Exam 1 Flashcards
What is the nursing process?
A systematic method for providing patient care
It includes assessment, diagnosis, planning, implementation, and evaluation.
What does cyanosis indicate?
A sign of inadequate oxygenation (hypoxia) due to heart dysfunction
It is caused by poor perfusion.
What is responsible for perfusion?
The heart
What are attitudes of critical thinkers? (select all that apply)
confidence, thinking independently, risk taking, creativity, discipline, responsibility and authority
In the nursing process, what does ‘assess’ mean?
Evaluate, examination, check
What is clinical inference?
part of the clinical decision-making process that occurs before you determine what your patient problems are
Define patient outcome.
A measurable goal for patient care
What is data validation?
The comparisson of data with another source to determine data accuracy
Give examples of objective data.
Vital signs, laboratory results, observable physical signs
Objective data is measurable and verifiable. (somehing you can see)
What is a data cluster?
organizing all data elements about a patient into meaningful patters
helps you to think less aboout individual data points and focus on a pattern
What nursing interventions do not require physician’s orders?
Patient education, basic nursing care, comfort measures
Specific tasks may vary by institution.
How should a patient with limitations be encouraged?
To do as much as they can on their own within their limitations
What should you do if a patient is short of breath after morning care?
Have them rest
What is an example of objective data?
A patient’s pulse rate
What are the steps of developing a nursing diagnosis in order?
Assessment, data analysis, diagnosis formulation, planning
This process includes prioritizing nursing diagnoses.
Define diffusion.
exchange of respiratory gases in the alveoli and capillaries
What is ventilation?
The physical process of lungs expanding
the process of moving gases into and out of the lungs
Differentiate diffusion from perfusion.
Diffusion is gas exchange; perfusion is blood flow
perfusion- what comes from the heart not lungs
What is the earliest sign of hypoxia?
Restlessness
How can we help patients thin secretions?
Hydrate
What is hypoventilation?
alveolar ventilation is inadequate to meet the oxygen demand of the body or to eliminate sufficient carbon dioxide
What type of lubricants should be used?
Water-soluble lubricants
What should you do for a patient who is having trouble breathing?
Raise the head of the bed first
What is important regarding oxygen devices?
- Nasal canula: 1-6 L = 24%
- Simple mask: 6-12 L = 45-60%
- Nonrebreather: 10-15 L = 60-90%
- Venturi mask: 4- 15 L = 24-60%
- based off different pieces
What should be done if a patient is uncomfortable with oxygen?
Humidify the oxygen
How should the nasal cannula be positioned?
Properly fitted in the nostrils pointing down
What happens if a patient with a tracheostomy can talk?
It indicates a problem if the trach is dislodged
What should you do if a patient gags during suctioning?
Stop and pull it back
What is a priority operation when performing oropharyngeal care for a patient receiving oxygen?
Have the face mask readily accessible
What is an example of an appropriate nursing diagnosis?
- problem
-etiology
ex. Risk for injury (problem) related to decreased visual acuity and decreased mobility (etiology)
How do you open sterile packaging?
Carefully to maintain sterility
drop the item 6-8 inches
What are symptoms of oxygen toxicity?
fatigue, nausea, vomitting, nonproductive cough, substernal pain
Symptoms may vary in severity.
What does a non-rebreather mask provide?
The highest percentage of oxygen
List early and late signs of hypoxia.
Early: restlessness, hypertension, tachypnea, confusion
Late: cyanotic skin, hypotension, bradypnea
Signs may vary by patient condition.
How long should you suction a patient?
10-15 seconds
What is the rationale for using an incentive spirometer? (select all that apply)
Increase lung volume, promote deep breathing, prevent atelectasis
-at least once an hour for every hour awake
What are suction pressure settings?
adult: 100-150
infant: 80-100
What should be prioritized in older patients?
managing medication at home
Why do older adults complain of being cold?
Due to circulation and decreased body fat
What are the differences between dementia, depression, and delirium?
Dementia: chronic progressive and possible has an unknow cause
Depression: mood disorder, chronic, acute, or gradual onset
Delirium: acute, can have physiological source or being related to a change in suroundings
What tests are included in age-related screens for older adults?
- Cognitive assessments
- vision and hearing tests
- functional ability tests
- osteoporosis screening
-cholesterole and diabetes screening
Does increased intestinal motility lead to an increased risk of diarrhea?
Not necessarily
What is presbycusis?
Age-related hearing loss affecting high pitch sounds
Patients may hear low pitch sounds normally.
How can we allow an older adult autonomy?
Allow them to make as many decisions as possible
