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FUNDAMENTALS 1 > FINAL > Flashcards

FINAL Flashcards

1
Q

Alternative interventions to attempt before using restraints

A

Distractions, frequent observation, diversion activities, sitting closer to nurses station, bed alarm, sitter, family, treatment change, environmental change, grip socks

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2
Q

Appropriate abbreviations to use for documenting vital signs

A

BP - blood pressure
RR - Respirations
HR - Heart rate
Temp - Temperature

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3
Q

Appropriate care of feet for diabetic patients

A

Put lotion on feet except for in-between the toes
Examine daily
File nails instead of cutting them
Slowly increase amount of time you wear new shoes
Avoid going barefoot

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4
Q

Appropriate infection control measure for a patient with TB

A

Airborne
M95 Mask
Gown
Gloves

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5
Q

Appropriate interventions for diagnosis of early osteoporosis

A

Weight bearing exercises,
Vitamin D + Calcium
Proper diet

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6
Q

Appropriate interventions to prevent back injuries in nurses

A 
Bend at knees
Keep back straight
No more than 35 pounds per nurse
wide base
pivot
keep what you're lifting close to your body
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7
Q

Appropriate methods for completing safe patient transfers

A

Gait belt
Use of equipment (hoyer, sit to stand, slideboard)
Bed patient is in is slightly higher than bed/stretcher they are going too
Neck stabilization if needed

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8
Q

Appropriate nursing diagnoses for patient prone to falling

A

Risk for injury

Risk for falls

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9
Q

Appropriate interventions for enema administration

A

Patient laying on left lateral side with right knee flexed
Insert 3-4 inches for adult
Insert 2-3 inches for child
Raise the bag 12-18 inches (30-45 cm)
If patient feels cramping in abdomen, lower the container to reduce pressure of flow
Have client retain fluid for prescribed amt or as long as possible
Luke warm temperature

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10
Q

Appropriate use of the logrolling method for position change

A

Spinal/back injury

Changing bed sheets

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11
Q

Assessment and terms used for vital signs

A 
Respiration Rate
Heart Rate
Temperature
Blood Pressure
Oxygen Saturation 
Assess pain
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12
Q

Differentiate assessment findings for localized and systemic infections

A

Localized – heat, excoriation, erythema (redness)

Systemic – Fever, tachycardia, tachypnea, restlessness, low BP, flaring nostrils, malaise, fatiguied

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13
Q

Assessment of the urinary system

A 
Color
Clarity
Amount
Odor
skin assessment (watch for erythema- redness)
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14
Q

Interventions for preventing UTI

A 
Wipe front to back
Empty bladder completely 
Fluids
Decrease amount of sugar intake
Urinate after sexual intercourse
Wear cotton panties
Wash with mild soap and water
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15
Q

Method for cleaning hearing aids

A

NO ALCOHOL
Clean with soapy water if ear mold is detachable
If not clean with damp cloth
Blow out excess moisture and use pipe cleaner or toothpick

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16
Q

Factors affecting/ causing alterations in vital sign

A 
Age
Exercise
Hormones
Stress
Environment
Medications
Obesity 
Smoking
Food intake
Fever cause heart rate to go up
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17
Q

Interventions for a patient with contractures

A

Ambulation
ROM
devicesuyt

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18
Q

Interventions for preventing UTI

A 
Wipe front to back
Empty bladder completely 
Fluids
Decrease amount of sugar intake
Urinate after sexual intercourse
Wear cotton panties
Wash with mild soap and water
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19
Q

Interventions to reduce risk of infection

A

hand hygiene
disinfecting
proper ppe

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20
Q

Methods for promoting healthy and normal elimination patterns

A 
*pooper scoop*
position
output
offer fluids
privacy
exercise
report results
size
consistency
accult blood
odor 
perastslasis
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21
Q

