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NURS 120 Final Exam > Exam 1 thru 3 Review > Flashcards

Exam 1 thru 3 Review Flashcards

1
Q

What are the aims of nursing?

A
  • To promote health
  • To prevent illness
  • To restore health
  • To facilitate coping w/ disability or death
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2
Q

What are the phases of the helping relationship?

A
  • Orientation = establish, clarify, ID
  • Working = provide, achieve
  • Termination = encourage, examine, suggest
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3
Q

What are the 3 stages of health promotion and illness prevention?

A

1) Primary = immunizations, education
2) Secondary = early detection, ID illness, apply treatment
3) Tertiary = convalescence period, physical therapy, rehab

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4
Q

What is the proper care w/ antiembolism stockings?

A
  • 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
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5
Q

What is a contraindication to measure a patient’s temperature rectally?

A

Patient has heart problems - trigger of vagus nerve will drop HR

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6
Q

What are some examples that require Airborne precautions?

A
  • Tuberculosis
  • Chickenpox (Varicella) and Shingles
  • Measles (Rubeola)
  • H1N1
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7
Q

What are the requirements for Airborne precautions?

A
  • Negative pressure room (door always shut)
  • Sign is posted
  • PPE + N95 mask
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8
Q

What are some examples that require Droplet precautions?

A
  • Influenza
  • Meningitis
  • Pertussis (Whooping cough)
  • German Measles (Rubella)
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9
Q

What are the requirements for Droplet precautions?

A
  • PPE

- Standard mask or face shield

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10
Q

What are some examples that require Contact precautions?

A
  • MRSA
  • VRE
  • C. difficile
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11
Q

What are the requirements for Contact precautions?

A
  • PPE

- Gloves

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12
Q

What are the stages of Erikson’s theory?

A
  • 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)
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13
Q

What is the Local Adaptation Syndrome?

A
  • -> LAS involves only 1 specific body part (tissue or organ):
  • Reflex pain response (rapid + automatic)
  • Inflammatory response (swelling + heat)
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14
Q

What is the General Adaptation Syndrome?

A
  • -> Biochemical model of stress:
  • Alarm reaction = “Fight or Flight”
  • Resistance = Stabilizing vitals
  • Exhaustion = Mobilize or die
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15
Q

What are the Psychological Adaptive Responses?

A

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)

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16
Q

What defines the 2 heart sounds?

A

Lub-dub
S1 = lub = T M = Contraction of ventricle
S2 = dub = A P = Relaxation of ventricle

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17
Q

What does the specific gravity measure?

A

Concentration of all chemical particles in urine.

Range = 1.010 to 1.025

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18
Q

What patients are most at risk for UTIs?

A
  • Sexually active women
  • Diaphragm as contraceptive
  • Post menopausal
  • Indwelling catheter pts
  • Diabetes pts
  • Elderly
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19
Q

What does the RN need to do if patient moves legs during indwelling catheter procedure?

A

If legs touched and contaminated sterile equipment, then stop procedure and start over with new sterile catheter equipment.

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20
Q

If the urine flow from an indwelling catheter was initially well established but later is diminished, what should the RN do?

A

Check tubing for kinking as the patient might have changed position and occluded tubing.

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21
Q

What can be done if urine leaks out of the meatus around the catheter?

A
  • 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
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22
Q

What does the RN need to do when male patient c/o pain while inflating balloon?

A
  • Stop inflation

- Be sure to insert catheter all the way to bifurcation (balloon is probably in urethra)

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23
Q

The RN cannot insert the catheter past 3” to 4”, rotating catheter and having patient breath is no help. What can the RN do?

A

If unable to place, stop. Notify physician.

–> Advancing or attempting again could cause TRAUMA

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24
Q

If initially, urine is flowing but w/ a large amount of sediment and suddenly stops, bladder remains palpable. What can the RN do?

A

The catheter is probably plugged w/ sediment:

–> After obtaining orders from physician, irrigate catheter to restore flow.

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25
Q

What is reflex incontinence?

A

Experience emptying of bladder w/out sensation of the need to void.

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26
Q

What is urge incontinence?

A

Involuntary loss of urine right after urge of urination.

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27
Q

What is the right order for all focused assessment, except abdominal?

A
  • Inspection
  • Palpation
  • Percussion
  • Auscultation

IPPA

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28
Q

What is the correct order for a focused abdominal assessment?

A
  • Inspection
  • Auscultation
  • Percussion
  • Palpation

IAPP

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29
Q

When is catheter irrigation used?

A

Only to relieve or prevent obstruction.

  • Need a physician’s order
30
Q

What should the RN do if a patient becomes chilled during a bed bath?

A

1) Adjust room temperature

2) Use an additional bath blanket

31
Q

What should the RN do if the patient becomes unstable during a bed bath?

A

Bathe the patient in stages

32
Q

What should the RN do if a large amount of bleeding is noticed from the gum while providing oral care?

A
  • Stop the brushing
  • Allow pt to gently rinse out with water
  • Check recent platelet level
  • Use toothette to provide oral care
33
Q

How many ounces are in a cup?

A

8 fl oz = 1 cup

34
Q

How many ounces in 1 liter?

A

32 fl oz = 1 L

35
Q

How many pounds in 1 kg?

A

2.2 lbs = 1 kg

36
Q

How many milliliters in 1 ounce?

A

30 mL = 1 oz

37
Q

What is the order for donning and removing PPE?

A

1) Don PPE - Gown > mask > goggles > gloves

2) Remove PPE - Gloves > goggles > gown > mask

38
Q

What should the RN do if the patient experiences pain during the application of the antiembolism stockings?

