final Flashcards
3 things in nutrition to help woh wound healing
Protein, Vitamin C, Zinc
Antibiotic therapy is vigorously initiated if blood cultures verify a __________ condition.
septicemia
this is the remedy for what type of Incontinence
Follow the prescribed schedule for emptying the bladder either through voiding or by intermittent catheterization.
Supply urine-containment products: condom catheter, undergarments, pads, briefs. Monitor for signs and symptoms of urinary retention and UTI.
Monitor for autonomic dysreflexia
Reflex Incontinence
Modes of Transmission where
- Contaminated items
- Water
- Drugs, solutions
- Blood
- Food (improperly handled, stored, or cooked; fresh or thawed meats)
Vehicles
Pre-filled syringe
Do not expel air bubble prior to administration
lovenox
type of IV Solution that
Uses
Intracellular/cellular hydration
Fluid management for a patient who is both volume-depleted and hyperosmolar
Hypotonic
is a disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep. There are three types central, obstructive, and mixed
Sleep apnea
What is the normal blood pressure range for adult
<120/80 B/P (mmHg)
Loss of continence because of causes outside the urinary tract. Usually related to functional deficits such as altered mobility and manual dexterity, cognitive impairment, poor motivation, or environmental barriers
Functional Incontinence
stage of pressure ulcer where
nonblanchable erythema of intact skin
1
less concentrated than plasma
action:fluid shifts from plasma into the cells
hypotonic
4 late Respiratory Signs and Symptoms of Hypoxia
Dyspnea at rest
Use of accessory muscles
Retractions on inspiration
Pause for breath between sentences, words
normal pH for urine
4.6-8.0
_________ disease is the infectious disease transmitted from one person to another.
Communicable
A patient is experiencing some problems with joint stability. The doctor has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught to use?
- Four-point
- Three-point
- Two-point
- Swing-through
-Four-point
type of Medications Long-term use
alters metabolism of anesthetic agents.
Anticonvulsants
is a symptom that patients experience when they have chronic difficulty falling asleep, frequent awakenings from sleep, and/or a short sleep or nonrestorative sleep
Insomnia
6 cause of Hypokalemia
Diuretics
- Diarrhea
- Vomiting
- Gastric suction
- Steroid administration
- Bulemia
D- drugs (steroids, diuretics, laxatives)
I- inadequate intake (nothing by mouth, anorexic)
T- too much (water, base, insulin)
C- Cushing syndrome
H- heavy fluid loss (suctioning)
Provide 60-80% concentrations of O2
Non-rebreather Face Mask with reservoir bag
Oral suctioning is performed with a ____ device.
Yankauer
______ determines if there is actual tissue damage v. reactive hyperemia.
Blanch test
Infiltration Score where
blanching, cool to touch, edema > 6 inches, Mild to moderate; numbness
3
Wound is left open to heal “from the ground up”—as in a contaminated wound
Takes longer time to heal, leaves bigger scar, greater risk for infection, can be more difficult for patient both physically and psychologically
Secondary intention:
Central Lines watch for what 6 things
Watch for: SOB, chest pain, cough, hypotension, tachycardia, anxiety after or during insertion
Clinical Manifestations :
- Anorexia, N/V
- Weakness
- Lethargy
- Confusion, headache
- Muscle cramps/twitching
- Seizures
- Coma
Hyponatremia
Type of Cleansing Enema that
Distends the colon
Stimulates peristalsis
Softens feces
Isotonic (Normal saline)
Oxygen Capability 24-48%
Nasal cannula
Clinical Presentation: Tachycardia Pulmonary Edema Tachypnea Confusion Coma
Metabolic Acidosis
Regulates amount of water in the body
Helps with electrical signals in the brain, nervous system and muscles
Sodium
Scraping or rubbing away of epidermis; may result in localized bleeding and later weeping of serous fluid.
Abrasion
Soft, pink, fleshy projections of tissue that form during the healing process in a wound not healing by primary intention.
