing down when exhaling and to minimize coughing

allow limited sitting in high fowlers position from 1-2 hours

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25
Q

venous thromboembolism formation

A

apply thigh or knee-high anti embolic stockings and/or intermittent pneumatic compression

tunr every 2 hours

administer anticoagulation therapy

initate ambulation or assist with dorsiflexion and plantar flexion of the foot

limit client sitting with feet in dependent position to 1-2 hours at one time

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26
Q

full weight bearing

A

healthy person can carry their own weight without any type of assistive device

upper extremities are also considered full weight bearing when lifting and moving objects without assistance

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27
Q

partial weight bearing

A

limitation that is greater than non-weight bearing

assistive device such as:

  • walker
  • cane
  • crutches
  • CAM walker boot

imagine that there is a raw egg underneath their foot and cannot crak it

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28
Q

toe touch weight bearing

A

client toes may lightly rest on ground while sitting, stnaidng or transferring to maintain balance

but no actual weight should be place on affected leg

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29
Q

non weight bearing

A

stricted limitation

no weight whatsoever, not even for a moemtn or 2 whether standing, walking or sitting

for an upper extremity:
- should wear sling or similar device to prevent client from placing weights on affected limb

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30
Q

stress incontinence

A

sudden increase in intra-abdominal pressure like sneezing or coughing or anything that puts pressure on the bladder

causes urine to leak from bladder

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31
Q

overflow incontinence

A

bladder empties incompletely so urine dribbles constantly

often due to an obstruction

exmaple: enlarge prostate in men

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32
Q

urge incontinence

A

overactive bladder

uncontrolled contraction of bladder results in urine leakage beofre one reaches the bathroom

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33
Q

functional incontinence

A

incontinence that is not due to organic reasons

impaired mobility may prevent client from reaching the bathroom in time

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34
Q

treatment in incontinence

A

structed peeing schedule
kegel exercises
protect skin integrity
surgery

35
Q

ileostomy

A

opening created ti bring the small intestine to surface of abdomen, specifically the ileum

always have liquid stool

poses the highest risk of skin breakdown

after surgery, stool will be dark green, then turns yellow when pt starts to eat

NO enteric coating medications because they dont dissolve

36
Q

colostomy

A

opening created to rbing large intestine to surface of abdomen

descending
ascending
transverse
sigmoid

descending and sigmoid: similar to normal consistency of regular stool

ascending: liquid stool
transverse: loose to partly formed stool

after surgery:
may pass mucous stool at first
- will be liquid at first then progress to what it should look like depending on the location

37
Q

colostomy and ileostomy diet teaching

A

start out slow for first 6 weeks

low fiber
small meals throughout the day

monitor hydration and electrolyte status

eat slowly and chew thoroughly, then advance as tolerated

with ileostomy, need to stay hydrated and consume fluid and electrolyte solutions like Gatorade

use caution and eat small amount of completely avoid foods that are not completely digestible:

  • conr
  • celery
  • peas
  • coleslaw
  • popcorn
  • nuts and seeds
  • raisins
  • skin of fruits
  • raw mushroom
  • pineapple
38
Q

colostomy and ileostomy pouch care

A

colostomy: put petroleum gauze over stoma to keep it moist
- then a sterile dressing until pouching system is in place

empty pouch when 1/3 to 1/2 full
change pouch when gut less active
- morning before breakfast

keep stoma and skin around stoma clean
watch for burning around skin or leaking

be familiar with various pouching system

when applying, be sure to measure the stoma and cut the opening of the skin barrier to be 1/8” larger than stoma

stoma irrigation may be ordered by the doctor

39
Q

colostomy and ileostomy pre-operation

A

educate what to expect, what it will look like, where it will be on abdomen

start teaching pouching system

MD may prescribe oral antibiotics
2-3 days before surgery soft or semi-liquid diet

cleansing solution and laxative may be ordered
NPO on day of surgery

40
Q

colostomy and ileostomy post operation

A

monitor signs of electrolytes and dehydration

after surgery, stoma will be swollen and large for 48-72 hours, but after couple months it’ll shrink down

should always look pink or red and be moist/shiny

if client has a blockage or notices a significant decrease of stool in pouch, the client should call their HCP immediately

