EXAM #1 Comprehensive Review Flashcards
What is an Advanced Directive?
Written directions about the care they wish to recieve in the event that they become incapacitated and are unable to make health care decisions.
Can nurses witness an advanced directive?
No
What is a power of attorney?
aka Health care proxy
Person chosen by the patient to make health care decisions on the patients behalf when the patient can no longer make decisions.
What is a DNR?
Do Not Resuscitate orders.
What is the nurses role in Advanced Directives?
-Discussing it with the patient
-Ensures the patient has had information given to them about AD
-Putting it in the medical record
-Notify the MD
-CANNOT sign as a witness
What is informed consent?
The surgeon performing the surgery is responsible for explaining the procedure and the nurse is responsible for obtaining the signature of the patient saying they understand the procedure.
Can nurses be a witness to informed consent?
Yes but only if the patient understand the procedure.
The nurse mus then document the witness and patient signature
What tasks can be delegated to LPN?
-Reinforcement of clinical teaching (NO NEW TEACHING)
-Enteral Feedings/PPN
-Medications (PO, SQ, IM, IV)
-Stable or chronic clients
-24-hour post-op clients
-Wound Care
What tasks which can be delegated to UAP?
-Vitals for stable clients
-Collecting I/O
-Un-Stable
-Remind client to do something but not how to do it
-Detach suction
What is unintentional tort?
Negligence and malpractice
What is an intentional tort?
Assualt, battery and false imprisionment
Can PHI be given over the phone?
No
How is a rectal temperature taken?
Left lying, 1.5 to 2 in towards the umbillicus (adults) & no more than 0.5in (infants)
What is rectal temperature contraindicated in?
-Fecal Impaction
-Diarrhea
-C-diff
-Immunocompromised
-Bleeding
What conditions is tympanic temperature contraindicated in?
-Ear Infection, lesion, incision or hearing aide
What BP is considered hypertensive crisis?
180/120
What is the MAP formula?
What type of patients is an oral temperature contraindicated in?
-Unconscious
-Seizure
-Combative
-Uncooperative
Emergent (Red) emergency triage includes:
-#1 Priority
-Life threatening injuries and need immediate attention and continuous evaluation.
-Have a HIGH probability of survival when stabilized
-Trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, acute neurological deficits, chemical splashes to the eyes
Urgent (Yellow) emergency triage includes:
-#2 Priority
-Patients who require treatment and whose injuries have complications that are non life-threatening, given 30 minutes to 2 hours
-Requires continious evaluation every 30-60 minutes thereafter
-Open fractures with a distal pulse and large wounds
Non-urgent (Green) emergency triage includes:
-#3 Priority
-Patients with local injuries who do not have immediate complications and who can wait at least 2 hours for tx
-Require evaluation every 1-2 hours thereafter
-Closed fracture, minor lacerations, sprains, strains, or contusions
Black emergency triage includes:
-Victim is dead or soon will be deceased because of injuries
-Would NOT benefit from any care
What is the normal range of of body temperature?
97 (36.1) to 99 (37.2)
What is an elevated hypertension?
120-129/less than 80
What is stage 1 hypertension?
130-139/80-89
What is stage 2 hypertension?
At least 140/90
What conditions are contraindicated in use of NSAIDs and aspirin (acetylsalicylic acid)?
-Gastric irritation
-Ulcer disease
-Allergy
Nursing concerns for NSAIDs and aspirin (acetylsalicylic acid)?
-Can amplify the effects of anticoagulants
-Bleeding
-Take with milk or snacks to reduce irritation
-hypoglycemia may result from taking ibuprofen with oral anti diabetics
-High risk of toxicity with ibuprofen with calcium channel blockers
What conditions is acetaminophen contrainidicated in?
-Hepatic or renal disease
-Alcoholism
-Hypersensitivity
Nursing concerns for Acetaminophen?
-Monitor LFTs
-Do not take longer than 10 days for adults and 5 days for children
-Monitor for n/v/d, abdominal pain or jaundice for hepatic damage
What is the antidote for acetaminophen?
Acetylcysteine
What is a normal sodium level?
135-145
What does sodium do in the body?
-Maintains osmotic pressure and acid-base balance
-transmission of nerve impulses
What causes high sodium?
-Dehydration
-Impaired renal function
-Increased dietary or IV intake
-aldosteronism
What causes low sodium?
