Final Exam Blueprint Flashcards

Question

Types of isolation

Answer 1

Contact precautions Droplet precautions Airborne precautions Transmission precautions Also just standard precautions: apply to blood, all body fluids, secretions, excretions (except sweat!), non-intact skin, and mucous membranes

Answer 2

CA warning signs (idk what CA means) - change in bowel pattern - blood in stool - rectal/abdominal pain - change in stool - sensation of incomplete post bowel movement

Answer 3

Distraction Humor Music Imagery Relaxation/Meditation Cutaneous - Stimulation Acupuncture Hypnosis Biofeedback Therapeutic Touch Animal-facilitated therapy

Answer 4

social worker, techniques to deal with stress like meditation and exercise

Answer 5

nurse assessment for safety - individuals - environment - specific risk factors -- falls -- impaired vision or balance -- medications -- confusion our job for safety: - assess - diagnose - plan - implement - preventing - educating

Answer 6

unmanageable expectations and responsibility of that role

Answer 7

1/4 to 1/2 inch needle gauge: 25-28 dose small, less than 0.5 mL angle: 5-15 degrees sites: inner surface of forearm, upper arm, upper back (no hair)

Answer 8

want to evaluate goals and learning objectives

Answer 9

- Routine urinalysis - Clean-catch or midstream specimens - Sterile specimens from indwelling catheter - urinary specimen from urinary diversion - 24hr urine specimen

Answer 10

- precautions for patients with an infection that is spread by LARGE-PARTICLE droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children - Use a private room, if available; door may remain open - Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the pt’s environment (mask and don PPE when entering pt room) - Transport patient out of room only when necessary and place a surgical mask on the patient if possible - Nurse should also wear mask when transporting pt - Keep visitors 3 ft from the infected person - Ex. influenza (flu); bronchitis (Anything with someone coughing) - Masks are to be worn for protection against potential exposure to infectious agents when the client is on droplet precautions

Answer 11

Total parenteral Nutrition Nutritional support, highly concentrated Infused through central line Used with clients who can’t meet nutritional needs PO or enteral. Complications; infection, f/e imbalance.

Answer 12

Stage 4: REM. Dream and brain activity. Most dreaming occurs. Body cannot regulate its temperature you may begin to feel hot or cold. Heart and respiratory rates increase  Limb muscles paralyzed  Increased brain activity

Answer 13

impaired Gas Exchange - high BMI -snoring -diabetes

Answer 14

- increased BP - distended jugular veins - rapid breathing - dyspnea

Answer 15

Small particles (<5 μm) spread through the air. Ex: tuberculosis requires a N95 respirator mask and negative air pressure room. <5 micrometers; door should remain closed

Answer 16

tendons, ligaments, muscles, bones, blood vessels

Answer 17

Fever (pyrexia)- increase above normal in body temperature due to a change of thermoregulatory set point  Temperature above 100.4 F (orally) - - Malaise  Chills, shivering (pt c/o being cold)  Aches, pains, fatigue  Headache, drowsiness, confusion  Nausea, decreased appetite  Hot, dry, flushed skin  Increased pulse and respirations  Dehydration, thirst  Diaphoresis (sweating)

Answer 18

-Susceptibility: degree of resistance -Compromised: a person at increased risk of infection

Answer 19

COPD patients because they have low oxygen as the drive to breathe and worry about them losing the drive to breathe

Answer 20

when you reach for container before pouring upon replacing container

Answer 21

Rest Ice Compression Elevation | First 48 hours you do ice for acute injury and then switch or alternate

Answer 22

change in response to a stressor in an effort to restore balance

Answer 23

Staff must be oriented and competent Oral analgesics must be evaluated in 45-60 minutes IV analgesics must be evaluated in 15 to 30 minutes Discharge planning must include pain management needs ----- Teach patients Determine pain rating goals Provide appropriate care

Answer 24

First, you discard urine If you empty the urine at 0600, you’ll collect the urine 24 hours later at 0600 Foley - i think you have the bag on ice Discard first urine Collect for 24 hours At the end, ask patient to void and add to collection

