Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

NUR 3200 FOUNDATIONS > Exam 3 Study Guide > Flashcards

Exam 3 Study Guide Flashcards

1
Q

Advantages to Oral, Buccal, & Sublingual Routes

A
  • Convenient & comfortable
  • Economical
  • Easy to administer
  • Often produce local or systemic effects
  • Rarely cause anxiety
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Hemorrhiods

A
  • Dilated engorged veins in rectum lining, internal or external
  • Signs: rectal pain, blood in stool
  • Causes: straining, pregnancy, heart failure & chronic liver disease related to incrd venous pressure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Nursing Responsibility in Medication Administration

A
  • Evaluate effects of med on pt’s health status
  • Open meds in front of pt and discuss reasoning
  • Teach pts about side effects
  • Reinforce importance of adherence to med regimen
  • Evaluate pt technique w/ self-admin
  • Evaluate use of herbal therapies that could interfere (garlic, ginger, & gingko interacts w/ antocoags)
  • If withholding a drug, record reason & follow institutional policy (notify HCP)
  • Instruct pt/family about purpose, action, dose, dosage intervals, side effects, food to avoid or take with med
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Electronic Infusion Device Infusion

A
  • IV pump
  • Will deliver an accurate hourly infusion rate
  • Uses positive pressure to deliver fluid
  • Has detectors & alarms for air or occlusion in tubing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Impaction

A
  • Collection of hardened feces wedged in rectum, can extend to sigmoid colon
  • Signs: oozing diarrhea, loss of appetite, N/V, abdominal distention & cramping, rectal pain
  • Causes: same as constipation & incr risk if debilitated, confused, unconcscious
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Signs of Intolerance w/ Enteral Nutrition

A
  • High gastric residuals
  • N/V
  • Abdominal cramping
  • Diarrhea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Extracellular Fluid Volume Excess Lab Findings

A
  • Dcrd hematocrit
  • BUN <10
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Hyponatremia S/S (5)

A
  • Apprehension
  • N/V
  • Headaches
  • Dcrd LOC & possible coma
  • Seizures
    (Na<135)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Advantages to (parenteral) SQ, IM, IV, ID routes

A
  • When oral meds are contraindicated
  • More rapid absorption
  • IV: pt is critically ill, long-term therapy, peripheral perfusion is poor
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Advantages of (mucus memb) Eyes, Ears, Nose, Vagina, Rectum, Ostomy Routes

A
  • Therapeutic effects provided by local application
  • Aqueous solutions readily absorbed & capable of causing systemic effects
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Topical Administration

A
  • Applied locally to intact skin
  • Also applied to mucus membs
  • Ointment, lotion, paste, transdermal disk or patch
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Maintaining IV Therapy

A
  • Ensure system is sterile & intact
  • Ensure tht rate of fluid or medication is maintained
  • Monitor IV site & patency
  • Change IV tubing, bags, & dressings per hospital protocol
  • Monitor for complications
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

PICC (peripherally inserted central catheters)

A

Enter a peripheral arm vein & extend through venous system to superior vena cava

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Hypernatremia S/S (7)

A
  • Extreme thirst
  • Dry & flushed skin
  • Postural hypotension
  • Fever
  • Confusion and/or agitation
  • Coma
  • Seizures
    (Na>145)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Nursing Responsibilities Using TPN pt.1

A
  • A solution >10% dextrose a central line is required
  • Need to confirm placement of central line
  • Confirm physician orders
  • Always need to use IV pump
  • Check solution for particulate matter
  • Need to have a dedicated line
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Subcutaneous Injection (SC or SQ)

A
  • Slower absorption
  • SQ med ex.: heparin, enoxaparin, insulin
  • Angle: 45-90 degrees
  • Needle size: 25-30 gauge (G), 3/8-5/8 inch needle
  • Max. injection vol.: 1mL or less
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Nasal Instillation

A
  • Decongestant spray or drops
  • Have pt self-administer if able
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Advantages to Inhalation

A
  • Provides rapid relief for local resp. problems
  • Used for intro of general anesthetic gases
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Enteral Feeding

A
  • Installation of liquid nutritional supplements or feedings into GI tract
  • Used when unable to swallow safely or can’t take enough nutrition orally but has a functioning GI tract
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Colonoscopy

A
  • Viewing of entire colon using a fiber optic scope through rectum
  • Clear liquids day before then NPO; bowel cleanser until stool is clear liquid, light sedation, abdominal bloating after procedure is common
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Hyponatremia

A
  • Water excess or water intoxication
  • More water than salt

(Na<135)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Buccal

A
  • Placed in mouth against mucus membs in cheek
  • Alternate cheeks to avoid mucosal irritation
  • No chewing, swallowing, or liquids until completely dissolved
  • (oral)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Parenteral Route

