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Final Flashcards

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1
Q

Effects of bedrest

A

Atrophy
Pressure ulcers
Osteoporosis

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2
Q

How to prevent bedrest complications

A 
Fall risk wristband
Non slip socks
Ted hose wrinkle free
Stress the need for pt to alert nurse when needing to use restroom
SCDs
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3
Q

Caring for patients with pain

A

Anticipate pain-offer relief/meds
Prevent future pain-long acting relief
Treat pain-a priority-reassess every 2-4 hr

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4
Q

Pain relief ladder for chronic pain

A

Non opioid
Opioid for mild to moderate
Opioid for moderate to severe

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5
Q

PQRST

A 
Pain assessment 
Provokes
Quality
Radiates
Severity 
Time
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6
Q

OLDCARTS

A 
Pain assessment 
Onset
Location
Duration
Characteristics
Alleviates/aggravates
Related
Treatment
Severity
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7
Q

Documentation of pain

A 
Pain rating scale 1-10
Faces scale (used for children)
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8
Q

SS of pain when pt can’t speak

A

Facial expression
Temp or BP increase
Fidgeting or guarding
Circling number on scale

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9
Q

Stages of grief/loss

A 
Kubler Ross 
Denial 
Anger
Bargaining
Depression 
Acceptance
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10
Q

Types of learning

A

Cognitive: the thinking aspect
Psychomotor: the physical aspect
Affective: the social/emotional/feeling aspect

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11
Q

Assessing readiness to learn

A

Make sure they are not in pain
See what motivates them
Assess anxiety-try to decrease stressors

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12
Q

Teaching strategies

A 
Assessment 
Incremental approach
Appropriate pacing
A/V materials and models
Establish purposes
Repetition
Focus on progress
Team approach
Interactive
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13
Q

Assessing wounds

A 
Wound size, color, odor
Surrounding skin
Tissue granulation
Drainage
Risk assessment-Braden scale
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14
Q

Getting wound culture

A

Wound care specialist would obtain culture
Clean with NS
Do not spread bacteria
Gram stain

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15
Q

Pressure ulcer

Stage 1

A

Skin is intact

Non blanchable erythema

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16
Q

Pressure ulcer

Stage 2

A

Partial skin loss with exposed dermis
Pink/red and moist
No granulation tissue present

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17
Q

Pressure ulcer

Stage 3

A

Full thickness loss of skin, adipose tissue visible

Granulation tissue and epibole (rolled wound edges) are usually present

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18
Q

Pressure ulcer

Stage 4

A

Full thickness of skin lost
Exposed adipose tissue
Exposed bone/muscle/tendon
Often includes undermining and tunneling

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19
Q

Pressure ulcer

Unstageable

A

Full thickness of skin lost
Ulcer is covered by slough and/or eschar
Necrotic tissue-doesn’t necessarily mean wound is infected, but the tissue attracts bacteria and puts pt at risk

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20
Q

How often do you check on a pt with restraints

A

every 2 hours

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21
Q

Assessment of sleep patterns and problems

A 
Sleep history
Disorders
Meds
Rituals or routines
Naps, sleep patterns
Sleep logs
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22
Q

Effects of noise, pain, anxiety, fear, depression

A

Causes sleep disruption

In the hospital: control pain, keep routine, dark room, less noise, cluster night care

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23
Q

Purpose of nursing care plan

A

To provide care that is individualized, holistic, effective, and efficient

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24
Q

Nursing process steps

A 
Assessment 
Diagnosis
Planning 
Implementation
Evaluation
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25
Q

Parts of a diagnosis

A

Problem
Etiology
Defining characteristics

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26
Q

Etiology

A

What is causing or contributing to the problem?

Described as “related to”

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27
Q

Defining characteristics

A

The evidence of the problem
“As evidence by”
“As manifested by”

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28
Q

Types of nursing diagnoses

A

Actual/problem based
Risk
Wellness/health promotion

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29
Q

Priority interventions in nursing process

A

ABCs
Take care of immediate life threatening issues first
Safety issues next
Then pt identified issues
Last nurse identified issues based on holistic care

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30
Q

Angina

A

Chest pain caused by reduced blood flow to the heart

A symptom of coronary artery disease

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31
Q

Ischemia

A

Decreased blood supply to a body part such as the heart

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32
Q

Effects of bedrest

Circulatory

A

Increased heart rate
Decreased cardiac reserve
Orthostatic hypotension
Venous thromboembolism