Red and moist, viable
granulation tissue
is a problem many patients experience as a result of dyssomnia. Causes include symptoms (e.g., fever, difficulty breathing, or pain) caused by illnesses, emotional stress, medications, environmental disturbances
Sleep deprivation
Provide 40-60% concentrations of O2
simple face mask
Provides 24%-60% oxygen
Venturi Mask
developed after prolonged intake or when a medication accumulates due to impaired metabolism
Toxic Effect
a flaring of moderate to severe pain despite therapeutic doses of analgesics
breakthrough pain
FLUID SPACING
Normal
Between
ICF & ECF
1st
Calcium (Normal Value: )
9-10.5 mEq
Clinical presentation:
Numbness
Muscle twitches
Seizures
Respiratory alkalosis
Injection locations
up to 3 ml
Vastus lateralis
nursing diagnosis
K
E
S
A
knowledge
experience
standards
attiudes
Specific gravity for urine
(1.0053-1.030),
an adaptive state characterized by a decreasing response to repeated constant doses of a drug or the need for increasing doses to maintain a constant response
tolerance
6 things that are on the Braden scale for prediction of PU Development
Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear
(protrusion of visceral organs through a wound opening) occurs.
Evisceration.
4 General rules of body mechanics
Assess the situation CAREFULLY before acting!
Use the large muscle groups whenever possible.
Work at appropriate height!
Use mechanical lifts
Sodium (Normal Value: )
135-145 mEq
wound drainage that is
Bright red; indicates active bleeding
Sanguineous
The nurse evaluates that the NAP has applied a patient’s sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.)
A. Initial patient measurement is made around the calves
B. Inflation pressure averages 40 mm Hg
C. Patient’s leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve.
D. Stockings are removed every 2 hours during application.
E. Yellow light indicates SCD device is functioning.
Patient’s leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve.
Inflation pressure averages 40 mm Hg
What is the normal pulse range for adult
60-100 HR/minute
PaCO2 normal range
34-45
Body measures of height, weight, and skinfolds to evaluate muscle atrophy.
anthropometric measurements
Provides 5-10L of O2
Minimum of 5L/min O2 required to prevent client from re-breathing exhaled carbon dioxide
Simple Face Mask
Loss of more water than sodium
Hypertonic imbalance
Water deficit
ECV Deficit + Hypernatremia
Gastroenteritis (Severe N&V)
clinical dehydration
Hypovolemia
smart goal means
S: specific M: measurable A: Achievable R: Relevant T: Time Bound
Type of Enema that
- lubricates and softens stool
Oil Retention
3 Hypokalemia interventions
Interventions:
-Administer potassium supplement
PO can have a bad taste and be irritating to the GI tract
IV must be well diluted and NEVER given as a bolus
- Assess renal status (UOP) prior to giving supplemental potassium
- Encourage foods rich in potassium
3 late Central Nervous System Signs and Symptoms of Hypoxia
- Combativeness
- Coma
- confusion
clinical manifestations
Thready pulse Decreased BP, Increased HR, Increased RR Decreased Cap Refill, cool clammy skin, poor skin turgor Hypoxia Weak, dizzy Decreased Weight Increased thirst Decreased urine output Confusion, changes in LOC, lethargy (seizures, coma)
Hypovolemia
Involuntary loss of urine occurring at somewhat predictable intervals when patient reaches specific bladder volume related to spinal cord damage between C1 to S2
Reflex Incontinence
size of catheter for
Most medical/surgical patients, daily use
20-24 gauge
Type of Cleansing Enema that
Irritate mucosa
Distends the colon
Soap suds
A nurse is instructing a patient who has decreased leg strength on the left side how to use a cane. Which action indicates proper cane use by the patient?
- The patient keeps the cane on the left side of the body.
- The patient slightly leans to one side while walking.
- The patient keeps two points of support on the floor at all times.
- After the patient places the cane forward, he or she then moves the right leg forward to the cane.