A
  • Administration by injections
  • SQ, ID, IM, IV
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Enteral Route

A
  • Administration through GI tract
  • Gastric
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Infection
- Infection at cath entry site - Signs: Redness, warmth, swelling, possible purulent drainage - Treatment: Discontinue IV, cleanse area w/ alcohol, apply new dressing, culture if needed/ordered
26
Eye Instillation
- Eye drops/ointment - OTC meds - Apply oitnment along lower eyelid
27
Phlebitis
- Inflammation of a vein - Sings: Redness, tenderness, warmth, palpable cord - Treatment: Discontinue IV, warm & moist compress
28
Extracellular Fluid Volume Deficit
- Fluid intake less than output - Dcrd body fluid volume
29
Complications of NG Tubes
- Pulmonary aspiration - Diarrhea or constipation - N/V - Abdominal cramping - Tube occlusion - Tube dislodgment - Delayed gastric emptying - Electrolyte imbalances - Fluid overload - Hyperosmolar dehydration
30
Components of a Medication Order
- Pt's full name - Date & time that order is written - Medication name - Dose - Route of administration - Time & frequency of administration - Signature of health care provider
31
Nursing Responsibilities Using TPN pt.2
- Requires collaboration w/ physician, dietician, & pharmacist - Daily labs required to adjust formula - Peripheral blood glucose (PBG) are required every 6 hrs - TPN must be gradually started and gradually stopped to prevent hypo or hyperglycemia - Monitor for metabolic & cath associated complications
32
Z-Track Method
- Given w/ intramuscular injections - Helps prevent injection going into subcut tissue - Use non-dominant hand to pull skin on side of injection site - Hold syringe like a dart at 90 degree angle
33
Gastric Tubes
- Placed in stomach - NG tube: short-term use - PEG tube: long-term use
34
Hyperkalemia S/S (4)
- Anxiety - Abdominal cramps & diarrhea - Muscle weakness - Cardiac dysrhythmias & cardiac arrest (K>5.0)
35
pH Values
- pH 0-4 indicates gastric placement - pH 6 indicated jejunum placement - pH 7+ indicated lung placement
36
Nursing Care w/ Enteral Nutriton
- HOB at 30-45 degrees at all time & 1 hr after feedings completed - Measure gastric residuals - Flush enteral feeding tubes q4hr w/ at least 30ml to keep tube patent - Verify placement q4-6hr by aspirating gastric contents - When initiating feedings start slow & incr rate q8-12hr per orders if no signs of intolerance
37
Decompression
- Removal of secretions & gas from GI tract - Prevention or relief of abdominal distention - Ex: bowel obstruction
38
6 Rights
1. Right medication 2. Right dose 3. Right patient 4. Right route 5. Right time 6. Right documentation
39
Compression
- Internal application of pressure by means of inflated balloon - Prevents internal esophageal or GI hemorrhage - Ex: esophageal varices bleed
40
Extracellular Fluid Volume Deficit S/S (6)
- Postural hypotension - Tachycardia - Oliguria - Dry mucous membranes - Restlessness & confusion - Hypovolemic shock
41
Intradermal Injection Sites
Surface of the Forearm Upper Back Below Scapula
42
Isotonic IV Fluid
- Same osmolality as body fluids - Cells do not gain or lose fluid - Replaces extracellular volume - Used to treat dehydration - Most common type of IV fluid - Normal saline (0.9%NS), Lactated Ringers (LR)
43
Abdominal X-ray
Includes abdomen, kidney, ureter, & bladder - KUB
44
Jejunostomy Tubes
- Placed nasally or surgically into jejunum - Long-term use
45
Hypertonic IV Fluid
- Osmolality is great than body fluids; fluid is more concentrated than body fluids, moves fluid out of cells into circulation - Can shrink cells - Used to correct electrolyte imbalances (hyponatremia) - Used when treating cerebral edema - D10W, 3-5% NS, D5NS, D5LR
46
Hypercalcemia S/S (9)
- Anorexia - N/V - Constipation - Fatigue & lethargy - Diminished reflexes - Change LOC & confusion - Cardiac dysrhythmias - Possible flank pain from renal calculi - Pathological fractures (Ca>10.5)
47
Focus on Older Adults (pt education)
- Begin & end w/ most important info - Slow, low tone of voice - Allow enough time for understanding - Emphasize concrete material - Specific info in frequent, small amounts - Repeat important info - Teach when pt is alert & rested
48
Hypermagnesemia S/S (7)
- Lethargy - Hypoactive reflexes - Bradycardia & hypotension - Flushing & sensation of warmth - Hypoventilation - Muscle paralysis - Cardiac dysrhythmias & cardiac arrest (Mg>2.5)
49
Ultrasound
- Use of sound waves to visualize organs - Preparation varies depending organ visualized
50
Hypokalemia S/S (3)