Answer 25

nasal cannula simple mask nonrebreather mask partial rebreather venturi mask

Answer 26

non-blanchable erythema of intact skin

Answer 27

partial-thickness skin loss - shallow, open ulcer

Answer 28

Amount deliver FIO2: - *Simple-A low-flow system that delivers 35–50% oxygen with a flow rate of 6–10 L/min (from slides) nursing interventions: - monitor frequently to check placement of mask - support patient if claustrophobic - secure nasal cannula (prescribed) to be used during meals

Answer 29

- compression socks - keeping patients mobile; not resting in bed too long

Answer 30

- can influence type of health care received - can influence medications receive - can influence hygiene practices - can influence dietary practices

Answer 31

constricts peripheral blood vessels decreases muscle spasms promotes comfort reduces blood flow to tissues decreases local release of pain producing substances decreases edema and inflammation alters tissue sensitivity - numbness

Answer 32

right patient right medication right dose right route right time right reason right assessment right education right refuse right response right documentation: drug, dose, route, time, initials, full signature, site of injection, clinical info

Answer 33

Male assessment: - lesions, swelling, excoriation, tenderness, discharge make sure to clean foreskin if uncircumcised - anal area: -- cracks, nodules, distended veins, masses, polyps perineal care: - clean from tip of penis toward pubic area - if uncircumcised, retract foreskin, wash, rinse, and put foreskin back in place - wash and rise scrotum and dry

Answer 34

full-thickness skin loss - subcutaneous fat may be visible

Answer 35

Hoyer lifts: allow person to be lifted and transferred with a minimum of physical effort – sit-to-stand hoyer lift – manual and powered hoyer lifts

Answer 36

Equipment:  Tympanic (ear)  Electronic, digital  Temporal artery – right or left side of forehead

Answer 37

factors affecting oxygenation: -sedentary activity patterns -exercise -smoking Smoking!!! (have to offer smoking cessation to any patient that smokes) Environmental - pollution Working with chemicals

Answer 38

No open flames No smoking No gas stoves or fireplace Monitor for skin breakdown around ears with cannula; around nose with CPAP

Answer 39

STEPS TO PUTTING ON FIRST STERILE GLOVE (ALWAYS DOMINANT HAND FIRST) - Use the thumb and forefinger of your non-dominant hand to grasp the cuff of the sterile glove for your dominant hand. - Touch only the inside surface of the glove. - Lift the glove above your waistline. - Place your dominant hand into the glove and pull on the glove. STEPS TO PUTTING ON SECOND STERILE GLOVE (NONDOMINANT HAND) - Hold the thumb of your gloved hand outward, and place your fingers inside the cuff of the remaining glove. - Lift it from the wrapper. - Place your non-dominant hand into the glove and pull it on, taking care not to touch your skin with the outer surface of the glove. STEPS TO EXTENDING CUFF ONCE STERILE GLOVES ARE ON - Slide the fingers of one hand under the cuff of the other. - Fully extend the cuff down your arm, being careful to only touch the sterile outside of the glove. - Repeat for the other hand. - Adjust gloves as needed STEPS FOR REMOVING STERILE GLOVES - Use your dominant hand to grasp the other glove near the cuff end on the outside of the glove. Contaminated surface does not come in contact with wrist. - Remove the glove by inverting it as it is pulled off, to keep the contaminated area (the outer surface of the glove) on the inside. Remove the gloves in a safe manner to prevent the spread of microorganisms that may be on the outside of the gloves. - Hold the removed glove in your gloved hand. Contaminated area does not come in contact with hand or wrist. - Slide the fingers of ungloved hand inside the remaining glove, between the glove and your skin. Do not touch the outside of the glove. Contaminated area does not come in contact with hand or wrist. - Grasp the glove on the inside and remove it by turning it inside out, over the hand and the other glove. Contaminated area does not come in contact with hand or wrist. - Perform hand hygiene. Wearing gloves does not eliminate the need for hand hygiene. It reduces the spread of microorganisms.