41
Q

loop stoma

A

usually temporary

proximal end of loop stoma is functioning end while distal end drains mucus

42
Q

double barrel

A

forms 2 stomas similar to a loop stoma, but the bowel is surgically severed

43
Q

sleep and SIDs

A

infants should be place on their back for sleep

cribs should be clear of pillows, toys and blankets

44
Q

risk factors of SIDs

A 
co-sleeping
history of SIDs
low birth weights
male
age under a year
prematurity
exposure to second hand smoke
twin births 
poverty
45
Q

infant play

A

tend to play alone or with caregivers

toys:

  • music boxes
  • teething toys
  • mobiles or large blocks
46
Q

toddlers play

A

alongside other childrenwithout interacting together

toys:
push-pull oys
- blocks
- thick crayons
- finger paints
- puzzles
- dolls
- trucks and dress up

play should be active and screen time should be limited to 1 hour a day

47
Q

preschool play

A

enjoy group play without rigid rules

toys:

  • tricycles
  • wagons
  • paints
  • crayons
  • puzzles
  • books
  • balls

play may be imaginative and dramatic

media time should be limited to 2 hours a day

48
Q

school age play

A

cooperative play

toys:

  • board games
  • jump ropes
  • books
  • bicycles
  • crafts or sports
49
Q

adolescent play

A

participating with peers during play

toys:

  • music, sports
  • career
  • training programs
  • books
  • movies
50
Q

blood administration

A

never use dextrose or LR to prime blood and administer blood products
- avoid giving any medications through same IV line used for transfusions

do not discard blood product and blood tubing
- send tubing and product to blood bank

O negative = universal red cell donor
AB blood = universal plasma donor

if transfusion cannot be started within 30 minutes from when product was released from blood bank, then nurse must return to blood bank

should never be stored on nursing unit, even if its refrigerated

51
Q

blood administration reaction

A

if reaction occurs:

disconnect blood product and blood tubing
- do not discard

maintain patent IV line with saline

obtain vital and monitor closely
notify blood bank and HCP imediately

send saved blood product and tubing to blookd bank

monitor urine output

52
Q

pediatrics: giving med orally

A

for meds with unpleasant taste, nurse may mix small amount of meds with

  • syrup
  • applesauce
  • sherbet

with younger children, use a small syringe or nipple giving time for swallowing
- place liquid medication at side of of mouth rather than to the back of the throat to avoid aspiration

53
Q

pediatrics: IM med

A

vastus lateralist: preferred location for infants and toddlers

  • with infants give 0.5mL/leg
  • older children may have up to 2 mL

ventrogluteal: route may less reactions or pain than vastus lateralist
- administer 0.5 mL for infants
- up to 2mL for older children

deltoid: faster absorption than other routes
- should not use this site for infants and small children
- administer 0.5 - 1mL/arm

54
Q

infiltration sxs

A

edema
pain
coolness around insertion site
infusion pump alarm

55
Q

infiltration nursing care

A 
discontinue IV
apply warm compress
apply sterile dressing
elevate arm
monitor for compartment syndrome
evaluate neruovascular status
56
Q

phlebitis sxs

A

reddened, warm are a around insertion site or path of vein
tenderness
swelling

57
Q

phlebitis nursing care

A

discontiue IV

apply warm, moist compress

58
Q

thrombphlebitis sxs

A 
pain
swelling
redness and warmth around insertion site or path of vein
fever
leukocytosis
59
Q

thrombophlebitis nursing care

A

discontinue IV
apply warm compress
elevate extremity

60
Q

hematoma sxs

A

ecchymosis
immediate swelling at site
leakage of blood at site

61
Q

hematoma nursing care

A

discontinue IV
apply pressure with sterile dressing
aply cool compress intermittently for 24 hours to site, followed by warm compress

62
Q

clotting sxs

A

decrease IV flow rate or infusion pump alarming

back flow of blood into tubing

63
Q

clotting nursing care

A

disconitnue IV
do not attempty to flush or irrigate the IV
do not aspirate clot from cannula

64
Q

circulatory overload sxs

A 
crackles
dyspnea
increased BP, HR
restlessness
anxiety
confusion
seizures
65
Q

circulatory overload nursing care

A

reduce IV rate to keep vein open
monitor vitals
notify HCP immediately

66
Q

central venous access device nursing care

A

strict hand hygiene
aseptic technique
close monitoring for sxs of complications

changing of administration sets, dressings and add-on devices at recommended intervals

CHG bathing
consulting with HCP for removal

monitor for resp distress, diminishe or absent breath sounds
monitor for chest pain or tracheal deviation from midline
- should not be accessed or used until correct placement has been confirmed via chest x-ray

67
Q

complications of CVA device

A 
catheter occlusion
local catheter infection
systemic catheter infection
embolism
catheter migration
68
Q

catheter occlusion sxs

A

inability to infused and/or aspirate from lumen

69
Q

catheter occlusion treatment

A

reposition client
“gently” flush client with 10mL NS
instill thrombolytic agent

70
Q

local catheter infections sxs

A 
redness
tenderness
warmth
edema
purulent drainage
71
Q

local catheter infection treatment

A 
change dressing
chlorhexidine biopatch
aspetic technique
"closed" system wit IV tubing
remove catheter if necessary
72
Q

systemic catheter infection treatment

A

remove catheter
culture tip of catheter
obtain blood cultures
start antibiotic therapy

73
Q

embolism sxs

A

sudden onset of resp distress
hypotension
tachycardia
chest pain

74
Q

embolism treatment

A

immediately place on their left side with head lower than heart
administer oxygen
notify HCP

75
Q

catheter migration sxs

A 
"gurgling" sound in ear
edema of chest or neck
inability to infused and/or aspirate blood from catheter
dysrhythmias
change in catheter length
76
Q

catheter migration treatment

A

stop any infusions
perform fluoroscopy or chest x-ray
remove catheter if needed

77
Q

interventions when caring for a client with CVAD

A 
hand hygeiene
bathe chlorhexidine on daily basis
scrub access port or hub with friction
sterile device
replace dressings that are wet, soiled, or dislodged
perform routine dressing changes
- with clean or sterile gloves

daily audits to see if CVAD is still needed

78
Q

parenteral nutrition or TPN preparation

A

prepared by or under the supervision of a pharmacist

aseptic technique under a laminar airflow hood

nothign should be added after it has been prepared

good for 24 hours
- mut be refrigerated until 30 minutes before use

79
Q

parenteral nutrition or TPN administration

A
  1. 22 micron filter with TPN without lipids
  2. 2 micron filter with TPN with lipids

always use infusion pump

use dedicated line for TPN

  • do not infused other solutions with TPN or administer intermittent IV meds
  • including IV push meds through the same line with TPN

before starting TPN infusion, nurse must verify that the ingredients in the solution match what the HCP ordered

80
Q

parenteral nutrition or TPN complications

A

hypoglycemia

  • can occur when TPN runs out before a new bag is available
  • should hang dextrose-containing IV solutions like (D5, D10, or D20%) until new TPn bag is available

hyperglycemia
- blood sugar should be checked

fluid/circulatory overload

81
Q

parenteral nutrition or TPN interventions

A

daily weights
accurate intake and output
blood sugar
regular lab tests

82
Q

teratogenic drug categories

A

category A:
no risk to fetus; controlled studies in humans

B: animals studies show no risk to fetus

C: no controlled studies in animals or humans

D: evidence of human risks to the fetus

X: fetal abnormalities in both animals and humans

83
Q

high alert medications

A 
potassium
insuline
narcotics
chemotherapy
heparin

NCLEX (21 decks)

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