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33
Q

Methods to ascertain heart rate

A

Radial
Antecubutal
Carotid
Apical

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34
Q

Measures to promote cardia circulation

A

Repositioning the patient
Monitoring I&Os
Fluid restriction if necessary

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35
Q

Blood flow through the heart

A 
Blood from systemic circuit
To vena cava
To right atrium
To right ventricle
To pulmonary trunk
To pulmonary arteries
To lungs
To pulmonary veins
To left atrium
To left ventricle
To aorta
To systemic circuit
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36
Q

Constipation

A

Decrease in frequency/amount of stool
Usually accompanied by prolonged or difficult passage
Tends to be hard and dry
Have to strain
May pause pain and hemorrhoids
May cause impact ion or bowel obstruction
Valsalva maneuver

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37
Q

Diarrhea

A

Increase in frequency/amount of stool
Usually informed or liquid
Suggests inappropriate absorption of fluid and nutrients

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38
Q

Clear liquids

A 
Coffee
Tea
Soda
Bouillon 
Clear fruit juice
Popsicles
Jello
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39
Q

Full liquids

A 
Milk
Icecream 
Vegetable juices
Yogurt
Strained cereals
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40
Q

Flatus

A

Gas in or from the intestines/stomach

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41
Q

Reasons for urinary catheterization

A 
To relieve discomfort 
To obtain a sterile urine specimen 
To measure residual urine amounts 
To provide continuous bladder drainage 
To provide continuous bladder irrigation
To monitor output (icu)
To promote repair to urinary structures after surgery
42
Q

Urinary catheter sizes

A

Adult: 14F to 16F with a 5-10 ml balloon
Child: 5F to 8F younger children
8F to 12F older children

43
Q

Urine sampling techniques

A

Routine urinalysis
Clean catch / midstream
Sterile

44
Q

Routine urinalysis

A

Collect urine during normal void, and indwelling catheter, or urinary collection bag
Must be freshly voided using clean cup

45
Q

Clean catch / midstream

A

Pt cleans area
Voids and discards small amount
Catches 30-60 ml in a sterile cup
Finishes voiding in toilet

46
Q

Sterile urine collection

A

May be obtained by catheterization

Or by thawing specimen from already in place indwelling catheter

47
Q

UTI

A

Burning on urination
Frequency
Urgency

48
Q

Minimally acceptable urine output per hour

A

30 ml

49
Q

Renin-angiotensin-aldosterone system

A

Regulates ecf volume by influencing how much sodium and water are excreted in urine
Also contributes to BP

RAAS is increased during hemorrhage or vomiting

50
Q

Atrial natriuretic factor

A

Regulates ecv by influencing how much sodium and water are excreted in the urine

ANP and ADP contrast

51
Q

Antidiuretic hormone

A

Regulates osmolarity of body fluids by influencing how much water is excreted in urine

ADH decreases when body fluids are too dilute
ADH increases when body fluids are to concentrated-dehydration, hemorrhage

52
Q

Which organ systems are involved in maintaining homeostasis?

A

Endocrine and nervous system

53
Q

Which two organs help regulate acid base balance

A

Lungs: regulate by eliminating/retaining CO2
Kidneys: regulate by selectively excreting/conserving bicarbonate and hydrogen ions slower to respond to change by control overall more powerful and lasting

54
Q

Hyponatremia

A

Below 135

CHF, burns, diarrhea, diuretics

55
Q

Sodium

A

135-145

56
Q

Hypernatremia

A

Above 145

Licorice (raises bp), dehydration, higher salt

57
Q

Hypocalcemia

A

Below 9

Eating disorders, osteoporosis, renal failure, prolonged vomiting

58
Q

Calcium

A

9-11

59
Q

Hypercalcemia

A

Above 11

Bone disease, parathyroid tumor, renal failure, immobilization

60
Q

Hypokalemia

A

Below 3.7

Diarrhea, vomiting, diuretics

61
Q

Potassium

A

3.7-5.2

62
Q

Hyperkalemia

A

Impaired renal excretion

Hemolysis

63
Q

Kussmaul’s breathing

A

Presence of diabetic acidosis
Respirations are very deep and steady
Fruity sugary breath smell
pH low

64
Q

Cheynes-Stokes

A

Periods of apnea followed by labored breathing

Sign of dying

65
Q

Biot’s respirations

A

Neurological disorder

Erratic breathing due to damage of the brain stem (medulla)

66
Q

Orthopnea

A

Breathing patterns that change based on body position

Associated with pulmonary disease

67
Q

Dyspnea

A

Any type of unusual breathing

68
Q

What a nurse can do to promote oxygenation

A 
Change in position
Ambulating/exercise
Promote comfort
Deep breathing and coughing
Meds: bronchodilators and expectorants
Incentive spirometer 
Postural drainage (head lower than bed)
Oxygen therapy
69
Q