Answer 40

Moist - cold compresses Dry/cold - ice bags/packs - cold packs (freezer) - hypothermia blanket or pad

Answer 41

ADPIE safety first

Answer 42

From internet: A urinary tract infection (UTI) can cause a variety of symptoms, including: A burning sensation or pain while urinating A strong urge to urinate, especially at night Cloudy, red, or bloody urine Urine with a strong odor Pain in the lower abdomen or pelvis Fever or feeling hot and shivery Nausea and/or vomiting Tiredness Pain in the back or side, below the ribs treated by antibiotics

Answer 43

Medical aseptic technique – hand hygiene before and after glove use – disposable gloves – do not contaminate outside of container w stool – obtain sample, package, label, and transport according to policy Patient guidelines: - void first so urine is not in stool sample - defecate into container rather than toilet - do not place toilet tissue in bedpan or specimen container - notify nurse when specimen available

Answer 44

- education - knowledge deficit -- need to teach about medications, oxygen therapy, assistive devices, catheter care, NGT care - reading proficiency - ability to communicate -- language barrier -- medications -- sensory loss - physical health state -- health and disease process -- illness - mental status - psychosocial health state -- stress and depression (decreased concentration, lack of judgment and decision making, lack of motivation in learning) in class review: Intellectual ability Health literacy Language Support systems Level of consciousness; mental status Financial status

Answer 45

Physiologic (involuntary) Behavioral (voluntary) Affective (psychological)

Answer 46

ability to adapt is lessened; becomes chronic - increased duration, intensity, and number of stressors increased risk for disease or injury; recovery and return to normal function is compromised

Answer 47

Prodromal Stage: Interval from the onset of nonspecific until specific symptoms appear Client is usually the most contagious

Answer 48

- patient can get tired or unable to complete hygiene for themselves or able to do ADLs

Answer 49

- only 12% of adults have proficient health literacy - health literacy: ability to understand instructions, navigate health care system, and communicate needs, and engage in self-care and chronic disease management might be affected by - intellectual ability - health literacy - language - support systems - level of consciousness - financial status assess patient learning with teach-back method always confirm understanding

Answer 50

- fecal incontinence - urinary incontinence watch for skin breakdown due to moisture exposure

Answer 51

Nerve pain

Answer 52

decreased respiratory, BP and pulse decreased vital signs and eye movements

Answer 53

measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) Be aware of patient’s hemoglobin level as well 95 – 100% normal < or = 90% abnormal

Answer 54

basal metabolic rate (BMR): energy (# of calories) required to fuel the involuntary activities of the body at rest after 12 hours; energy needed to sustain metabolic activities of cells and tissues males have a higher BMR due to larger muscle mass, generally factors that increase BMR: - growth, infections, fever, emotional tension, extreme environmental temps, elevated levels of certain hormones factors that decrease BMR: - aging, prolonged fasting, sleep

Answer 55

A. Contact Direct Indirect B. Airborne Transmission C. Droplet transmission D. Vehicle Transmission E. Vector Transmission

Answer 56

- Occurs from cumulative effect due to poor metabolism/excretion (one dose cannot be metabolized prior to the next dose) - Impairing an organ; bad effects endangers health - risk for permanent damage or death

Answer 57

- IV infusion sluggish or may cease - heat, redness, tenderness at site

Answer 58

- You cannot take your eyes off the sterile field once it is set up -- If you have to leave the room → the sterile field must be reset up - If out of your range of vision or below your waist, it is considered contaminated - A wet field is contaminated - Prolonged exposure to the air will contaminate Basic Principles of Surgical Asepsis: - Touching Sterile Objects: Only sterile objects should touch other sterile objects. Any unsterile contact contaminates the sterile object. - Opening Sterile Packages: Open packages so that the first edge of the wrapper is directed away from the worker to prevent contamination. - Avoiding Spills: Do not spill solutions onto cloth or paper fields as moisture can cause contamination. - Handling Sterile Objects: Hold sterile items above waist level to keep them in sight and prevent contamination. - Avoiding Contamination: Do not talk, cough, or sneeze over sterile fields, and never turn your back on or walk away from a sterile field. Do not reach over sterile fields. - Edge Contamination: The outer 1-inch margin of a sterile field is considered contaminated. - Doubtful Sterility: Consider any object contaminated if there is doubt about its sterility.