-Addisons disease
-Decrease intake of dierary sodium
-DKA
-Diuretic therapy
-Diarrhea
-Excessive perspiration
-Water intoxication
What is a normal potassium level?
3.5-5
What does potassium do in the body?
-Cellular water balance
-Eletrical conduction in muscle cells
-Acid-base balance
What causes elevated potassium?
-AKI
-CKD
-Addisons disease
-Dehydration
-DKA
-Excessive dietary or IV intake
-Massive tissue destruction
-Metabolic acidosis
What causes low potassium?
-Burns
-Cushings
-Deficient dietary intake
-Diarrhea
-diuretic therapy
-GI fistula
-Insulin
-Pyloric obstruction
-Starvation
-Vomiting
What does aPTT measure?
Evaluates how well the coagulation sequence is functioning by measuring the amount of time it takes in seconds for plasma to clot after partial thromboplastin is added to it.
What is the normal range for aPTT?
30-40 seconds
1.5 to 2.5X normal when on Heparin
What does PT measure?
The amount of time it takes in seconds to clot formation and is used to monitor response to warfain, to screen for abnormal clotting r/t liver disease, vitamin K deficiency, or DIC
What is a normal PT value?
11-12.5 seconds
What does INR measure?
Measures the effect of some anticoagulants
What is a normal INR value?
0.81 to 1.20
What is normal platelet count levels?
150,000 to 400,000
What is the normal values for hemoglobin?
Male: 14-28
Female:12-26
What is the normal values for hematocrit?
Male: 45-52%
Female: 37-47%
How long should a patient fast for lipid testing?
12-14 hours for foods a fluids (except water)
24 hours from alcohol
What is the normal value for cholesterol?
<200
What is the normal value for HDLs?
> 60
What is the normal value for LDLs?
<100
What is the normal values for triglycerides?
Male: 40-160
Female: 35-135
What conditions cause high LDL and cholesterol?
Biliary obstruction
Cirrhosis hyperlipidemia
Hypothyroidism
Idiopathic hypercholesterolemia
Renal disease
Uncontrolled diabetes
Oral contraceptive use
What conditions cause low cholesterol and LDLs?
-Extensive liver disease
-Hyperthyroidism
-Malnutrition
-Use of corticosteroid therapy
What is a normal fasting glucose?
70-99
What are nursing considerations for fasting glucose testing?
-Instruct the client to fast for 8 to 12 hours before the test.
-Instruct a client with diabetes mellitus to withhold morning insulin or oral hypoglycemic medication until after the blood is drawn.
What causes elevated fasting glucose levels?
-Acute stress
-Cerebral lesions
-Cushing’s syndrome
-Diabetes mellitus
-Hyperthyroidism
-Pancreatic insufficiency
What causes low fasting glucose levels?
-Addison’s disease
-Hepatic disease
-Hypothyroidism
-Insulin overdosage
-Pancreatic tumor
-Pituitary hypofunction
-Postdumping syndrome
What is the normal range for A1C?
-<5.7%.
-A level of 5.7% to 6.4% indicates prediabetes
-A level of 6.5% or more indicates diabetes
-Within the 5.7% to 6.4% prediabetes range
What does serum creatinine measure?
-Specific indicator of renal function.
-Increased levels of creatinine indicate a slowing of the glomerular filtration rate.
What should the patient avoid before the test for creatinine?
Avoid excessive exercise for 8 hours and excessive red meat intake for 24 hours before the test.
What are the normal ranges for creatinine?
-Male: 0.6 to 1.2 mg/dL
-Female: 0.5 to 1.1 mg/dL
What does BUN measure?
- Urea nitrogen is the nitrogen portion of urea, a substance formed in the liver through an enzymatic protein breakdown process.
- Urea is normally freely filtered through the renal glomeruli, with a small amount reabsorbed in the tubules and the remainder excreted in the urine.
What is a normal BUN level?
10-20
What conditions cause high BUN levels?
-Elevated levels indicate a slowing of the glomerular filtration rate.
-Burns
-Dehydration
-GI bleeding
-Increase in protein catabolism (fever, stress)
-Renal disease
-Shock
-Urinary tract infection
What conditions cause low BUN levels?
-Fluid overload
-Malnutrition
-Severe liver damage
-Syndrome of inappropriate antidiuretic hormone
What is a normal WBC count?
5000 to 10,000
What conditions cause high WBCs?
Inflammatory and infectious processes leukemia
What causes low WBCs?