- Fatigue & muscle weakness - N/V - Cardiac dysrhythmias (K<3.5)
51
CLABSI Interventions
- Change tubing every 24hrs - Do not hang for more than 24hrs or lipids more than 12hrs - Utilize sterile technique during dressing changes - Change dressing per institution policy or when becomes wet/contaminated
52
Mini Infuser Infusion
- Used to deliver small volumes - Uses syringes
53
Flatulence
- Bowel stretches & distends w/in intestine (passing gas) or escapes mouth (belching) - Sings: abdominal distention, severe & sharp abdominal pain, abdominal cramping & pain - Causes: immobilization, medications, general anesthesia, abdominal surgery
54
Hypocalcemia S/S (7)
- Numbness & tingling of fingers & mouth - Hyperactive reflexes - Muscle twitching - Tetany - Seizures - Laryngospasm - Cardiac dysrhythmias (Ca<8.4)
55
Sublingual
- Readily absorbed - Placed under tongue - Hold fluids until completely dissolved - (oral)
56
Disadvantages & Contradictions of Oral, Buccal, & Sublingual Routes
- (oral) Alts in GI function (N/V), reduced GI motility (after anesthesia or bowel inflamm), & surgical resection of GI tract - Pt is unable to swallow (oral) - Pt unconscious, confused, unwilling to swallow, hold med under tongue - Gastric suction - Irritate lining of GI tract, discolor teeth, have unpleasant taste - Gastric secretions destroy some meds
57
Hypernatremia
- Water deficit - More salt than water (Na>145)
58
Hypokalemia
- K < 3.5 - Decreased potassium intake & absorption, a shift of K from ECF into cells, & incrd K output
59
Disadvantages to Mucous Membranes
- Highly sensitive - Ruptured eardrum - Insertion of rectal & vaginal med often causes embarrassment - Rectal surgery or active rectal bleeding
60
Oral Administration
- Easiest & most desirable route - Contraindications: NPO, alts in GI func, aspiration risk, dcrd LOC, gastric suction or recent surgery, prior to certain tests, procedures, or surgery - Can't be crushed: enteric coated, sustained release
61
Principles of Enteral Nutrition
62
Lavage
- Irrigation of stomach - Used in cases of active bleeding, poisoning or gastric dilation - Ex: overdose of medication
63
Constipation
- Bowel movement less than every 3 days - Signs: difficulty passing stool, excessive straining, hard feces - Causes: dcr fluid intake, lack of exercise, medications
64
Air Embolism Interventions
- Maintain integrity of closed IV system when changing caps & tubing - Have pt perform a Valsalva maneuver while assuming a left lateral decubitus position during cath insertion - When removing line have pt bear down when pulling out line
65
Intramuscular Injection SItes
Deltoid Vastus Lateralis Ventrogluteal Upper Arm
66
Positive Learning Environment
- Well lit, good ventilation, appropriate furniture, comfortable temperature - Quiet - Infrequent interruptions - Group setting require pts to be w/in hearing distance & to allow participants to observe one another
67
Interventions to Promote Bowel Elimination
- Diet education: incr fiber, fluids, fruit juices - Activity & exercise - Positioning to facilitate elimination - Medications: laxatives/cathartics, enema, antidiarrheals - Establish bowel regimen
68
Inflitration
- When IV fluid enters the subcutaneous tissue - Caused by catheter dislodgment or rupture of vein - Signs: Edema, cool to touch, skin around cath is taut, blanched skin - Treatment: Discontinue IV, elevate extremity, warm & moist compress
69
Non-Parenteral Route
- Administration other than parenteral - enteral, topical, inhalation
70
Computerized Tomography Scan (CT)
- Scan of body from various angles, analyzed by computer - NPO; pt needs to lie still - Typically give dye by mouth & intravenous
71
Extracellular Fluid Volume Deficit Lab Findings
- Incrd hematocrit - BUN >25 - Urine specific gravity >1.030
72
Disadvantages to Inhalation
Some local agents can cause systemic effects
73
Enteroclysis
- X-ray of entire small intestine w/ use of contrast - Into of contrast into small intestine via NG tube
74
Intramuscular Injection (IM)
- Deposits med in muscle tissue - Faster absorption - Angle: 90 degrees - Needle size: 18-25 gauge, 5/8- 1 1/2 inches - Max. injection vol.: 3mL - Z track method recommended to reduce tissue irritation
75
Factors Influencing Bowel Elimination
- Age; infancy, older adult - Diet - Fluid intake - Positioning - Physical activity - Psychosocial - Alterations in personal habits - Medications - Pain - Pregnancy - Surgery/anesthesia
76
Central IV
- Long term use - Use w/ meds that are vesicants - Parenteral nutrition - Pts w/ difficult intravenous access
77