Oxygen delivery systems

A

Nasal cannula
Face tent
Face mask

70
Q

Oxygen in room air

Each liter

A

21% oxygen in room air

Increased 3-4% each liter

71
Q

Methods of infection control

A

Hand washing
PPE
Isolation

72
Q

Isolation procedures

A

PPE must be worn

Minimize delegation

73
Q

Contact vs droplet

A

Direct: person to person
Indirect: personal contact of host with contaminated inanimate object
Droplet: large particles that travel up to 3 ft during coughing, sneezing, or talking and come into contact with host

74
Q

Types of isolation

A

Private rooms
Special rooms with positive pressure airflow (used for highly susceptible pt)
Cards are used outside rooms to note level of isolation

75
Q

Nosocomial infection

A

An infection that originated in the hospital

76
Q

Infectious phases

A 
Incubation
Prodromal
Illness
Decline
Convalescence
77
Q

Multi drug resistant organism

MDROs

A

Have developed resistance to one or more broad spectrum antibiotics
MRSA
VRE
C. Diff

78
Q

Perioperative care

A

PreOp
IntraOp
PostOp

79
Q

PreOp

A

May be several hours to several days
Findings and assessments here are important baselines for postOp
Informed consent and teaching
Routine safety checklist
All meds are discontinued until HCP reorders after

80
Q

IntraOp

A 
Transport to operating room
Admission to operating room
Looks at skin integrity and mobility 
Acute care: prep, allergies, anesthesia, positioning, documentation 
Actual surgery
81
Q

PostOp

A

Family is notified: status, results, complications
Handoff report to PACU
monitoring and assessing changes in mental status and level of activity
Aim is prevention
If not, early recognition

82
Q

Anesthesia recovery

A 
Looks at activity level, respiratory level, circulation level
Consciousness
Oxygen level
Wound dressing
Pain level
Ambulatory ability
Ability to eat (nausea) 
Urine output
83
Q

Atelectasis

A

Partial collapse of the small airways

One of the most common breathing complications after surgery

84
Q

After surgery

A

Encourage pt to cough: helps clear lungs and lowers risk of pneumonia and atelectasis
Turn the pt: reduces change of decubiti, bedsores, and muscle loss

85
Q

IV sites

A

Peripheral or central
Best for blood draw: median cubical, accessory cephalic, antebrachial
Best for IV: dorsal venous network, accessory cephalic

86
Q

IV patency

A

Make sure the line is free flowing

To test: may use a syringe of saline solution to limit clothing

87
Q

Infiltration:

A

Redness, swelling, blanching, pain, tenderness, cool around site
Occurs when the catheter goes through or comes out of the vein

88
Q

Phlebitis

A

Redness, swelling, warmth, tenderness
Inflammation of the vein
Can be caused by the catheter, the fluids, or an infection

89
Q

Needle gauge for blood admin

A

18 gauge is standard

90
Q

Safe body mechanics when moving patients or objects

A

Before lifting, assess weight and determine if assistance is needed
Use pt safe handling equipment if pt is unable to help
Lift teams of two should be used to reduce injury risk

91
Q

Delegation

Important notes

A

RN is still accountable for outcome

Must document! If It wasn’t documented, It wasn’t done

92
Q

Some delegates tasks

A 
Vital signs
I&Os 
Postmortem care
Bathing/feeding/weighing 
CPR
93
Q

Tasks you may not delegate

A 
Assessment
Data interpretation 
Diagnosis 
Creating nursing care plan
Education
94
Q

Rights of delegation

A 
Right task
Circumstance
Person 
Communication 
Supervisor
95
Q

Therapeutic communications

A 
Active listening 
Empathy
Using touch or silence depending on situation
Clarifying
Paraphrasing
Validating 
Summarizing
Asking appropriate questions
96
Q

SBAR

A 
Situation
Background
Assessment
Recommendation
Able to relay relevant info in a timely manner
97
Q

Durable power of attorney

A

Supersedes legal next of kin in making decisions

May cause family conflict

98
Q

What constitutes a HIPPA violation?

A

Disclosing confidential pt info through gossip or discussing in public areas
Assessing info for pt not in your care
Improperly discarding documents that should be shredded
Leaving info visible to unauthorized individuals
Sharing info or photographs on social media

99
Q

What to do if pt refuses treatment

A

Pt must sign consent form refusing treatment

Must document that refusal

100
Q

Cardiac output

A

SV x HR = CO

101
Q

Symptoms of a transfusion reaction

A

Chills
Tachycardia
Flushing

Nursing Fundamentals (4 decks)

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