-Aplastic anemia
-Autoimmune diseases
-Overwhelming infection
-Side effects of chemotherapy and irradiation
What are some major food sources for carbs?
-Milk
-Grains
-Fruits
-Vegetables.
What are the fat soluble vitamins?
A,D,E,K
WHat are the water soluble vitamins?
B and C, can be excreted in the urine
What foods contain folic acid?
Green leafy vegetables, liver, beef, fish, legumes, grapefruit, oranges
What foods contain Niacin?
poultry, fish, beans, peanuts, grains
What foods contain Vitamin B2 (Thiamine)?
Pork, nuts, whole-grain cereals, legumes
What foods contain Vitamin B6 (Riboflavin)?
-Milk, lean meats, fish, grains
What foods contain Vitamin B12 (Cobalamin)?
Meat, liver
What foods contain Vitamin C (Ascorbic acid)?
Citrus fruits, tomatoes, broccoli, cabbage
What foods contain vitamin A?
Dairy products, fish, liver, green or orange vegetables, fruits
What foods contain Vitamin D?
Fortified milk, fish oils, most cereals
What foods contain Vitamin E?
Vegetable oils and products made with vegetable oil (margarine and salad dressing), fruits, vegetables, grains, nuts (almonds and hazelnuts), seeds (e.g., sunflower seeds), and fortified cereals
What foods contain Vitamin K?
Green leafy and cruciferous vegetables, such as turnip greens, spinach, cauliflower, cabbage, and broccoli; and certain vegetable oils, including soybean oil, cottonseed oil, canola oil, and olive oil
What foods contain Calcium?
Dairy products (milk, cheese, yogurt)
Tofu
Green leafy vegetables (broccoli, collards, kale, mustard greens, turnip greens, bok choy)
Salmon and sardines
Almonds, Brazil nuts, sunflower seeds, tahini, and dried beans
Blackstrap molasses
What food contains Chloride?
Salt
What food contains iron?
Dried beans
Dried fruits
Egg yolks
Iron-fortified cereals
Liver
Meat (especially lean red meat, poultry)
Oysters
Salmon
Tuna
Whole grains
What foods contain Magnesium?
Dark green leafy vegetables
Fruits (such as bananas, dried apricots, and avocados)
Nuts (such as almonds and cashews)
Peas and beans (legumes), seeds
Soy products (such as soy flour and tofu)
Whole grains (such as brown rice and millet)
Milk
What foods contain phosphorus?
Seeds (sunflower, pumpkin, and squash seeds))
Whey
Cheese
Cornmeal
Beans
Nuts, salt-free (almonds, peanuts)
What foods contain postassuim?
All meats (red meat and chicken) and fish (salmon, cod, flounder, and sardines)
Soy products and veggie burgers
Vegetables (broccoli, peas, lima beans, tomatoes, potatoes [particularly their skins], sweet potatoes, and winter squash)
Fruits (citrus, cantaloupe, bananas, kiwi, prunes, and dried apricot)
Milk and yogurt
Nuts
What foods contain sodium?
Sodium chloride (table salt)
Milk
Beets
Celery
Some drinking waters
Food products (Worcestershire sauce, soy sauce, onion salt, garlic salt, and bouillon cubes)
Processed meats (bacon, sausage, and ham)
Canned soups and vegetables
Processed baked goods
Fast foods
What foods contain zinc?
Animal proteins (beef, pork, and lamb)
Nuts
Whole grains
Legumes
Yeast
What order do you do a physical exam?
Inspect, palpate, percussion, and auscultation
What way should the ear be moved when visualizing the ear of an adult?
Pull the pinna up and backwards
What is a positive romberg’s sign?
Significant sway with standing with the eyes closed. Not normal.
How to calculate smoking history:
The number of packs per day times the number of years smoked
Fine crackles
High pitched crackling and popping heard during inspiration
Not cleared by cough
-Pneumonia, HF, asthma, restrictive pulmonary diseases
Coarse crackles
Low-pitched, bubbling or gurgling sounds that start early in inspiration and first part of expiration
Not cleared by cough
-Pulmonary edema and fibrosis
Wheeze
High-pitched muscial sound.
Common during expiration and sometimes inspiration
-Asthma
Rhonchi
Low pitched, coarse, loud, snoring or moaning tone.
Primarily during expiration sometimes inspiration
-Cough may clear
-Disorders causing obstruction of trachea or bronchus, chronic bronchitis
Pleural friction rub
Low pitched, coarse rubbing or grating sound
-Expiration and inspiration
-Not cleared by cough
-Pleurisy or pleuritis
What order do assess abdomen in?