Answer 59

high or low fiber diets idk eat fruits and veggies

Answer 60

transmitted through food or water

Answer 61

- use clock face language to tell a patient where something is. - making sure they dont trip on the IV line - clearing paths - clear communication

Answer 62

12-20 Bradypnea: slow breathing; regular rate that is less than 10 rpm -Tachypnea: rapid breathing; regular rate that is more than 24 -Apnea: period without breathing - Dyspnea: difficult or labored breathing - Hyperventilation: increased rate and depth -Hypoventilation: decreased rate and depth -Orthopnea: difficulty breathing in any position except upright sitting or standing -Cheyne Stokes: regular pattern, alternating hyperventilation with apnea

Answer 63

dilates peripheral blood vessels – increases local blood flow – increases supply of oxygen and nutrients to area increases tissue metabolism decreases blood viscosity increases capillary permeability decreases muscle tension helps relieve pain

Answer 64

Ask on scale 0-10 PQRST or OLDCARTS Unsure on this just guessing

Answer 65

Clear liquid: juice, broth, water, coffee Full liquid: “Clears” plus: - milk - pudding and custard want pourable liquid supplements

Answer 66

aspiration

Answer 67

- wrist restraint (cloth, leather) - jacket or body restraint - geriatric chairs - bed rails - medications as well

Answer 68

Common reservoirs: - Human body, animals, insects - Fomites (inanimate objects ex. soil) Must provide microorganism-specific environment to survive: - food, oxygen, water, temperature, ph, light

Answer 69

designed for patients who cannot bear any weight

Answer 70

Approximately 80% suffer with chronic illness accompanied by varying degrees of discomfort Many myths surround pain management

Answer 71

transmitted through insect or fomite

Answer 72

Cannot have any identifying information in writing yourself notes Do not speak about patients in common, public areas

Answer 73

call bell in reach, bed lowered, and personal belongings within reach

Answer 74

1. patient's full name 2. date and time order is written 3. drug name 4. dosage 5. route of administration 6. time and frequency 7. signature of person writing order

Answer 75

Can be a respiratory complication peri/post-op Can develop from lack of movement in bed? - is bacterial or viral Prevent by moving patient around using breathing exercises

Answer 76

Alcohol-Based Hand Rubs: Preferred when hands are not visibly soiled. They are effective in reducing bacterial counts quickly. Soap and Water: Necessary when hands are visibly dirty or after contact with C. difficile spores since alcohol-based rubs are ineffective against these spores.

Answer 77

When the human body is the reservoir - -Skin & mucous membranes -Respiratory tract -Genitourinary tract -Gastrointestinal tract -Blood & tissue

Answer 78

Powered Stand-assist and repositioning lifts: for patients with weight-bearing ability, able to follow directions, and cooperation

Answer 79

Amount delivered FIO2: - 4-6 L/min - 24-40% nursing interventions: - requires careful monitoring to verify FIO2 at flow rate ordered - check that air intake valves are not blocked

Answer 80

Subclavian, jugular, PICC line she noted: IV in hand is not a central line

Answer 81

Top of crutches should be 1-2 in below armpit, weight should be on hands not armpit. handgrips should be even with top of hips. Navigating Stairs Up Stairs: Lead with your uninjured leg, moving it to the next step first, then move your crutches and injured leg to the same step. Remember the phrase: “Up with the good.” Down Stairs: Place the crutches on the lower step, move your injured leg down next, and then follow with your uninjured leg. Remember: “Down with the bad.”

Answer 82

- local acute tenderness - warmth, redness, edema above insertion site

Answer 83

Promoting comfort with oxygenation - positioning allows free movement of the diaphragm and expansion of the chest wall

Answer 84

stand between the back legs of the walker with arms relaxed at the side top of walker should align w/ the crease on inside of patient wrist grip top of the walker at the handles with elbows slightly bent lift walker and position about one step ahead; keep back upright place one leg inside the walker (ensure doesn’t roll away if wheels) push straight down on grips of walker and step forward with remaining eg repeat process

Answer 85

Widen a person’s base of support, should not be for bearing weight hold cane on stronger side cane about 4 inches to side of foot and extend to wrist crease elbow slightly bent; flexed 15 degrees teach patients to stand erect and not lean on it patient stand w/ weight evenly distributed cane on stronger side and advance one small stride ahead supporting weight on stronger leg and cane, patient advances the weaker foot forward to parallel to the cane supporting weight on weaker leg and cane, patient brings stronger leg forward to finish the step

