Final exam Flashcards
Define Abduction, Adduction, Flexion, Extension
Abduction: away from body
Adduction: towards the body
Flexion: contract
Extension: straigten
Who does the work in passive ROM and active ROM
Patient= active
nurse= passive
COAL: What side does the cane go one.
Cane Opposite Affected Leg
Cane goes on strong side
What foot do you step with when using a Walker
Wandering Willa’s Always Late
Walk With Affected Leg
Prone Position
face down ass up
Supine
Supine you’re on your spine
laying flat on your back, face up
Sims
Laying on side with your legs separated
Lateral
laying on side with legs together
Fowlers: high and semi
Semi: 45 HOB, up right position
High: 90 HOB up right position
Sterile Field Rules
1” margin, is unsterile
Sterile touches sterile
What safety measures are needed when getting a patient up to walk to the bathroom
Lower bed, non skid socks, gait belt
What is the process of log rolling? Who is it used for
Grab chuk under patient and roll to side, careful of head making sure it is being moved at the same time.
Used when patients have head or spine injury
Normal hourly urine output is?
40 mL
What interventions can the nurse implement to prevent constipation?
Ability, hydration, high fiber diet, proper positioning, privacy
What is normal infant vital signs ranges
T: same as adult (100 is fever)
R: 20-30
P: 80-140
BP: 70-100/ 60
O2: 90% >
if a bp cuff is too big, what does it do to the reading
increases blood pressure
skin breakdown can occur in as little as ___ hours
2
what 2 factors lead to skin breakdown
fiction and shear
moisture
pressure
what are the 5 p’s
pain
position
potty
pathways
personal belongings
How many tiers of isolation are there? What are they?
1: standard precautions
2: transmission based
What Braden score indicates risk for skin breakdown?
<9
Does a high number or a low number indicate a fall risk on the Morse Fall Tool?
high
Name 4 interventions to prevent a patient from falling
non- skid socks, lowering bed, bed rails, fall risk bracelet, gait belt, walker, bed alarm
Name 3 never events
falls, distribution of wrong blood, foreign objects in body
How do you wash the eyes
inner to outer
1 tsp= ? mL
5
10 kg= ? lb
22
1 oz. = ? ml
30
1 gm= ? mg
1,000
54 g= ? kg
0.054
1.8 mg= ? mcg
1,800
5 L= ? ml
5,000
510 mg= ? g
0.510
1 tbsp= ? ml
15
1 tbsp= ? tsp
3
What are the 3 transmission based precautions?
- contact: gloves and gown
- Droplet: mask, gloves, glown
- airborne: full PPE
What are some things to consider with Neutropenic Precautions?
no fresh flowers, no food that come from outside, or could have possible diseases, leave door closed.
When is range of motion best performed?
with hygiene activities (ex. during a bed bath)
With a cane what side should it be held on, and what foot should be stepped first?
Held on strong side
Cane, strong foot, weak foot
With a walker, what should be the steps when walked
walker and weak leg first followed by strong leg
What are the point of crutches?
to assist with eliminating weight bearing on the legs.
What are some good body mechanics?
bed working height
wide base of support
squat to lift
push vs. lift
get help
factors that affect mobility and activity
lifespan
nutrition
lifestyle
stress
disease
Define transfer definitions:
Atrophy
hypertrophy
Flaccidity
Spasticity
Tremor
Paresis
Paresthesia
Atrophy: wasting muscle away
hypertrophy: enlargement
Flaccidity: soft or limb
Spasticity: abnormal increase in muscle tone
Tremor: shakes
Paresis: partial paralysis
Paresthesia: numbness or tingling
Safety interventions for fall risk patients: equipment and actions
Equipment: low bed, floor mats, fall risk bracelet, slippers, gait belt, bed alarm
Actions: orientate patient, reduce clutter, toileting schedule, hourly checks
What are every time actions when collecting specimen?
label clearly
utilize gloves and hand hygiene
utilize appropriate containers
transport in a specimen transport bag
be aware of the timing
Do you need a full stool for stool specimen collection?
no, just grab a little
Also, use a toilet hat to collect patients stool.
Things to know for a clean catch/midstream urine specimen
must use specific wiping packets before use (each wipe= 1 cloth) (females each side of labia front to back, then down the middle)
begin voiding, without stopping the stream insert the container and collect a sample, finish voiding
Things to remember with foley UA
alcohol swab the specimen port before
clamp catheter tubing for 20-30 minutes
use sterile syringe 10-20 ml of urine
clean up with alcohol wipe again and UNCLAMP the catheter
Timed urine samples
Specimen containers are refrigerated during collection in the soiled utility room refrigerator
if you miss any output, the collection and time must be restarted