Inspection, auscultation, percussion, and palpation
Cranial nerve I
Olfactory
-Sensory smell
-Test: Close eyes and occlude one nostril ask the pt to identify the odor
Cranial nerve II
Optic
-Sensory controls vision
-Test: Snellen chart, color, and opthalmoscopic exam
Cranial nerve III
Oculomotor
-Motor, pupillary constriction, upper eyelid, and eye movement
-Test for III, IV, VI: look for drooping, and ocular eye movements. Accomodation and light reflexes
Cranial nerve IV
Trochlear
-Motor, controls downward and inward eye movement
Cranial nerve V
Trigeminal
-Sensory and motor
-Controls sensation of the cornea, nasal and oral mucosa, facial skin and mastication
-Test: clinch jaw, touch cornea with cotton wisp, close eyes and lightly touch the forehead, cheeks and chin noting if pt feels sensation equally
Cranial nerve VI
Abducens
-Motor, lateral eye movement
Cranial nerve VII
Facial
-Sensory and motor
-Movement of the face and taste
-Test: Taste, smile, frown, show teeth, puff out the cheeks, and close eye tightly
Cranial nerve VIII
Acoustic or Vestibular
-Sensory
-Hearing
-Testing: Hearing, balance, swaying, Weber’s or Rinne’s test with tuning fork
Cranial nerve IX
Glossopharyngeal
-Sensory and motor
-Swallowing, soft palate, taste and salivation
-Test For IX and X: Taste bitter and sour tastes, symmetrical elevation of soft palate when pt says “ahh”, gag reflex
Cranial nerve X
Vagus
-Sensory and motor
-Phonation, sensation, thoracic and abdominal viscera
Cranial nerve XI
Spinal accessory
-Motor, controls strength of necks and shoulder muscles
-Test: Pt pushed chin against nurses hand and pt shrugs shoulders against nurses resistance
Cranial nerve XII
Hypoglossal
-Motor, tongue movements involved in swallowing and speech
-Test: Tongue symmetry and movement from side to side
What does Brudzinki’s sign and Kernig’s sign test for?
Meningeal irritation
-Positive is pain in response to the movement
What does RACE stand for?
-Rescue and remove clients who are in immediate danger
-Activate the fire alarm
-Confine the fire
-Extinguish the fire
What does PASS stand for?
-Pull the pin in the fire extinguisher
-Aim at the base of the fire
-Squeeze the extinguisher handle
-Sweep the extinguisher from side to side
What diseases are airborne?
-Measles
-Chicken pox (varicella)
-TB
-COVID-19
Nursing interventions for airborne precautions:
-Negative pressure room
-HEPA filter
-N95 mask
-Place face mask on patient if they need to leave the room
What diseases are droplet?
-Adenovirus
-Diptheria
-Epiglottitis
-Flu
-Meningitis
-Mycoplasmal and meningococcal pneumonia
-Pertussis
-Rubella
-Scarlet fever
-Sepsis
-Strep pharyngitis
-COVID-19
Nursing interventions for droplet precautions:
-Private room or pt with the same illness
-Wear surgical mask within 3 ft of pt
-Place a mask on the pt if they leave the room
What diseases are contact precautions?
-C-diff
-Wound infections
-Diptheria
-Herpes
-Impetigo
-Pediculosis
-Scabies
-Staph
-Varicella zoster
-Eye infections
-Adenovirus
-COVID-19
Nursing interventions for contact precautions:
-Private room or same illness
-Use gloves and gown
-Use hand washing for c-diff and chlorine (bleach) for equipment
What is the minimum output of urine per hour?
30ml/hr
Patient teaching for IS:
-Have the patient sit up
-Place their mouth tightlty over the mouthpiece
-Inhale slowly to raise and maintain the flow rate indicator
-Hold the breathe for 5 seconds and then exhale through pursed lips
-Repear 10X/hr
How a patient should sit/stand with crutches:
-Place unaffected leg agaisnt the front of the chair
-Move the crutches to the affected side and grasp the arm of the chair with the hand on the unaffected side
-Flex the knee of the unaffected leg to lower self into the chair while placing the affected leg straight out in front
-Reverse the steps to stand up
How to go up/down the stairs with crutches
-The patient moves the unaffected leg up first
-The patient moves the affected leg and crutches up
-Reverse the steps to go down
