Final Exam Flashcards
what is the format of a two part nursing diagnosis?
RK, RS
risk for ____ related to
readiness for _____ as evidenced by
what is the diffrence between a risk for statement and a readiness for statement?
- risk for: is it used for potential problems, therfore will not have syptoms
- focuses more on primairy prevention
what does SOAP stand for?
subject
objective
assesment
plan
what are the main roles preformed by nurses?
E, A, M, L, CO, R, CA, D, PM
- educator
- advocator
- manager
- leader
- collab
- researcher
- careprovider
- delagtor
- policy maker
what is the hendrich II risk model?
falls assesment tool
what are the characteristics of a sterile field?
above the waist
below elbows
chest
sterile touching sterile
tables are sterile at waist level
What are characteritsics of a contaminated field?
broken seals/ packaging
wet or damp surface
sterile touching clean
outside 1 in
if it flaps back
below the wasit
above elbows
back
reaching over field
what are the common barriers to EBP?
research is costly
a lot of info is already out
delays into applying research in practice
what are the diffrent domains of learning?
CD, PMD, AD
cognitive domain
pyschomotor domain
affective domain
what is cognitive domain?
earning comprises knowledge and material that is remembered
what is pyschomotor domain?
teach back method
learning incorpartes physical movemnet and the use of motor skills into learning
what is affective domain?
learning recognizes the emotional component of intergrating new knowledge
what is dementia?
global impairment of cognitive function that is progressive and interferes with normal functioning
what is delirium?
acute
develops quickly
reversible
can fluctuate
when is discharge process started?
upon admission
what are the five stages of grief according to kubler- ross?
DAB DA
denial
anger
bargining
depression
acceptance
what is an example of an isotonic solution?
NS, LR
- normal saline
- D5W
- Lactated ringers
what is the body’s normal pH?
7.35- 7. 45
what are the blood transfusion reactions?
BP, C, F, FF
back pain
chills
fever
“feeling funny”
what is the lab value for hyponatermia and hypernatermia?
MPCS
hypo- less than 135 mEq/L
hyper- greater than 145 mEq/L
what is the lab value for hypokalemia and hyperkalemia ?
MPCS
hypo- less than 3.5 mEq/L
hyper- greater than 5.0 mEq/L
what is the lab value for hypocalcemia and hypercalcemia?
MPCS
hypo- less than 9mg/dL
hyper- greater than 10.5 mg/dL
what is the lab value for hypomagnesemia and hypermagnesemia?
MPCS
hypo- less than 1.3 mEq/ L
hyper- greater than 2.1 mEq/L
what measurement of blood pH is considered acidosis?
do do re mi fa sol la ti do
less than 7.35
what measurement of blood pH is considered alkalosis?
the alk is greater than the doe
Greater than 7.45
what is the normal value for co2?
35-45
what are th normal values for HCO3- ?
22- 26
what are the signs and syptoms of a fluid imbalance?
N/V, DMM, UO
N/V
dry mucuos membranes
urine osmarlity
what are the signs and syptoms of fluid retention?
WG, IP, LR, PE, CL,
weight gain
100 + pulse
labored respirations
3+ pitting edema
crackling lungs
what are the main components of a post op phase?
AWM, MVS, NS, PM, 24HRFR
airway management
monitoring vital signs
neuro status
pain management
24 hr fall risk
what are tasks that can’t be delagated to a UAP?
E, A, T
- evaluatation
- teaching
- assesments
What is the ANA’s current postion of assisted suicide?
no
what is the diffrence between assault and battery?
assault- verbal threats
battery- physical harm
what would be an example of a misdemenor?
stealing from the hospital
what is an example of a felony?
working outside of your scope or working w/o license
if a pt has/ or is aspirating what are the signs and syptoms?
co, g, f, cy, do2
- coughing
- gagging
- fever
- cynanosis
- decreased O2
what position do you put the patient in for the insertion of a cather?
DR
- dorsal recumbent
what is the opposite of polyuria?
oliguria
when is appropriate to call the HCP about a patient expriencing decreased urination?
less than 300ml/hr
what should ice be documented as?
1/2
when are patients assesed for fall risks?
everyday
what does PICO stand for?
Problem
intervention
comparison
outcome
what assesment is most accurate to asses excessive fluid volume/ fluid retention?
daily weights
what does it mean for a wound to be dehisced?
opened up
how often is TPN tubing changed?
every 24hr because bacteria can stick to the tubing
what is the diffrence between primary and secondary data?
- primary comes directly from the patient
- secondary comes from family, friends, objective data
what is left lateral recumbent?
patient is semiprone on the left side of the body
what is supine?
the patient laying on their backs
what is prone?
when the patient is laying on their stomach
what is trendelenburg?
patient is supine with the legs elevated and the head down low
what are the three stages of normal healing?
I, P, M
- inflammatory
- proliferative
- maturation
what are the characteristics of a stage I pressure ucler?
non blanchable redness, skin intact
what are the characteristics of a stage II pressure ucler?
partial thickness skin loss or blistering
what are the characteristics of a stage III pressure ucler?
full thickness skin loss, the fat is visible
what are the characteristics of a stage IV pressure ucler?
full thickness tissue, muscle and bone is visible
what is serous wound drainage?
its just water its not that serious
clear, watery fluid from plasma
what is serosanguinous wound drainage?
pink to pale red
mix of serous fluid and sanguineous
what is sanguineous wound drainage?
RED PENGUIN
bright red, usually indicates bleeding
what is purulent wound drainage?
thick yellow, beige with an odor usually indicated infection
what are the indicated theraputic use for NG tubes?
GD, N, MA
gastric decompression
nutrition
medication admin
what is a needle aspiration biopsy?
A needle biopsy is a procedure to obtain a sample of cells from your body for laboratory testing
what is the diffrence between phlebitis and infiltration?
phlebitis- inflammation of a vein caused by infection, injury, or irratation
inflitration- leakage of fluid or IV medication into surrounding tissue