Answer 86

Convalescence: period when acute symptoms disappear

Answer 87

Protein, fat, carbs

Answer 88

effects that are not intended

Answer 89

- Often the same as exit routes ** Gain entrance into host Skin & mucous membranes Respiratory tract Genitourinary tract Gastrointestinal tract Blood & tissue

Answer 90

length: 3/8 to 1 inch (based on subcutaneous tissue) 25-30 gauge (dose no more than 1 mL) angle: 45-90 degrees (based on needle length/adipose tissue) sites: upper arm, anterior thigh, abdomen, upper back and upper dorsogluteal be sure to rotate sites

Answer 91

they need to tell you when they need the meds, but to tell you before the pain is severe. if you wait until it is terrible, it will take more meds or longer to go away

Answer 92

frustration when one feels inadequate in performing tasks the role is assumed to be responsible for

Answer 93

Delegation of vital signs based on:  patient situation  abilities of unlicensed personnel; sufficient knowledge to perform task delegated, can perform accurately  RN is responsible for validating and reporting/acting on findings

Answer 94

stool sample culture is only official way to diagnose

Answer 95

teaching w patient and measures to recommend: -Reduce anxiety -Eat a high-protein/high-calorie diet -Maintain a high fowlers position when possible/ tend to sit in tripod position watch for barrel chest and clubbing Venturi mask good for these patients

Answer 96

Therapeutic diets: - consistent carbohydrate - fat or sodium restricted (cardiac) - high or low fiber (GI) - renal (monitor potassium) Modified consistency diets: - clear liquid (juice, broth, water, coffee) - pureed (usually for swallowing issues) - mechanically altered (finely chopped, thickener in liquids)

Answer 97

ear, finger, toes normal range: 95-100%

Answer 98

Techniques: - bolus feeding (delivering a large volume of formula at once using a syringe), - continuous feeding (administering a steady stream of formula over a long period using a pump), - cyclic feeding (delivering a large volume of formula over a shorter period, often several hours, using a pump), - intermittent feeding (giving smaller volumes of formula at regular intervals, usually with a pump or gravity) depending on the patient’s needs and the placement of the feeding tube (stomach vs. small intestine) Monitoring: Enteral feeding - Feeding schedule and formulas, and pumps - monitor for tolerance – gastric residual volume (GRV) - promote patient safety - monitor for complications - provide comfort measures - provide education

Answer 99

core temp increase pulse rate increase RR increase bp increase

Answer 100

- use frequent face to face contact - speak calmly, simply, and directly to patient - orient and reorient patient - orient patient to time, place, and person - offer explanations

Answer 101

Dry heat: - hot water bottles - electric heating pads - aquathermia pads: water is enclosed - hot packs (instant) - warming blankets Moist heat: - warm moist compresses - sitz bath - warm soaks

Answer 102

Direct Contact: Close proximity between host and carrier (e.g., touching, kissing). Indirect Contact: Via vectors (e.g., insects) or fomites (e.g., contaminated equipment).

Answer 103

INCUBATION The interval between the entrance of the pathogen into the body and the appearance of the first symptoms The organisms are growing and multiplying

Answer 104

dispel any misconceptions learned from internet or other sources assess prior knowledge before teaching

Answer 105

They are supposed to exhale air and then inhale through the incentive spirometer. The goal is to keep the ball between arrows on the side and see how high the patient can get and/or reach the level marker. When inspiration increases, they are improving. Good for: encourages maximizing lung inflation and preventing/reducing atelectasis

Answer 106

- patient experiences so much sensory stimuli that brain unable to respond meaningfully or ignore stimuli - patient feels out of control and exhibits manifestations observed in sensory deprivation - nursing care focuses on reducing distressing stimuli and helping the patient gain control over the environment

Answer 107

5/8 to 1 1/2 inches (based on site and patient age) needle gauge: 18-25 angle of insertion: 72-90 degrees sites: Vastus lateralis (thigh) - 4mL max Deltoid (upper arm) - 1mL max Ventrogluteal (hip area) - 4mL max

Answer 108

2 hours before

Answer 109

Hands are washed between client contacts; after contact with blood, body fluids, secretions, and excretions and after contact with equipment or articles contaminated by them; and immediately after gloves are removed. WHO's 5 Moments for Hand Hygiene: - Before touching a patient. - Before a clean or aseptic procedure. - After body fluid exposure risk. - After touching a patient. - After touching patient surroundings.