The patient keeps two points of support on the floor at all times.
By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude?
- Curiosity
- Adequacy
- Discipline
- Thinking independently
Discipline
causes
Intake
Decreased PO intake
Decreased Na intake
Inability to drink/express thirst
Output
Diarrhea, vomiting
Profuse sweating, drainage
Hemorrhage
Drugs
Diuretics, laxatives
Diseases
Renal disease
Third spacing: burns
Hypovolemia
Accidental administration of a non-vesicant solution into subcutaneous tissues.
The severity of the swelling is measured an a standardized scale
Infiltration
Immunizations are often given _______
Intramuscular (IM)
wound drainage that is
Clear, watery plasma
Serous
Provides 6-10 L of O2 per minute
rebreathe first third of exhaled air in conjunction with O2.
Patient is still taking in room air.
Partial Non-rebreather with a reservoir bag
Infiltration Score where
blanching, cool to touch, edema >6 inches pitting, Moderate to severe pain, Circulatory impairment
4
A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:
A. Decreased peristalsis
B. Decreased heart rate
C. Increased blood pressure
D. Increased urinary output
Decreased peristalsis
Modes of Transmission where
• Personal contact of susceptible host with contaminated inanimate object (e.g., needles or sharp objects, dressings, environment)
Indirect
What is your role as a nurse during a fire? (Select all that apply.)
- Help to evacuate patients
- Shut off medical gases
- Use a fire extinguisher
- Single carry patients out
- Direct ambulatory patients
- Help to evacuate patients
- Shut off medical gases
- Use a fire extinguisher
- Direct ambulatory patients
Clinical Manifestations: - + Chvostek’s sign - + Trousseau’s sign Numbness/tingling Muscle twitch Cramping Hyperactive reflexes Tetany Seizures
Hypocalcemia
stage of pressure ulcer where
full-thickness tissue loss; not involving underlying fascia. SC fat may be visible. May include tunneling and undermining.
3
one of a group of analgesics that act on higher centers of the brain and spinal cord to modify perceptions of moderate to severe pain
opioid
Respiratory alkalosis cause
Deep and Fast Breathing!
A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? (Select all that apply.)
- Check the patient’s peripheral pulse in the restrained extremity
- Evaluate the patient’s need for toileting
- Offer the patient fluids if appropriate
- Release both limbs at the same time to perform range of motion (ROM)
- Inspect the skin under each restraint
Check the patient’s peripheral pulse in the restrained extremity
Evaluate the patient’s need for toileting
Offer the patient fluids if appropriate
- Inspect the skin under each restraint
Type of Anesthesia where
Administration of drugs by inhalation, intravenous, rectal, or oral route
a patient loses all sensation, consciousness, and reflexes, including gag and blink reflexes.
involves major procedures with extensive tissue manipulation
General
(the movement of gases in and out of the lungs)
VENTILATION
treatment approaches used to complement conventional medical treatments
complimentary therapies
Syringe (1 to 3 mL) and needle (25- to 27-gauge, 3/8- to 5/8-inch)
when injecting, If you can grasp 2 inches insert at a 90-degree angle; (1 inch) of tissue, 45-degree
Subcutaneous:
Clinical Manifestations:
- F: fever/flushed dry skin
- R: restless
- I: Increased fluid retention
- E: Edema
- D: Decreased urine output
- Seizures
- Irritability/hallucinations
- Thirst, sticky mucus membranes
Hypernatremia
Worst possible score = __
Best possible score = __
braden scale
6
23
This is required for tests of renal function and urine composition
If urine is accidentally discarded or contaminated or the patient is incontinent, restart the time period.
.
