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Intro to Healthcare > EXAM 2 > Flashcards

EXAM 2 Flashcards

1
Q

Identify parts of the nursing process

A

assessment, diagnosis, outcome identification, planning, implementation, evaluation

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2
Q

Who is the primary source and examples of subjective/objective data?

A

primary source= the patient
subjective- what the patient tells the nurse
objective- what the nurse sees through observation and examination

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3
Q

Who are the secondary sources?

A

family, healthcare, medical records, scientific literature

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4
Q

Define motivational interview

A

help/ motivate change

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5
Q

Give examples of effective communication

Hint-4 Cs

A

courtesy, comfort, connection and confirmation

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6
Q

What is a closed loop?

A

giving feedback

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7
Q

What is interview prep?

A

going over history (hx)

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8
Q

Culturally competent responses/ diagnosis/ interventions

A
  1. ask for clarification (tactfully)
  2. respect the unfamiliar and be sensitive to the pt uniqueness
  3. eye contact (may be disrespectful)
  4. some cultures (female-female; male-male)
  5. communication between couples
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9
Q

This term is the introduction, Ask patient what name they prefer to be called, HIPAA sign, Ask patient if they prefer assessment to be done privately or with visitors present when conducting patient centered interview

A

courtesy

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10
Q

This term is to perform comfort measures, privacy, appropriate temperature, no sound/ distractions, paying attention when conducting patient centered interview

A

comfort

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11
Q

This term is Making patients feel cared for by providing eye contact, start with open questions, Listen, sit at eye level, respect silence, be attentive when conducting patient centered interview

A

connection

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12
Q

When conducting a patient centered interview summarizing discussion and ask “Is there anything else you would like to share?”. If you cannot answer questions say so and follow up if possible.

A

confirmation

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13
Q

What are the phases of interview?

A
  1. orientation and setting an agenda
  2. working phase : open ended Q’s, allow pt to
    tell their stories
  3. termination: end of interview, inform pt when you will return, thank pt
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14
Q

data clusters

A

form patterns, set of cues, signs/symptoms gathered during assessment

data interpretation: nursing dx provides basis for selection of nursing interventions you will select as a
way to achieve the outcomes/goals ID

nursing dx: defining characteristics “of disease process”> help guide interventions

initiating original care plan, place the highest priority nursing dx first

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15
Q

How to formulate a nursing diagnosis

A

ID the correct dx label with associated defining characteristics or risk factors and a related factors

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16
Q

Related factors of NANDA

A
  1. pathophysiology/biological or psychological
  2. tx related
  3. situational
    (environmental or personal)
  4. maturational
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17
Q

actual existing diagnosis not a med diagnosis (focuses on the human response to the medical dx and pathophysiology) related to etiology or causative factor

A

problem focused

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18
Q

“at risk for” hasn’t happened yet, but could happen, if risk factors are present. vulnerability of an
individual for developing an undesirable human response to health conditions/life process.

A

risk

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19
Q

patient expressing readiness to enhance/improve health

A

health promotion

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20
Q

What are the steps to establish priorities/ planning phase

A
  1. High: emergency
  2. immediate: non-life threatening
  3. low: affect pt future well being
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21
Q

broad statement that describes the desired change in pt condition, perceptions or behavior

A

goal

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22
Q

measurable change that must be achieved to reach a goal

A

expected outcome

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23
Q

Patient centered when identifying goals and outcomes would be listed as..

A

SMART

  1. specific
  2. measurable
  3. attainable
  4. realistic
  5. time
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24
Q

When selecting the appropriate intervention to promote the nursing diagnosis and illness, you as a nurse should….

A

review the set of all possible nursing interventions, review possible consequences, probability of all
possible consequences to pt. share adverse/side effects >education. reassessing pt. continuously.

