Exam 1 thru 3 Review Flashcards
What are the aims of nursing?
- To promote health
- To prevent illness
- To restore health
- To facilitate coping w/ disability or death
What are the phases of the helping relationship?
- Orientation = establish, clarify, ID
- Working = provide, achieve
- Termination = encourage, examine, suggest
What are the 3 stages of health promotion and illness prevention?
1) Primary = immunizations, education
2) Secondary = early detection, ID illness, apply treatment
3) Tertiary = convalescence period, physical therapy, rehab
What is the proper care w/ antiembolism stockings?
- Apply before pt is out of bed and supine
- Check skin for redness, swelling…
- Remove once a shift for assessment
- Leave off for 20-30 min and replace
What is a contraindication to measure a patient’s temperature rectally?
Patient has heart problems - trigger of vagus nerve will drop HR
What are some examples that require Airborne precautions?
- Tuberculosis
- Chickenpox (Varicella) and Shingles
- Measles (Rubeola)
- H1N1
What are the requirements for Airborne precautions?
- Negative pressure room (door always shut)
- Sign is posted
- PPE + N95 mask
What are some examples that require Droplet precautions?
- Influenza
- Meningitis
- Pertussis (Whooping cough)
- German Measles (Rubella)
What are the requirements for Droplet precautions?
- PPE
- Standard mask or face shield
What are some examples that require Contact precautions?
- MRSA
- VRE
- C. difficile
What are the requirements for Contact precautions?
- PPE
- Gloves
What are the stages of Erikson’s theory?
- Identity vs confusion (adolescence)
- Intimacy vs isolation (young adulthood)
- Generativity vs stagnation (middle adulthood) –> RN listens to stories, giving them sense of fulfillment.
- Ego integrity vs despair (later adulthood)
What is the Local Adaptation Syndrome?
- -> LAS involves only 1 specific body part (tissue or organ):
- Reflex pain response (rapid + automatic)
- Inflammatory response (swelling + heat)
What is the General Adaptation Syndrome?
- -> Biochemical model of stress:
- Alarm reaction = “Fight or Flight”
- Resistance = Stabilizing vitals
- Exhaustion = Mobilize or die
What are the Psychological Adaptive Responses?
1) Psychosomatic = psychological stressor + physiologic response
2) Anxiety = discomfort or dread from unknown source
3) Coping mechanisms = are behaviors -> crying, exercise, smoking, withdrawal
4) Defense mechanisms = are psychological -> protect one’s self-esteem (compensation, denial, introjection, projection)
What defines the 2 heart sounds?
Lub-dub
S1 = lub = T M = Contraction of ventricle
S2 = dub = A P = Relaxation of ventricle
What does the specific gravity measure?
Concentration of all chemical particles in urine.
Range = 1.010 to 1.025
What patients are most at risk for UTIs?
- Sexually active women
- Diaphragm as contraceptive
- Post menopausal
- Indwelling catheter pts
- Diabetes pts
- Elderly
What does the RN need to do if patient moves legs during indwelling catheter procedure?
If legs touched and contaminated sterile equipment, then stop procedure and start over with new sterile catheter equipment.
If the urine flow from an indwelling catheter was initially well established but later is diminished, what should the RN do?
Check tubing for kinking as the patient might have changed position and occluded tubing.
What can be done if urine leaks out of the meatus around the catheter?
- Assure the smallest size catheter is used
- If leakage persists, assess for UTI
- Ensure the correct amount of solution was used to fill the balloon –> could be dislodged and cause leakage if not in proper place
- If RN suspects under fill balloon, remove and replace
- Assess for constipation = full bowel could cause pressure on bladder
What does the RN need to do when male patient c/o pain while inflating balloon?
- Stop inflation
- Be sure to insert catheter all the way to bifurcation (balloon is probably in urethra)
The RN cannot insert the catheter past 3” to 4”, rotating catheter and having patient breath is no help. What can the RN do?
If unable to place, stop. Notify physician.
–> Advancing or attempting again could cause TRAUMA
If initially, urine is flowing but w/ a large amount of sediment and suddenly stops, bladder remains palpable. What can the RN do?
The catheter is probably plugged w/ sediment:
–> After obtaining orders from physician, irrigate catheter to restore flow.
What is reflex incontinence?
Experience emptying of bladder w/out sensation of the need to void.
What is urge incontinence?
Involuntary loss of urine right after urge of urination.
What is the right order for all focused assessment, except abdominal?
- Inspection
- Palpation
- Percussion
- Auscultation
IPPA
What is the correct order for a focused abdominal assessment?
- Inspection
- Auscultation
- Percussion
- Palpation
IAPP
When is catheter irrigation used?
Only to relieve or prevent obstruction.
- Need a physician’s order
What should the RN do if a patient becomes chilled during a bed bath?
1) Adjust room temperature
2) Use an additional bath blanket
What should the RN do if the patient becomes unstable during a bed bath?
Bathe the patient in stages
What should the RN do if a large amount of bleeding is noticed from the gum while providing oral care?
- Stop the brushing
- Allow pt to gently rinse out with water
- Check recent platelet level
- Use toothette to provide oral care
How many ounces are in a cup?
8 fl oz = 1 cup
How many ounces in 1 liter?
32 fl oz = 1 L
How many pounds in 1 kg?
2.2 lbs = 1 kg
How many milliliters in 1 ounce?
30 mL = 1 oz
What is the order for donning and removing PPE?
1) Don PPE - Gown > mask > goggles > gloves
2) Remove PPE - Gloves > goggles > gown > mask
What should the RN do if the patient experiences pain during the application of the antiembolism stockings?
