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Foundations II > Final Exam > Flashcards

Final Exam Flashcards

1
Q

ADPIE

A 
Assessment
Nursing Diagnosis
Planning
Intervention
Evaluation
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2
Q

Subjective Data

A

Info the pt or client tells the nurse

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3
Q

Objective Data

A

info that is measurable & observable

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4
Q

Which of the following best describes the responsibilities nurses have for educating clients?

  1. Legally, the client must be told detailed information about the medical diagnosis.
  2. Teaching is the primary role for the registered nurse.
  3. Because of short hospital stays, nurses attempt to teach clients about discharge.
  4. The American Hospital Association formalized the client’s right to information.
A

Number 2
Role of the nurse in client education is a legal mandate. The Nurse Practice Act in each state indicates that teaching is the primary role for the registered nurse

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5
Q

Actual Nursing Diagnosis

A

current problems that the pt has

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6
Q

Priority Nursing Diagnosis

A

determining which problem is most important for the pt

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7
Q

Risk for Nursing Diagnosis

A

a health problem that may develop if preventive actions aren’t taken

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8
Q

What are the parts of a Nursing Diagnosis?

A

Nursing Diagnosis
Related to (r/t)
As evidence by (aeb)

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9
Q

What is the classification of Heparin?
What are common side effects of Heparin?
Nursing consideration/interventions…

A
  • anticoagulant
  • bleeding
  • no aspiration, no massage
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10
Q

Needle sizes:

  • Intradermal
  • Subcutaneous
  • Intramuscular
A
  • Intradermal: 1 cc/ml, 3/8-5/8” needle
  • Subcutaneous: 3/8-5/8” needle
  • Intramuscular: 1-1.5” needle (21-23 gauge)
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11
Q

Mixing Insulin

A

-wipe rubber seals of vials
-roll NPH
-inject air into NPH
-inject air into Reg & draw it up
-draw up NPH
-have 2nd nurse verify before removing
(clear to cloudy)

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12
Q 
The nurse is preparing to administer 
0.9% NS to infuse at 100 ml/hour per 
the physician orders.  
A.)What would the nurse 
program into the infusion pump?  There are two 
 (2) items to answer this question.
B.)  How would the nurse check the infusion 
pump  to make sure it is correct?
A

A) 100 ml VTBI

B) count the drips per minute

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13
Q

4 most common sites for Intramuscular injections (IM)

A
  • deltoid
  • vastus lateralis
  • ventrogluteal
  • dorsogluteal
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14
Q

What are the 3 categories for Central Venous Access Devices (CVAD)?

A
  • central (triple lumens)
  • peripheral (PICC)
  • implanted ports (Port-a-cath)
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15
Q

3 common complications associated w/CVAD’s

A
  • air embolism
  • bleeding
  • catheter occlusion/damage
  • Sepsis (CLABSI)
  • Hematoma
  • Hemothorax/ pneumothorax
  • Phlebitis (PICC)
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16
Q
  1. How often should nurse flush a CVAD?
  2. How many ml flush does evidence-based practice recommend to use w/CVAD?
  3. How often should the nurse assess the site of a CVAD?
  4. Who is responsible to change the CVAD site dressing?
A
  1. flush every 12 hours
  2. 10 ml NS
  3. Assess site every 2 hrs If infusing IVF; every 4 hrs if adapted
  4. specially trained nurse of IV team changes site dressing
17
Q

When setting up a PCA pump, what is needed/considered?

A
  • 2nd nurse to double check
  • Narcan available
  • allergies checked
  • pt must be able to push trigger button & understand the pump
  • running IV
  • program pump
  • provide education
18
Q

What are some interventions/ nursing care for pt receiving TPN/PPN?

A
  • I & O
  • monitor electrolytes
  • blood glucose checks (every 6 hours)
  • assessments
  • change tubing every 24 hrs
  • submit TPN orders daily
  • D10 available
  • assess IV site/infusion pump every 2 hrs
  • *DO NOT CATCH UP
19
Q

Isotonic Solution

A

osmotic pressure that is equal of plasma….no net movement (PERFECT)

  • Normal Saline
  • Ringer’s Lactate
20
Q

Hypertonic Solution

A 
Electrolytes leave cell; less water, more solutes
-fluid moves from less solutes to more solutes
**cell shrivels**
DEXTROSE
-D5LR
-D5NS
-D50
-D5.1/2NS
21
Q

Hypotonic Solution

A

Electrolytes enter cell; more water, less solutes

  • fluid moves from less solutes to more solutes
  • *cell swells
  • 0.2% saline
  • 0.45 saline
  • D2.5 W
  • D5W
22
Q

Oliguria

A

diminished/small amount of urine

23
Q

Anuria

A

absence of urine

24
Q

Polyuria

A

excess amount of urine

25
Q

Dysuria

A

difficult/painful urination

26
Q

Urinary Frequency

A

urination in short intervals

27
Q

Urinary Hesitancy

A

delay in starting to urinate w/decreased force of stream

28
Q

Straight catheter

A
  • temporary; one time use

- relief of urinary retention/ to obtain specimen from bladder

29
Q

Indwelling catheter

A
  • long-term use

- catheter remains in bladder after insertion

30
Q

How is a 24hr urine specimen collected?

A
  • void 1st specimen in morning & then count each urination for 24 hrs
  • keep on ice
  • if missed specimen, must start over
31
Q

How is a urinalysis specimen collected from an indwelling catheter?

A
  • clamp tubing for 15 min & clean port

- aspirate w/syringe

32
Q

The physician had ordered LR
3000 ml to infuse over 48 hours.
Drop factor is 10 gtts/ml.
What will the nurse set the infusion pump at?

A

63 ml/hr
950 VTBI
11 gtts/min

will have to use 3-1000ml bags

33
Q

Why would a nurse want to know if their pt has COPD?

A

COPD pts live w/high levels of CO2, their only drive to breathe is from low O2 levels

***normal pt drive to breathe is increased CO2 levels

34
Q

What are some indications for nasopharyngeal/pharyngeal, tracheal suctioning?

A
  • decreased SaO2
  • adventitious breath sounds
  • visual resp secrections
  • cyanosis
  • restlessness
  • tachycardia
  • absence of spontaneous cough
35
Q

Hypervolemia

A
  • both water & sodium are retained in abnormally high proportions
  • VS: tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure
  • neuromusculoskeletal: confusion, muscle weakness
  • GI: weight gain, ascites
  • respiratory: dyspnea, orthopnea, crackles

edema, distended neck veins

36
Q

What nasogastric tube cannot be used for suctioning?

A

Dobhoff

37
Q

Diff between gastric lavage & gastric gavage

A
  • gastric lavage: removal of contents

- gastric gavage: providing nutrients/meds

Foundations II (2 decks)

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