Answer 110

patient literally teaches if back to you after you teach them

Answer 111

effects from medication, but are not the desired effect some are expected like headache, weight loss, hair growth

Answer 112

pain that occurs in a specific area of skin, called a dermatome, that is connected to a single spinal nerve. Dermatomal pain can be caused by damage or dysfunction to the spinal nerve, which can be due to infection, compression, or injury.

Answer 113

assess prior knowledge (what they already know)

Answer 114

Metabolic syndrome: have been linked to high fat diets; cluster of symptoms that include excess abdominal fat, high blood glucose levels, high triglycerides, low HDL and hypertension If one has three or more → diagnosed with metabolic syndrome aka Syndrome X Risk of mortality increases related to diabetes, obesity, and cardiovascular disease

Answer 115

body organs in thorax, cranium, and abdomen

Answer 116

- compensation - denial - displacement: taking stress out on others - rationalization: trying to rationalize what's happening

Answer 117

Full stage of illness: the presence of specific disease symptoms

Answer 118

o Wedges and Pillows o Mattresses o Adjustable Beds o Trapeze Bar o High-top Sneakers o Hand splints

Answer 119

- affects physical status - increases risk for disease or injury - compromises recovery and return to normal function - associated with specific diseases (cancer, anything with breathing or SOB, anything life threatening or severe like MI)

Answer 120

Taking breaks; doing it in steps

Answer 121

S & S: dyspnea, increased BP, increased pulse, pallor, cyanosis, anxiety, restlessness, confusion, and drowsiness

Answer 122

Medical Asepsis (clean technique): activities that reduce the number and transfer of pathogens . . Cleansing: the removal of visible foreign material from objects (soap/water) . Disinfecting: destroying pathogens * use when risk for infection is high

Answer 123

full-thickness skin loss with exposure bone, tendon, or muscle

Answer 124

medication that has to be controlled on a pump like TPN

Answer 125

- precautions used for patients who are infected or colonized by a multidrug-resistant organism (MDRO) - Place the pt in a private room, if available - Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient’s environment (gloves, gown, don PPE when entering pt room) -- Change gloves after having contact with infective material -- Remove PPE before leaving the patient environment, and wash hands with an antimicrobial or waterless antiseptic agent -- Limit movement of the patient out of the room -- Avoid sharing patient-care equipment - Do not need to apply a face mask, N-95 respirator, goggles, or face shield to prevent contamination through contact with the client or equipment

Answer 126

Larger particles (>5 μm) spread through activities like coughing. generally need to be 3ft or more away from patient Example: influenza

Answer 127

- edema, pain and coolness at site - significant decrease in flow rate

Answer 128

Frequent urination

Answer 129

(im gonna add ranges in the next cards)

Answer 130

very little urine output; 24 hour urine output is less than 50 mL (maybe the key here is "less than") HOWEVER, online it says when kidneys aren’t producing urine. which makes sense because of the prefix

Answer 131

Same concentration of particles as plasma Definition: solutions with the same osmolality as body fluids - do not enter the cells because there is no osmotic force to shift the fluids - increases ECF volume Example: 0.9% NS, Lactated ringer

Answer 132

A condition that occurs when the body gets used to a medicine so that either more medicine is needed or different medicine is needed

Answer 133

base of ulcer covered by slough and/or eschar in wound bed

Answer 134

pump can be set to a ml/hr gravity - set to specific height

Answer 135

used to steady patients, not to lift them avoid using them on patients with abdominal or thoracic issues

Answer 136

OTCs, herbal meds, supplements

Answer 137

originates in one part of the body but is perceived in an area distant from its point of origin; transmitted to a cutaneous site different from its origin

Answer 138

Pattern of respirations Meds Health history Recent changes Lifestyle and environment

Answer 139

Repeat verbal orders back

Answer 140

symptoms: - dilated pupils - dry mouth - headache - backache - constipation or diarrhea - increased pulse - increased BP - increased respirations - increased gastric acid production - nausea - sleep disturbances - increased perspiration - chest pain - weight gain or loss - decreased sex drive psychological responses: - anxiety, anger, depression