Flexible Sigmoidoscopy
- Exam of sigmoid colon thru scope/tube - NPO; prep similar to barium enema, light sedation
78
Air Embolism
- May occur during insertion, removal, or when changing tubing or cap - Air enters into the vasculature
79
Subcutaneous Injection Sites
- Outer posterior upper arm - Abdomen - Thigh
80
Intradermal Injections (ID)
- Used for skin testing; TB screening & allergy tests on the dermal layer - Angle: 5-15 degree - Needle size: 27-31 gauge, 1/2 inch - Very small volume
81
Types of Enteral Administration
- Gastric tubes - Jejunostomy tubes
82
Indications for Parenteral Nutrition (TPN)
- Nonfunctional gastrointestinal tract: bowel obstructions, ineffective absorption, fistulas - Extended bowel rest - Preoperative TPN - Highly stressed physiological states: sepsis, head injury, burn
83
Vaginal Medications
Instruct pt to remain on back for at least 10 mins to allow med to absorb
84
Upper GI (Barium Swallow)
X-ray using contrast (barium) to examin structure & movement of upper GI tract (pharynx, esophagus, & stomach)
85
Advantages of Topical Routes
- Provides local effect - Painless - Limited side effects - Prolonged systemic effects
86
Hyperkalemia
Incrd potassium intake & absorption, shift of K from cells into ECF, & drcd K output (K>5.0)
87
Catheter Sepsis (CLABSI)
- A central line associated bloodstream infection tht develops w/in 48hrs of central line insertion - Fever, chills, glucose intolerance, positive blood culture
88
Gravity Infusion
Infusion of bag that needs to be above pt
89
Hypotonic IV Fluid
- Osmolality is less than body fluids; fluid can be more diluted than body fluids, moves fluid into cells - Can cause hypotension - Replaces extracellular volume and rehydrates cell - Used with dehydration or to treat hypernatremia - 1/4 normal saline (0.225%NS), 1/2 normal saline (0.45%NS)
90
Diarrhea
- Incr in # of stools, liquid, & unformed - Sings: frequent liquid stools - Causes: antibiotics, enteral nutrition, food allergies, food borne pathogens, disorders related to absorption (Cdiff, chrons, ulcerative colitis)
91
Incontinence
- Inability to control passage of feces and gas - Can affect body image & skin integrity - Causes: age, confusion
92
Goals of TPN
- To provide nutrition when unable to use GI tract - To move towards the use of GI tract; disuse leads to villus atrophy, cell shrinkage, movement of bacteria up GI tract - septicemia
93
Magnetic Resonance Imaging (MRI)
- Noninvasive exam using magnets & radiowaves to produce pic of inner organs/body - NPO 4-6hrs before, no metallic objects
94
Measuring Gastric Redisuals
- q4-6hr for continuous feedings - Immediately prior to administering bolus or intermittent feedings - Don't assess w/ small bore tubes - Delayed gastric emptying is a concern if residual is >250ml for 2 consec. checks of >500ml in a single measure
95
Disadvantages to SQ, IM, IV, ID routes
- Risk of introducing infection - Expensive meds - Pain from repeated needlesticks - Bleeding tendencies - Risk of tissue damage - Higher absorption rates = higher risk of reactions - Cause considerable anxiety
96
Extracellular Fluid Volume Excess S/S (5)
- Sudden weight gain - Edema - Crackles in dependent portion of lungs - Pulmonary edema; high risk for resp failure - Jugular vein distention (JVD)
97
Ear Instillation
- At room temp to prevent vertigo, dizziness, or nausea - Straighten ear canal by pulling auricle upward & outward (adult) - Remain side-lying fore 2-3 mins
98
Subclavian or Jugular
Tunneled through subcutaneous tissue before entering a central vein
99
Nursing Role in Patient Education
- Teach the parents/family - Place priority on self-management - ADPIE
100
Disadvantage of Topical Routes
- Skin abrasions at higher risk for rapid med absorption & systemic effects - Meds are absorbed through skin slowly - Med can leave oily or pasty substance on skin & clothing
101
Upper Endoscopy
- Viewing of upper GI tract through fiber optic scope - NPO; light sedation is required, important to check for return of gag reflex after procedure
102
Rectal Medications
- Sims' position - Insert 10cm/4inches (adult) - Remain flat for at least 5 mins
103
Hypomagnesemia S/S (8)
- Hyperactive reflexes - Insomnia - Muscle cramps & twitching - Dysphagia - Tachycardia & HTN - Tetany - Seizures - Cardiac dysrhythmias (Mg<1.5)
104
Barium Enema
- X-ray w/ contrast to examine lower GI - NPO after midnight, bowel preparation
105
Extracellular Fluid Volume Excess
- Fluid intake greater than output - Incrd body fluid volume

NUR 3200 FOUNDATIONS (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions