Exam 1 Flashcards
1
Q
Bradypnea
A
Respiration rate slower than 12/min
2
Q
Tachypnea
A
Respiration rate faster than 20/min
3
Q
apnea
A
Absence of spontaneous respirations
4
Q
What helps regulate breathing?
A
Medulla and level of carbon dioxide in the blood
5
Q
Inspiration
A
Active process when external muscles contract, diaphragm moves down, and chest cavity expands
6
Q
expiration
A
Passive process when external intercostal muscles relax, diaphragm moves up
7
Q
What three things should you monitor during respiration?
A
Rate, rhythm, and depth
8
Q
How long do you count respirations for when the rhythm is irregular?
A
1 full minute
9
Q
What can increase respiratory rates?
A
Anxiety, fever, exercise, low hemoglobin
10
Q
Cheyne- stokes respiration
A
Breathing cycles that increase in rate and depth then decrease and are followed by a period of apnea
-Heart failure or ICP (increased cranial pressure)
11
Q
Biots respirations
A
Slow and deep or rapid and shallow followed by apnea
- central nervous system abnormalities
Big D slow and deep but sometimes fast and shallow
12
Q
Kussmauls respirations
A
Deep and gasping respirations
- Renal failure, septic shock, or diabetic ketoacidosis.
Cuz helps me I’m dying
13
Q
Diabetic Ketoacidosis
A
Fatal condition when body cannot produce enough insulin (Fruity smell)
14
Q
Tidal volume (depth)
A
Amount of air that moves in and out of the lungs with each breath
15
Q
PMI
A
Point of maximum impulse
16
Q
How should you position the patient when evaluating the apical pulse? What should you ask?
A
Supine or sitting
Are you taking any cardiovascular medications?
17
Q
Name the peripheral sites that you can palpate a pulse at
A
Popliteal, dorsalis pedis, radial, carotid, superficial temporal, brachial
18
Q
Bounding pulse
A
Pulse feeling like heart is racing
19
Q
How do you calculate pulse deficit?
A
You subtract radial pulse from Apical
20
Q
What are descriptive words used to describe a pulse?
A
Absent, weak, diminished, strong, or bounding
21
Q
Do men or women typically have a faster pulse?
A
women
22
Q
What produces the S1 sound?
A
Tricuspid and mitral valves close at the end of ventricular filling
23
Q
What produces the S2 sound?
A
The pulmonary and aortic valves closing at the end of contraction
24
Q
what is the normal blood pressure?
A
120/80
25
systole
contraction phase of the cardiac cycle. During this phase blood is driven into the aorta and pulmonary arteries (pressure in arteries during heart contraction)
26
Diastole
Relaxation phase of the cardiac cycle where the heart muscle is relaxed and the chambers of the heart fill with blood (pressure in arteries during relaxation)
27
What is a normal BP range?
Systole 90-119 mm Hg
Diastole 60-79mm Hg
28
What is an aneroid manometer? used to take BP
metal parts that can expand and contract at certain temperatures
29
Orthostatic hypotension
Systolic pressure drops more than 20mm Hg or pulse increased by 20 or more/min when moving.
Often related to decrease in blood volume
30
When taking axilla temperature where should you position the patients arm?
Across abdomen
31
How should you measure temporal temperature?
Start at the center of the forehead and move across head to the hairline, next place the probe behind ear.
32
When measuring tympanic temperature how should you move the pinna?
Back, up, and out
33
What is the normal oral temperature?
97.6-98.6
34
How much lower are axillary temperatures in comparison to oral?
0.9
35
how do you convert Celsius to Fahrenheit
multiple by 9/5 and add 32
36
How do you convert Fahrenheit to Celsius
subtract 32 and multiple by 5/9
37
When should you wait to take oral temperature?
When client has been eating, drinking, smoking or exercising wait 30 minutes
38
what can affect oxygen saturation reading?
client movement, hypothermia, medications that cause vasoconstriction, peripheral edema, hypotension, and abnormal hemoglobin levels
39
How do you measure a core temperature?
Tympanic
40
chemical thermometers
single use only
41
pyrexia
increased temperature (fever)
42
What are some symptoms of pyrexia
Rapid heartbeat, dehydration, decreased urinary output
43
Hyperthermia
Increase in body temperature
44
Hypothermia
Decrease in body temperature
45
40% circumference and
46
can a client who has low hemoglobin appear to have a normal sp02
Yes, because this measures the hemoglobin that is available and the saturation of those
47
Hypertension 2
Greater than 140 or equal and 90
48
BP and eating
Patient should avoid eating food 20 minutes prior to BP and should avoid caffeine for at least 3 hours prior
49
cerumen
earwax discharge
50
suspension
contains small fine particles of medication that do no dissolve completely in water
50
why position the arm at heart level when doing BP
Patients will contract arm muscles and increase diastolic reading or if arm is over heart this can create decrease
51
solution
contains medication dissolved in water or 0.9% sodium chloride, furosemide, or loop diuretic
52
Elixir
contains water, alcohol, sweetener, and medication
53
diaphoresis
Excessive, abnormal sweating that affects the entire body
- Rationale for changing linen frequently
54
Chlorhexidine
Use for a patient who is unconscious for oral care. This medication is an germicidal mouthwash
55
when providing care for a postoperative patient should you accommodate their typical morning routine?
yes
56
should you change the bedding (including pillowcase) when making a patient's bed?
No. You only have to change the bedding if its wet or soiled.
57
When providing bed bath which of the following actions should a nurse take?
Raise the room temperature so patient is comfortable
58
What action should a nurse take to reduce risk of infection while performing bed bathe?
Clean the least soiled areas prior to cleaning the most soiled
59
Describes the sequence to give a bed bath
Introduce yourself, confirm client, verify providers orders, gather supplies, confirm privacy, supplies near bedside, perform hand hygiene, explain procedure and don gloves
60
Fowler's position and semi-fowlers
Fowlers position the bed 45-60 degrees
Semi Fowlers position 15-45 degrees
61
Halitosis
Bad breath
62
Periodontitis
Untreated gingivitis can lead to gum disease which causes redness, swelling, and bleeding
63
Effleurage
back massage after a bath which helps patient relax
64
cerumen
ear wax
65
sims position
Placing patient on their side
66
Erythematous
Abnormal redness
67
What finding would indicate adverse effect to oxygen therapy?
Cracks in the oral mucosa
-Oxygen, especially when delivered long-term and without sufficient humidification, has a drying effect that can cause cracks in the nasal and oral mucosa
68
Venturi mask
Most often used for critically ill patients - most accurate form of oxygen delivery
(ventilation)
69
what type of water is used for humidification? Sterile or distilled water?
sterile water
70
How far away should an oxygen tank be away from heat sources?
At least 10 feet away
71
Is cyanosis usually shown for acute or late stages of hypoxia?
late stage of hypoxia
72
What is a patient most likely to experience in the early stages of hypoxia?
Elevated BP
73
What is the advantage of using a nonrebreather mask?
Provides highest concentration of the low flow systems
74
What symptoms are shown in late stages of hypoxia?
Hypotension, bradycardia, and metabolic acidosis,
75
what are signs of chronic hypoxia?
finger and toes clubbing, right sided heart failure, and oxygen saturation below 87%, respiratory acidosis
76
respiratory acidosis
Lungs cannot remove enough carbon dioxide from the body, making blook acidic
77
Metabolic acidosis
occurs due to the production of ketone and lactic acid
involves kidney and urinary system
78
Nonrebreather mask information
bag attached
Low flow mask
used for acutely ill patients
10-15 L/min
80-90%
79
Venturi mask information
Hose attached
High flow
Best for patients with chronic diseases like COPD
24-50%
2-15 L/min
80
when should you use sterile water for oxygen therapy?