24-Hour Urine Specimen
6 Hyperkalemia interventions
Interventions:
- Eliminate parenteral potassium
- Kayexalate
- Monitor EKG
- Administer calcium gluconate to protect the heart
- IV loop diuretics
- Renal dialysis
wound drainage that is
Thick, yellow, green, tan, or brown
Purulent
3 early Central Nervous System Signs and Symptoms of Hypoxia
apprehension
restlessness or irritability
confusion, poor concentration and lethargy
3 late Cardiovascular Signs and Symptoms of Hypoxia
Dysrhythmias
Cyanosis
Cool, clammy skin
type of Medications cause adrenal atrophy, reducing the ability of the body to withstand stress. Before and during surgery, dosages are often increased
Corticosteroids
Potassium (Normal Value: )
3.5-5.0 mEq
What is the correct order of steps for removal of protective barriers after leaving an isolation room?
- Remove gloves.
- Perform hand hygiene.
- Remove eyewear or goggles.
- Untie top and then bottom mask strings and remove from face.
- Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.
-1, 3, 5, 4, 2
____________ heals by forming new tissue, a process that can take longer
Involves granulation
full-thickness wound
What is the normal respiratory range for adult
12-20
—fruits and vegetables, bran, chocolate, alcohol, coffee
Foods with laxative effect
—cheese, lean meat, eggs, pasta
Constipating foods
______ or workplace bullying between colleagues sometimes occurs and includes behaviors such as withholding information, backbiting, making snide remarks or put downs, and nonverbal expressions of disapproval such as raising eyebrows or making faces.
Lateral violence
Interval between entrance of pathogen into body and appearance of first symptoms (e.g., chickenpox, 14 to 16 days after exposure; common cold, 1 to 2 days; influenza, 1 to 4 days; measles, 10 to 12 days; mumps, 16 to 18 days; Ebola 2 to 21 days
Incubation Period
, considered one of the most tolerated and safest analgesics available, is available in a variety of over-the-counter (OTC) oral medications (e.g., cold and flu remedies) or rectal forms and in an intravenous (IV) preparation (Ofirmev).
Acetaminophen (Tylenol)
FLUID SPACING
Abnormal
Trapped, cannot be easily exchanged with the ECF
ACITES
EDEMA (a/w burns, trauma, sepsis)
3rd
Which is the correct gait when a patient is ascending stairs on crutches?
- A modified two-point gait (The affected leg is advanced between the crutches to the stairs.)
- A modified three-point gait (The unaffected leg is advanced between the crutches to the stairs.)
- A swing-through gait
- A modified four-point gait. (Both legs advance between the crutches to the stairs.)
A modified three-point gait (The unaffected leg is advanced between the crutches to the stairs.)
_______ wound extends into the subcutaneous layer, and the depth and tissue type varies, depending on body location
A full-thickness
Clinical Manifestations: - Muscle weakness - Constipation - Anorexia, N/V - Dysrhythmias - Neurosis Diminished reflexes Renal calculi (flank pain)
Hypercalcemia
Pain at access site with erythema or edema
is a grade __ on the Phlebitis Scale
2
Decrease pressure times- limit pressure every___ hours whether sitting in a chair, lying in bed, laying on a bony prominence
2
Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chicken pox/herpes zoster? (Select all that apply.)
- Disposable gown
- N 95 respirator mask
- Face shield or goggles
- Surgical mask
- Gloves
Disposable gown
N 95 respirator mask
Gloves
type of Medications such as beta blockers and calcium channel blockers interact with anesthetic agents to cause bradycardia, hypotension, and impaired circulation. They inhibit synthesis and storage of norepinephrine in sympathetic nerve endings
Antihypertensives
size of catheter for
Small children, Older adults, small vein access
22-24 gauge
Clinical Manifestations: - Muscle weakness - Bradycardia Dysrhythmias Flaccid paralysis Intestinal colic Tall T waves on EKG
M-muscles weakness U- urine output decreased R- respiratory failure D- decreased cardiac contractility E- early muscle twitching R- rhythem changes
Hyperkalemia
Type of Anesthesia where
Used for short-term procedures, diagnostic, and therapeutic procedures that do not require complete anesthesia but rather a depressed level of consciousness
Conscious sedation
Pain at access site with erythema and edema, streak, palpable cord>1 inch in length & purulent drainage
is a grade __ on the Phlebitis Scale
4
A patient who has been isolated for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.)