1) Desired patient outcomes
2) Characteristics of the nursing diagnosis
3) Research base knowledge for the intervention
4) Feasibility for doing the interventions
5) Acceptability to the patient
6) Your own competency

25
Q

Lab value of Potassium (K+)

A

3.5 to 5.0 mEq/L

26
Q

Lab value of Calcium (Ca2+)

A

8.4 to 10.5 mEq/L

27
Q

Lab value of Magnesium (Mg2+)

A

1.3-2.1 mEq/L

28
Q

Lab value of Chloride

A

98 to 106 mEq/L

29
Q

Lab value of Phosphate

A

2.7 to 4.5 mg/dL

30
Q

Lab value of Anion gap

A

5 to 11 mEq/L

31
Q

Lab value of Bicarbonate (arterial)

A

22-26 mEq/L

32
Q

Lab value of Total CO2

A

22 to 30 mmol/L

33
Q

Normal value of pH

A

7.35-7.45

34
Q

Normal value of PaCO2

A

35-45 mmHg

35
Q

Normal value of HCO3 (bicarbonate)

A

22-26 mEq/L

36
Q

Normal value of O2 saturation

A

95-100%

37
Q

The normal range for osmolality of serum blood

A

280 to 300 mmol/kg of water

38
Q

Normal value of sodium

A

136-145

39
Q

pH scale of very acidic and very basic? neutral?

A

1.0 (very acid) to 14.0 (very base); 7.0

40
Q

Which acid/base balance?
Arises from alveolar hypoventilation
Lungs unable to excrete enough CO2
Excess carbonic acid in the blood decreases pH

A

Respiratory acidosis

41
Q

Which acid/base balance?
Arises from alveolar hyperventilation
Lungs excrete too much CO2
Deficit of carbonic acid in the blood increases pH.

A

Respiratory alkalosis

42
Q

Which acid/base balance?
Arises from increase in metabolic acid or decrease in base (bicarbonate)
Kidneys unable to excrete enough metabolic acids, which accumulate in the blood
Results in decreased level of consciousness

A

Metabolic acidosis

43
Q

Which acid/base balance?
Arises from direct increase in base (bicarbonate) or decrease in metabolic acid
Results in increased blood bicarbonate

A

Metabolic alkalosis

44
Q

Causes for imbalances are?

A

GI tract is a common and important cause of fluid, electrolyte, and acid-base imbalances that requires careful assessment.

Acute conditions that place patients at high risk for fluid, electrolyte, and acid-base alterations include respiratory diseases, burns, trauma, GI alterations, and acute oliguric renal disease.

Surgery may cause fluid loss, fluid overload effecting electrolyte levels

45
Q

What is the purpose of TPN?

total parenteral nutrition

A

Patients unable to digest or absorb enteral nutrition or are in highly stressed physiological states

  1. Bypass GI tract
  2. Allow GI system to rest/heal
46
Q

Enema administration includes…?

A
  1. Sterile technique is unnecessary.
  2. Wear gloves.
  3. Explain the procedure, positioning, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation
47
Q

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

a. Check to see whether the catheter is patent.
b. reassure the client that it is not possible for her to urinate.
c. re catheterize the bladder with a larger‐gauge catheter.
d. Collect a urine specimen for analysis.

A

a. CORRECT: a clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate.

48
Q

A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.)

a. Frequent sexual intercourse
b. lowering of testosterone levels
c. Wiping from front to back
d. location of the urethra in relation to the anus
e. Frequent catheterization

A

a. CORRECT: Having frequent sexual intercourse increases the risk of UTIs in both men and women.
B. the decrease in estrogen levels during menopause increases a woman’s susceptibility to UTIs.
C. Wiping from front to back decreases a woman’s risk of UTIs.
D. CORRECT: the close proximity of the female urethra to the anus is a factor that increases the risk of UTIs.
E. CORRECT: Frequent catheterization and the use of indwelling catheters are risk factors for UTIs.

49
Q

A nurse is preparing to initiate a bladder‐retraining program for?

a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.)

a. Establish a schedule of urinating prior to meal times.
b. Have the client record urination times.
c. Gradually increase the urination intervals.
d. remind the client to hold urine until the next scheduled urination time.
e. Provide a sterile container for urine.

A

a. Bladder training involves voiding at scheduled frequent intervals and gradually increasing these intervals to 4 hr. meal times are
not regular, and the intervals can be longer than every 4 hr.
B. CORRECT: the nurse should ask the client to keep track of urination times as a record of progress toward the goal of 4‐hr intervals between urination.
C. CORRECT: Gradually increasing the urination intervals helps the client progress toward the goal of 4‐hr intervals between urination.
D. CORRECT: the nurse should remind the client to hold urine until the next scheduled urination time as part of progressing toward the goal of 4‐hr intervals between urination.
E. a bladder‐retraining program does not involve collecting sterile urine specimens.