The patient may be premedicated.
- If the pain is unexpected, physician needs to be notified, the patient may be developing a DVT
What can the RN do if the patient’s pulse is irregular or unpalpable?
1) Monitor the pulse for a full minute if the pulse is irregular
2) Use a Doppler if the pulse is difficult to palpate
How long does an enema solution is being instilled for?
5 to 10 min by elevating the solution NO higher than 18”
What if the enema solution does not flow into rectum?
1) Reposition rectal tube
2) If still unsuccessful, remove tube and check for fecal contents
What can the RN do if the patient c/o severe cramping while introducing the enema solution?
- Lower solution container
- Check temperature and flow rate
- If the temperature is too cold or flow rate too fast, severe cramping can occur
Who is responsible for obtaining the informed consent?
It is the responsibility of the health professional who will perform the diagnostic or treatment procedure or the research study.
What is the definition of paternalism?
Acting for patients w/out their consent to secure good or prevent harm.
What can red or black stool be a sign of?
1) If red stool, can be a sign of bleeding in the lower GI
2) If black stool, can be a sign of bleeding in the upper GI
What are the expected sounds heard while percussing the abdomen?
1) Tympany sounds over air-filled areas (stomach, empty bladder)
2) Dull sounds over solid organs and structures (liver, full bladder)
- Dullness can be normal, but over a large area can be indicative of a tumor
What type of sounds can be expected during percussion of the lung field?
- Resonance = clear lungs
- Hyperresonance = emphysematuous lungs
- Dullness = fluid in lungs
Is a tracheostomy being suction often and why?
No, because of the numerous complications it can cause:
- Hypoxia
- Infection
- Tracheal tissue damage
- Dysrhythmias
- Atelectasis
What should the RN do if the pulse oximetry gives an absent or weak signal?
- Check vital signs
- Patient’s condition
- If extremity is cold, warm up w/ a blanket
- Consider that hypotension can make an accurate reading difficult
What is the flow that can be used for the nasal cannula?
- Note room air gives 21% of oxygen
1 L/min to 6 L/ min –> 24-40%
- 2 - 3 L/min is the max for a patient w/ chronic lung disease
What is the oxygen flow that can be given via simple mask?
6 to 10 L/min –> 35-60%
5 L/ min is the min setting
What is the oxygen flow used for a partial rebreather mask?
6 to 15 L/ min –> 70-90%
- Keep reservoir free of twists or kinks
What is the oxygen flow rate used for nonrebreather mask?
6 to 15 L/ min –> 60-100%
- It delivers the highest concentration of oxygen via a mask to a spontaneously breathing patient
What is the best position for the patient to be in while performing drainage of the lungs?
1) High Fowler if hemothorax is present
2) Semi Fowler if pneumothorax is present
Scenario: During oxygen therapy, patient was previously fine but now is cyanotic and the pulse oximetry reads < 93%
What can the RN do?
- Check that the tubing is still connected to the flow meter and still on the previous setting.
- Check that the oxygen is still on
- Assess lung sounds
Scenario: During oxygen therapy, the RN notices redness over ears and back of head. What can the RN do?
- Ensure that area is adequately padded and that tubing is not pulled too tight
- -> Skin care team can be referred to
What is an acceptable residual amount when a patient is on feeding via NG tube?
10-20% above the hourly rate is acceptable
If more than 200-250 or greater –> Risk of aspiration
What are the S x S that a patient would demonstrate if he suffered from over feeding?
1) Nausea
2) Vomiting
3) Fullness
4) Distention
When and why can the RN give free water to patient on NG feeding tube?
1) To dilute medication
2) To prevent constipation
How is the BMR measure for both male and women?
Male = 1 cal/kg/hr Female = 0.9 cal/kg/hr
What are some patient teaching tips the RN needs to share when a patient has to be on oxygen therapy at home?
1) Avoid synthetic clothing
2) Do not smoke around oxygen tank!
3) Be aware of when to refill tank
At what stage is it normal for a wound to bleed?
Right after surgery –> exudate should not be sanguineous afterwards
What IV fluids are considered isotonic solutions?
1) Lactaded ringer
2) NS 0.9%
3) D5 W
4) D5 1/4 NS
What IV fluids are considered hypotonic solutions?
1) 0.45% NS
2) 0.33% NS
What IV fluids are considered hypertonic solution?
1) D5 1/2 NS
2) D5 NS
3) D10 W
4) D20 W
5) D50 W
6) 3% NS
When using the IV pump, how can a dose be calculated?
Ex: Order is 50 mL infused over 30 min. The pump can only be programmed to 60 min…
Step 1) 50/30 = x/60
Step 2) 30x = 3000
Step 3) x = 100 mL
What are the S x S of infiltration at an IV site?
1) Swelling
2) Pallor
3) Coldness
4) Pain
What are the S x S of phlebitis at an IV site?
1) Local, acute tenderness
2) Redness
3) Warmth
4) Slight edema of the vein above insertion site
What are the S x S of speed shock when a patient has an intravenous infusion?
1) Pounding headache
2) Fainting
3) Rapid pulse rate
4) Apprehension
5) Chills
6) Back pains
7) Dyspnea
What are the S x S of fluid overload when a patient is on intravenous infusion?
1) Engorged neck veins
2) ⬆ BP
3) Dyspnea
What are the S x S of air embolus when patient is on intravenous infusion?
1) Respiratory distress
2) ⬆ HR
3) Cyanosis
4) ⬇ BP
5) Change in level of consciousness