A

The patient may be premedicated.

  • If the pain is unexpected, physician needs to be notified, the patient may be developing a DVT
39
Q

What can the RN do if the patient’s pulse is irregular or unpalpable?

A

1) Monitor the pulse for a full minute if the pulse is irregular
2) Use a Doppler if the pulse is difficult to palpate

40
Q

How long does an enema solution is being instilled for?

A

5 to 10 min by elevating the solution NO higher than 18”

41
Q

What if the enema solution does not flow into rectum?

A

1) Reposition rectal tube

2) If still unsuccessful, remove tube and check for fecal contents

42
Q

What can the RN do if the patient c/o severe cramping while introducing the enema solution?

A
  • Lower solution container
  • Check temperature and flow rate
  • If the temperature is too cold or flow rate too fast, severe cramping can occur
43
Q

Who is responsible for obtaining the informed consent?

A

It is the responsibility of the health professional who will perform the diagnostic or treatment procedure or the research study.

44
Q

What is the definition of paternalism?

A

Acting for patients w/out their consent to secure good or prevent harm.

45
Q

What can red or black stool be a sign of?

A

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

46
Q

What are the expected sounds heard while percussing the abdomen?

A

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
47
Q

What type of sounds can be expected during percussion of the lung field?

A
  • Resonance = clear lungs
  • Hyperresonance = emphysematuous lungs
  • Dullness = fluid in lungs
48
Q

Is a tracheostomy being suction often and why?

A

No, because of the numerous complications it can cause:

  • Hypoxia
  • Infection
  • Tracheal tissue damage
  • Dysrhythmias
  • Atelectasis
49
Q

What should the RN do if the pulse oximetry gives an absent or weak signal?

A
  • Check vital signs
  • Patient’s condition
  • If extremity is cold, warm up w/ a blanket
  • Consider that hypotension can make an accurate reading difficult
50
Q

What is the flow that can be used for the nasal cannula?

  • Note room air gives 21% of oxygen
A

1 L/min to 6 L/ min –> 24-40%

  • 2 - 3 L/min is the max for a patient w/ chronic lung disease
51
Q

What is the oxygen flow that can be given via simple mask?

A

6 to 10 L/min –> 35-60%

5 L/ min is the min setting

52
Q

What is the oxygen flow used for a partial rebreather mask?

A

6 to 15 L/ min –> 70-90%

  • Keep reservoir free of twists or kinks
53
Q

What is the oxygen flow rate used for nonrebreather mask?

A

6 to 15 L/ min –> 60-100%

  • It delivers the highest concentration of oxygen via a mask to a spontaneously breathing patient
54
Q

What is the best position for the patient to be in while performing drainage of the lungs?

A

1) High Fowler if hemothorax is present

2) Semi Fowler if pneumothorax is present

55
Q

Scenario: During oxygen therapy, patient was previously fine but now is cyanotic and the pulse oximetry reads < 93%
What can the RN do?

A
  • 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
56
Q

Scenario: During oxygen therapy, the RN notices redness over ears and back of head. What can the RN do?

A
  • Ensure that area is adequately padded and that tubing is not pulled too tight
  • -> Skin care team can be referred to
57
Q

What is an acceptable residual amount when a patient is on feeding via NG tube?

A

10-20% above the hourly rate is acceptable

If more than 200-250 or greater –> Risk of aspiration

58
Q

What are the S x S that a patient would demonstrate if he suffered from over feeding?

A

1) Nausea
2) Vomiting
3) Fullness
4) Distention

59
Q

When and why can the RN give free water to patient on NG feeding tube?

A

1) To dilute medication

2) To prevent constipation

60
Q

How is the BMR measure for both male and women?

A 
Male = 1 cal/kg/hr
Female = 0.9 cal/kg/hr
61
Q

What are some patient teaching tips the RN needs to share when a patient has to be on oxygen therapy at home?

A

1) Avoid synthetic clothing
2) Do not smoke around oxygen tank!
3) Be aware of when to refill tank

62
Q

At what stage is it normal for a wound to bleed?

A

Right after surgery –> exudate should not be sanguineous afterwards

63
Q

What IV fluids are considered isotonic solutions?

A

1) Lactaded ringer
2) NS 0.9%
3) D5 W
4) D5 1/4 NS

64
Q

What IV fluids are considered hypotonic solutions?

A

1) 0.45% NS

2) 0.33% NS

65
Q

What IV fluids are considered hypertonic solution?

A

1) D5 1/2 NS
2) D5 NS
3) D10 W
4) D20 W
5) D50 W
6) 3% NS

66
Q

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…

A

Step 1) 50/30 = x/60
Step 2) 30x = 3000
Step 3) x = 100 mL

67
Q

What are the S x S of infiltration at an IV site?

A

1) Swelling
2) Pallor
3) Coldness
4) Pain

68
Q

What are the S x S of phlebitis at an IV site?

A

1) Local, acute tenderness
2) Redness
3) Warmth
4) Slight edema of the vein above insertion site

69
Q

What are the S x S of speed shock when a patient has an intravenous infusion?

A

1) Pounding headache
2) Fainting
3) Rapid pulse rate
4) Apprehension
5) Chills
6) Back pains
7) Dyspnea

70
Q

What are the S x S of fluid overload when a patient is on intravenous infusion?

A

1) Engorged neck veins
2) ⬆ BP
3) Dyspnea

71
Q

What are the S x S of air embolus when patient is on intravenous infusion?

A

1) Respiratory distress
2) ⬆ HR
3) Cyanosis
4) ⬇ BP
5) Change in level of consciousness

NURS 120 Final Exam (1 decks)

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