50
Q

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make?

a. “Water helps clear the tube so it doesn’t get clogged.”
b. “Flushing helps make sure the tube stays in place.”
c. “this will help you get enough fluids.”
d. “adding water makes the formula less concentrated.”

A

a. CORRECT: the nurse should flush the tube after instilling the feeding to help keep the Ng tube patent by clearing any excess formula from the tube so that it doesn’t clump and clog the tube

51
Q

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?

a. auscultate breath sounds.
b. stop the feeding.
c. obtain a chest x‐ray.
d. initiate oxygen therapy

A

b. CORRECT: the greatest risk to the client is aspiration pneumonia. the first action the nurse should take is to stop the feeding so that no more formula can enter the lungs

52
Q

A nurse is caring for a client in a long‐term care facility who is receiving enteral feedings via an Ng tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (select all that apply.)

a. auscultate bowel sounds.
b. assist the client to an upright position.
c. test the pH of gastric aspirate.
d. Warm the formula to body temperature.
e. discard any residual gastric contents

A

a. CORRECT: the nurse should auscultate for bowel sounds, because the client’s gastrointestinal tract might not be able to absorb nutrients. the nurse should then withhold feedings and notify the provider.
b. CORRECT: the nurse should place the client in an upright position, with at least a 30° elevation of the head of the
bed. upright positioning helps prevent aspiration.
c. CORRECT: before administering enteral feedings, the nurse should verify the placement of the Ng tube. the only reliable method is x‐ray confirmation, which is impractical prior to every feeding. testing the pH of gastric aspirate is an acceptable method between x‐ray confirmations.

53
Q

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care?

a. Infuse hypotonic IV fluids.
b. Implement a fluid restriction.
c. Increase sodium intake.
d. administer sodium polystyrene sulfonate.

A

a. CORRECT: Hypotonic IV fluids, such as 0.225% sodium chloride, are indicated for the treatment of hypernatremia related to fluid loss to expand the EcF volume and rehydrate the cells.

54
Q

A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/l. When notifying the provider, the nurse should anticipate which of the following actions?

a. starting an IV infusion of 0.9% sodium chloride
b. consulting with dietitian to increase intake of potassium
c. Initiating continuous cardiac monitoring
d. Preparing the client for gastric lavage

A

c. CORRECT: a potassium level of 5.2 mEq/l indicates hyperkalemia. the nurse should anticipate the initiation of continuous cardiac monitoring due to the client’s risk for dysrhythmias such as ventricular fibrillation.

55
Q

A nurse is collecting data from a client who has hypercalcemia as a result of long‐term use of glucocorticoids. Which of the following findings should the nurse expect? (select all that apply.)

a. Hyperreflexia
b. confusion
c. Positive chvostek’s sign
d. bone pain
e. nausea and vomiting

A

B. CORRECT: the nurse should expect the client who has hypercalcemia to have confusion and a possible decreased level of consciousness.
D. CORRECT: the nurse should expect the client who has hypercalcemia to have bone pain.
E. CORRECT: the nurse should expect the client who has hypercalcemia to have nausea and vomiting along with anorexia.

56
Q

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas
levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and , 24. The nurse interprets these laboratory values to indicate:

  1. Metabolic acidosis.
  2. Metabolic alkalosis.
  3. Respiratory acidosis.
  4. Respiratory alkalosis.
A
  1. Respiratory acidosis
57
Q

Which assessment does a nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit?

  1. Dryness of mucous membranes
  2. Presence or absence of edema
  3. Fullness of neck veins when supine
  4. Fullness of neck veins when upright
A

3

58
Q

A patient has severe hypercalcemia. What are the priority nursing interventions? (Select all that apply.)

  1. Fall prevention interventions
  2. Teaching regarding sodium restriction
  3. Encouraging increased fluid intake
  4. Monitoring for constipation
  5. Explaining how to take daily weights
A

1,3,4

Intro to Healthcare (8 decks)

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