4L and above requires humidification
81
Nasal cannula
low flow used for non-acute situations
2-6 L/ min
24-44%
82
simple mask
moderate flow used for non-acute situations
used for short periods of time
6-10 L/min
40-60%
83
mechanical ventilation
Breathing assisted by either positive or negative pressure devices
84
CPAP
Positive airway pressure throughout breathing cycle
Commonly used for patients with sleep apnea because it keeps airways open
Helps with inspiration
85
BiPAP
Provides assistance during inspiration and keeps airway from closing during expiration
2 air pressures provided
86
Hypercapnia
Increased levels of c02
COPD patient is at risk for developing this
87
Hypoxemia
Decreased levels of arterial oxygen saturation
COPD patient is at risk for developing this
88
what promotes lung expansion?
Turning, repositioning, coughing, and deep breathing exercises
89
Hyperbaric chamber
pure oxygen delivery in a pressured environment
90
pallor
pale color of the skin
91
If a patient is having loose stools after a colostomy bag, should they eat foods with low or high fibers?
Foods low in fiber will help thicken the stool
92
Skin excoriation
Mechanical damage to the skin
93
When should a patient empty their ileostomy bag? Especially if they are concerned about smell.
1/3 to 1/2 full
94
Is it okay to clean the peristomal area with soap?
In most cases no because it will cause irritation
95
when should a patient expect effluent from a newly created stoma (colostomy)
2-5 days
96
when should a patient expect effluent from a newly created stoma
1 to 2 days
97
How do you identify the generic name on medications?
Typically, all lower-case letters, longer, and sometimes in parenthesis
98
what affects cardiac output?
Heart rate, preload, afterload, and contractility
99
What is the normal amount of blood pumped through the heart for a healthy individual?
3 to 5 liters
100
what is the equation for stroke volume?
end diastolic volume- end systolic volume
the stroke volume is the amount of blood being pumped by each ventricle
101
preload
the amount of blood in the ventricles at the end of diastole
102
what increases preload?
regurgitation of cardia valves, heart failure and hypervolemia
103
afterload
resistance left ventricle must overcome to circulate blood
104
what increased afterload?
hypertension, vasoconstriction
105
Name the risk factors associated with decreased perfusion
Hyperlipidemia
Atherosclerosis
Diabetes mellitus
PAD
sickle cell disease
106
Perfusion definition
passage of fluid through the circulatory system or lymphatic system to an organ or tissue, usually referring to the delivery of blood to capillary bed
107
Korotkoff sounds
Blood flow sounds
108
PQRST
provocation, quality, region, severity, time course
109
Factors that influence heat loss
evaporation, convection, hypothermia, radiation
110
Factors that influence heat production
Hyperthermia, Heatstroke
111
evaporation
dispersion of heat through water vapor
112
radiation
transfer of heat from one object to another without contact
113
convection
dispersion of heat through water vapor
114
conduction
Transfer of heat from the body directly to another surface
115
What does pulse quality help indicate?
Helps indicate abnormalities in electrical activity of the heart
116
Eupnea
Regular respiratory rhythm
117
orthopnea
shortness of breath while lying down
117
wheeze
crackling sound, may be fine or coarse, heard frequently on inspiration
118
crackle
coarse, harsh, loud sound, best heard on expiration
119
gurgle
continuous, high pitched musical sound best heard on expiration
120
febrile
symptoms of fever or nervousness
121
sequence of putting on PPE
Gown, mask, goggles, gloves
122
atelectasis
alveoli full of fluid
123
sequence of taking off PPE
gloves, goggles, gown, mask
124
cyanosis
blue discoloration
125
hypertensive crisis
higher than 180n
higher than 120
126
urinalysis
1.005-1.030
127
Things that are bad to find in urine
Protein, glucose, glucose, leukocytes, nitrates
128
BUN
Normal range 10-20mg/dl
129
albumin
3.5-5g/dl
130
eGFR
>90ml/min
Decreased renal filtering if less than
131
WBC
5-10 x 10/L
132
Hct
Female 37-47%
Male 42-52%
133
Hgb
Female 12-16 g/dl
Male 14-18g/dl
134
Dyspnea
Labored breathing
135
polyps
small growth intestinal system
136
colectomy
surgical removal of entire colon
137
exploratory laparotomy
surgical opening of the abdominal cavity
138
volvulus
twisting of the intestine
139
hematemesis
vomiting bright red or coffee ground blood
140