The organism is usually transmitted through the fecal-
oral route.
- Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer.
- Everyone coming into the room must be wearing a gown and gloves.
-While the patient is in contact precautions, he cannot
leave the room.
-C. difficile dies quickly once outside the body.
The organism is usually transmitted through the fecal-
oral route.
- Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer.
- Everyone coming into the room must be wearing a gown and gloves.
A nurse enters a 72-year-old patient’s home and begins to observe her behaviors and examine her physical condition. The nurse learns that the patient lives alone and notices bruising on the patient’s leg. When watching the patient walk, the nurse notes that she has an unsteady gait and leans to one side. The patient admits to having fallen in the past. The nurse identifies the patient as having the nursing diagnosis of Risk for Falls. This scenario is an example of:
- Inference.
- Basic critical thinking.
- Evaluation.
- Diagnostic reasoning
Diagnostic reasoning
A healthy adult patient tells the nurse that he obtained his blood pressure in “one of those quick machines in the mall” and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.)
- Cuff too small
- Arm positioned above heart level
- Slow inflation of the cuff by the machine
- Patient did not remove his long-sleeved shirt
- Insufficient time between measurements
Cuff too small
- Insufficient time between measurements
size of catheter for
Trauma, large volume at a rapid rate
14-16 gauge
Nuts, beans
Canned entrees
Frozen bread, meals
Smoked/cured/canned meat and poultry
are all rich in ______
Sodium
size of catheter for
Surgical patient, rapid administration of fluids and blood products
18 gauge
________ wound heals by regeneration;
Involves epithelialization.
A partial-thickness
PaO2 normal range
80-100
type of IV Solution that
Examples:
0.9%NS
Lactated Ringers (LR)
D5W (note: D5W is the low end of isotonic, this can also be considered hypotonic)
Isotonic
type of Medications potentiate electrolyte imbalances (particularly potassium) after surgery.
Diuretics
- Visual examination of the tracheobronchial tree through a narrow, flexible fiberoptic bronchoscope
- Performed to obtain fluid, sputum, or biopsy samples; remove mucus plugs or foreign bodie
Bronchoscopy
4 Hyponatremia interventions
Interventions:
- Restrict fluid intake (if that is the cause of the hyponatremia)
- Replace sodium
- Hypertonic IV fluids (infuse slowly)
- Seizure precautions
Keep O2 delivery systems ___ feet from open flames
10
Nurses signature on informed consent indicates what 2 things
- Patient signed without coercion
2. Patient was alert &; aware (competent)
absence of sensitivity to pain
analgesia
Urine is collected after voiding is initiated (midstream) and before voiding is completed
Midstream urine specimen
2 early Respiratory Signs and Symptoms of Hypoxia
Tachypnea
Dyspnea on exertion (DOE)
When an incision fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen formation (3 to 11 days after injury).
Dehiscence
three types of analgesics:
nonopioids, including acetaminophen and nonsteroidal antiinflammatory drugs
opioids (traditionally called narcotics); and
adjuvants or co-analgesics, a variety of medications that enhance analgesics or have analgesic properties that were originally unknown
Blood Transfusion Reactions
Anaphylactic Reaction is promptly treated with
_______,_____________ & _______________
antihistamines, steroids, and epinephrine
aspect of critical thinking where you must
Be open-minded as you look at information about a patient.
Do not make careless assumptions.
Does the data reveal a problem or trend that you believe is true, or are there other options?
Analysis
Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.)
- Set up sterile field before patient and other staff come to the operating suite.
- Keep the sterile field in view at all times.
- Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.
- Only health care personnel within the sterile field must wear personal protective equipment.
- The sterile gown must be put on before the surgical scrub is performed.
- Keep the sterile field in view at all times.
- Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.
7 things that must be on a medication order
patients full name date and time order is written medication name dosage route time and frequency of administration signature of health care provider