Normal and abnormal assessment findings for urinary and fecal elimination

A

clear yellow, within pH of 4.5-8,no blood , 1200-1500ml per day
brown, log shaped, formed soft

abnormal- black tarry, blood, offensive odor, cloudy, hard dry, pungent odor

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22
Q

Normal assessment of hair

A

evenly distributed
clean
no parasites or signs of infection

23
Q

Nursing assessment to determine risk for injury

A

Level of conciousness
strength/ ROM
Activity tollerance

24
Q

Nursing care for a urinary diversion

A

make sure stoma is clean, pink, moist, go from stoma out when cleaning

25
Q

Nursing care plan goals for a client at risk for injury

A

patient will remain injury free for my whole shift

26
Q

Nursing diagnoses for patient on bed rest

A

risk for constipation
risk for skin breakdown
risk for muscle atrophy

27
Q

Nursing interventions for diagnosis of Risk for impaired skin integrity

A

Reposition often
keep an eye on bony prominences
skin barrier creme
clean and dry skin

28
Q

Nursing interventions for diagnosis of Risk for infection

A

hand hygiene

disinfection

29
Q

Nursing interventions for prevention and treatment of constipation

A

Ambulation
Increase fluid
increase fiber

30
Q

Nursing interventions for treating a patient’s elevated temperature

A

cool rag

fluids

31
Q

Palpated blood pressure assessment

A

Apply cuff & pump to 180

first pulsation is systolic

32
Q

Patient conditions/ treatments that increase risk for nosocomial infections

A

immuno compromised patient

33
Q

Patient positioning to assess respiratory status

A

High Fowler’s

34
Q

Factors that can effect pulse oximeter readings.

A

nail polish

35
Q

Physiological barriers of the body’s defense against microorganisms

A

skin, mucous membranes, cillia, tears, earwax, stomach acid

36
Q

Promoting a positive bathing experience for patients with dementia

A 
explain what youre doing
let them do as much as they can
let them decide time
provide privacy
protect patient dignity
keep them covered as much as possible
37
Q

Reasons for daily bathing of patients

A

reduce risk of infection

38
Q

S&S of fecal impaction

A

seepage/ overflow diarrhea

39
Q

S&S of necrosis in a urinary stoma

A

purple/black

dry

40
Q

S&S of UTI in elderly patients

A

confusion

41
Q

S&S to monitor for related to orthostatic hypotension

A

dizziness
light headed
bp drops when standing

42
Q

Safety measures for preventing falls in patients with dementia

A

Distractions, bed alarm

43
Q

Skills that can and cannot be delegated by the nurse to UAPs

A

Med administration

Interpret vital signs

44
Q

Steps for placing patient on a bedpan

A

logroll patient to lateral position, put bedpan under them, make patient comfortable

45
Q

Steps for responding to a choking victim

A

Ask if they are okay

Start CPR if unresponsive

46
Q

Nursing assessments and interventions for patients in pain

A

Ask them to rate pain

47
Q

Nursing assessment and interventions in tube feedings

A

assess that the tube is in the stomach
flush before and after with 15-30 mL saline
Lukewarm formula

48
Q

Nitrogen balance testing

A

the difference between the amount of nitrogen ingested and the amount excreted in the urine and feces

49
Q

Clear and Full liquid diets

A

clear liquid - can see through

full liquid- anything liquid at room temp

50
Q

Nursing Diagnosis for patients on TPN

A

Risk for malnutrition

51
Q

What to do in case of needle stick

A

wash hands
notify employee health nurse
fill out report
get blood drawn

52
Q

Interventions to promote feeding, increase appetite, and promote adequate nutrition.

A

Food should smell good

Environment clean and appealing

53
Q

Expected actions of hypotonic, isotonic and hypertonic enemas.

A

hypotonic&isotonic- distends the colon stimulates peristalsis & softens stools.
hypertonic- - draws water into colon

54
Q

Causes of foul-smelling flatus

A

Bacteria in your GI tract (infection, diet, etc.)

FUNDAMENTALS 1 (1 decks)

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