Capitals of Asia Flashcards
most gerontologist no longer give precedence to the concept of
disengagement theory
a patient is admitted with urinary retention there is a order to insert an indwelling catheter but when you go in he voids 100cc’s prior. What would you do?
perform a bladder scan to determine the amount of urine retained
after you administer a medication for diarrhea. What is the most important thing for a nurse to do?
assess the patient for abdominal distension
the nurse has a patient who is in the hospital who is developing some respiratory complications and he is on bedrest. What should you ensure?
that he doesn’t get hypostatic pneumonia
how many tablespoons are in 1 fluid ounce
2
you have a patient who has a resection of the prostate gland and he has a three way catheter for continuous irrigation if there is blood
notify the physician immediately
when the patient needs to do a Kegel exercise may greatly reduce or stop
incontinence
kg to pounds
multiply by 2.2
patient has a pooling of blood under the skin after a fall. The nurse will need to document
this is a hematoma
a patient has skeletal traction and she is concerned about clear fluid oozing. Inform her that
this is normal
the nurse has a group of patients and out of the group that needs to be a priority is the
patient that has a tracheostomy and pneumonia
the nurse is doing a neurovascular assessment on a patient with a long leg cast. The nurse knows this is a indication of altered perfusion because the patient has
numbness in the distal limb
a patient has collapsed and cannot be aroused and you say are you okay? The next step would be
call for help (if you have assistance have them get help)
a patient is using a trapeze
left heel
the parameters for nasopharyngeal suctioning
80 to 120
the nurse is auscultating lung sounds and she hears a high pitch. They are harsh musical sounds
this is stridor
you have a 10 month old baby who has watery green stools for two days now and refusing the bottle. The primary concern is?
metabolic acidosis
a nurse provides care for a client who has a ng tube to intermittent suction. One of the action s the nurse will do is check for?
abdominal distension
a nurse is providing care for a group of patients. OUT of these patient which of these patients should be reassigned to a RN
the patient that has asthma and on oxygen via a non breather
a new nurse is doing an indwelling urinary catheter. Tell the new nurse is to
review the agency’s policy and procedure manual
you have a patient with c- diff. what type of hand hygiene do you use?
antibacterial soap
the nurse ha s a 92 year old patient. She is writing the care plan up a good nursing diagnosis would be?
potential for fall related to confusion
a patient is on a vegan diet. Which foods would raise their irons
mustard greens
several hormones affect urine output and fluid balance. When then blood becomes concentrated decreased circuitry blood volume
released in adh
patient on iv therapy. a sign that they are receiving too much iv fluids would be
full bounding pulse
24 urine specimens the nurse accidently discards some of the urine. What do you do?
notify the charge nurse and restart the whole test
to help parents to plan for any possible changes in their life the adult children should keep communication lines open
within the family
one affect of immobility on the brain is a decrease in
sensory input
passive range of motion exercises are usually to prevent…
decreased joint mobility
an older adult will frequently develop clouding of the lens of the eye. This is called?
cataracts
when you have a older adult confusion can be reversible in patients who are ?
delirious
if a nurse assumes every patient has a transmittable disease in a health care setting is called?
standard precautions
sertraline, propylene, and fluoroxytine are all examples of?
SSRI’s
30 cc’s is in a
fluid ounce
the device that a nurse would use for total parenteral is administered through a?
central venous access
an isotonic state exists within a patients body fluids when the solute concentration of
intracellular and extracellular are equal
the nurse points out that a non electrolyte product of metabolism are as important to health as electrolytes are. Name one non electrolyte
an amino acid
a patient has a vitamin deficiency. The nurse understands they would have a deficiency of ?
calcium
you have some small ions such as glucose, oxygen, carbon dioxide, and the three redistribute themselves through a semi permeable membrane by a process called?
diffusion
neuromuscular irritability is assessed when there is imbalances in which electrolytes?
calcium and magnesium
a patient with COPD will be in?
respiratory acidosis
you have a anxious patient and there respiratory rate is 40 have them breathe through a
rebreather mask
the nurse is aware that a more dynamic process that moves the molecules into the cells regardless of their electrical charge there concentration in the cell and requires cellular energy
active transport
when you have a fluid volume deficit there is decrease fluid going to the brain this could decrease mental status. what electrolyte balance will this affect
sodium
pounds to kilograms
divide by 2.2
the nurse has 46 year old and he is admitted with decreased level of consciousness and he has symptoms of influenza and he is a diabetic. His blood gasses are ph 7.32 CO2 of 36 and a HCO3 of 20. The nurse would assess
metabolic acidosis
one way of tracking a patient with CHF their fluid status by their
daily weights
a male patient is admitted with elevated blood pressure, elevated edema, and rapid weight gain and might have CHF. They have
fluid excess
a patient has been advised to increase their calcium intake. What food can they eat?
canned salmon with bones
a 90 year old with vomiting and diarrhea. His skin is cool dry and pale. his pulse is up and bp is down. This indicates…
he is dehydrated
you have a patient on Lasix and the lab indicates the potassium is 3.3
the patient has hypokalemia
the patient complains of headache, confusion, muscle cramps, and anorexia
the patient is in hyponatremia
the patient is having difficulty breathing its important to reduce her anxiety. anxiety tenses the muscles which
uses up oxygen
you have a patient who needs suctioning through a nasal tracheal route hold the catheter with your dominate hand after you place
sterile gloves on
your patient is post op who can breathe okay, but he is having trouble maintain his airway because of his tongue falling back in his throat place a
pharyngeal airway
the nurse see’s when there is a decrease amount of oxygen in the blood it is called?
hypoxemia
your applying a bandage to the leg of a patient. To perform overlap turns of the bandage
equally
the patient is on iron supplement they complain they have dark almost black stools
tell the patient this is expected and not harmful
the nurse is examining the results for a urinalysis test. What distinguishes dehydration?
the specific gravity
you have a patient who breaks his hip and is on bedrest. the patient appears bored. Encourage
the family to visit different times throughout the day
the nurse is looking for a patient that would be at risk for insensible fluid loss of 800 mL per day. A patient with a fast…
respiratory rate
the patient that would be at risk for developing third spacing would be the patient with
diabetes mellitus
the nurse understands that a potassium value of 5.5 would be noted in a?
traumatic burn patient
the nurse notes echomotic areas on the arms and buttocks is brought into the ER. The client tells the nurse in confidence that her daughter hits her when she gets in her way. Tell her you have a legal obligation to?
report this type of abuse
You have a client who has a hemoglobin of 10.8 the client can have
iron deficiency anemia
the nurse has a lab result that needs to be called into the doctor.
a sodium of 148
the nurse has a potassium level that she is concerned about
potassium level of 3.2
a blood glucose level that is concerning is
240
a patient is having trouble with blood clotting encourage the client to eat
green leafy vegetables
which food would be apart of the low sodium diet
baked turkey
a patient is on the clear liquid diet. You can offer them fat free?
beef broth
the nurse has a patient with post op complications. Which post op complication would require further observation
urinary out of 20 mL an hour
the nurse has a pt that is post op. the bp is 100/60 resp. 20 . Is this concerning?
no
the patient is coming back post op. Check the patency of the?
airway
the nurse monitors the post op. knowing that respiratory secretions can lead to further medical complications such as?
pneumonia
the nurse is caring for a patient who has a drainage. WHAT intervention SHOULD THE NURSE not AVOID?
securing the drain by curling, folding, and taping it to the body
which would indicate potential infection when looking at a wound or surgical incision
purulent drainage
when administering cleansing enema to a client with a fecal impaction. Which position would you place the pt
left sims position with the HOB flat
the nurse is inserting a nasogastric tube
the pt needs to be sitting up
your turning a post op pt who had extensive spinal surgery and you want to turn him by
logrolling
the nurse is preparing to feed a pt who has intermittent tube feeding and pulls out 50 cc’s of residual.
reinstill the residual and administer the feeding
your placing a nasogastric tube and you aspirate the clients stomach contents and check the ph
a normal ph would be 3.5
your inserting a indwelling catheter to a male patient the urine begins to the tubing. The nurse should take which step next
insert the catheter 2.5 to 5 cm and then inflate the balloon
the patient ahs a chest tube for crepitus. The patient has subcutaneous emphysema. Which method should be used?
palpate for leakage of air into the subcutaneous tissue
the nurse is assigned to assess for a chest tube and the nurse sees fluctuations in the water seal chamber based on this observation. Which action would be appropriate
document the findings
the nurse is going to start a tube feeding in a nasogastric patient
the patient needs to be sitting up with the HOB at 45 degrees
you have a client who is reminiscing about past life experiences . This indicates a normal psychosocial response
normal psychosocoal
the pt is on dijoxin the nurse understands that which age related change would lead to toxicity
glomerular filtration rate and
you have a client who is having trouble hearing. What do you do?
low pitched tones
your preparing to communicate with a client who is hearing impaired. which implementation would you do first ?
stand in front of them
which would include a client who is experiencing ineffective coping because of the loss of a spouse ?
constantly neglect personal grooming
the nurse has a client who says they don’t speak English. What is the best intervention?
uses hospital resources
the patient that has a stage 2 pressure injury =. The nurse would expect to find
partial skin loss of the epidermis
when you remove sutures you clip the suture above the knot
above the knot
what reduces the functional hemoglobin which limits the oxygen carrying ability of the blood?
smoking
loss of interference with circulation especially over a bony prominence can lead to pressure injurys
pressure injurys
during what do you determine whether the expected outcomes set during the planning stages have been met?
evaluation