Answer 141

- previous and current drug use - allergies, response to drugs - compliance with regimen - attitude/understanding of drugs - perceptual/coordination problems related to administration Other assessments: - MAR - diet and fluid orders - lab values - ability to swallow - muscle mass - GI motility - venous access - body system assessment - pt's health status

Answer 142

- personal habits like drugs and alcohol, illicit or street drugs - activity and exercise - nutrition and elimination - interpersonal relationships and resources - spiritual resources - lack of eye contact - limiting relationships to those with similar values and interests - attack behaviors - compromise behaviors - withdrawal need to consider coping mechanisms for the adult especially dealing with careers and family

Answer 143

amount delivered FIO2 (fraction inspired oxygen): - maximum flow 60 L/min - 10 L/min = 65% - 15 L/min = 90% nursing interventions: - monitor respiratory status - often better tolerated by children than other noninvasive delivery methods

Answer 144

Most common sleep disorder -Transient insomnia - Less than one month. * Short-term insomnia – Between one and six months. * Chronic insomnia – More than six months.

Answer 145

- physiologic makeup - genetic inheritance - very young - very old - altered physical or mental health - inadequate nutrition - sleep deficits - poor support systems and relationships

Answer 146

a person must assume opposing roles with incompatible expectations Ex: adult daughter now caregiver and medical decision maker for elderly parent

Answer 147

Axillary: 36.5°C, 97.7°F Oral: 37.0°C, 98.6°F Rectal: 37.5°C, 99.5°F Tympanic: 37.5ºC, 99.5°F Temporal: 37.5°C, 99.5°F

Answer 148

Teaching those with altered oxygenation from COPD or asthma: -Reduce anxiety -Eat a high-protein/high-calorie diet -Maintain a high fowlers position when possible Increase activity levels and exercise; no smoking; have adequate fluid intake levels to thin secretions

Answer 149

- environment with decreased/monotonous stimuli - impaired ability to receive stimuli - inability to process stimuli

Answer 150

those with impaired kidney or liver function depending on what the drug is and how it is excreted

Answer 151

condition in which the human system experiences changes in its normal balanced state

Answer 152

Acute vs chronic ABC Emergent > urgent

Answer 153

Oral: - avoid medical terminology - avoid jargon - teach back Written: - use pictures - use handouts in person's language - confirm ability to read Always confirm patient understanding The interview: - purpose is to obtain subjective data to complete a health history - establish trust - teach about health state - build therapeutic relationship - health promotion

Answer 154

- services to meet unique diverse needs of patients with consideration to culture - recognize that culture matters in certain clinical encounters - recognize limits of knowledge of a patient's situation - avoid generalizing assumptions - be aware of provider and patient biases - ensure mutual understanding through patient centered communication - respectfully asking open ended questions about patient's circumstances and values when appropriate - understand health related behaviors resulting from cultural beliefs - recognize values stemming from individual experience and cultural background

Answer 155

*Bacteria  Shape – cocci, bacilli, spirochete  Gram stain – negative or positive  Need for oxygen – anaerobic or aerobic *Fungi molds and yeasts *Parasites  Viruses – smallest microorganisms  Multicellular

Answer 156

BRAT: banana, rice, applesauce, toast

Answer 157

Amount delivered FIO2 (fraction inspired oxygen): - 1-2L/min = 24-28& - 3-5L/min = 32-40% - 6L/min = 44% nursing interventions: - check frequently is in both nares - chronic lung disease: limit rate to minimum needed to raise ox sat to 88-92%

Answer 158

<120/80 mm Hg (Adults ages 18 and older) = = Hypertension -Systolic pressure >130 mm Hg or diastolic >80 mm Hg - - Hypotension-<90/diastolic pressure <60 mm Hg or pressure 20-30 mm Hg lower than usual - - Orthostatic-abnormal drop in blood pressure that occurs upon standing up from a sitting or lying down position - Increase of 40 beats in pulse rate or decrease of 20 mm Hg in blood pressure

Answer 159

very young and very old

Answer 160

Referred Visceral Somatic Dermatomal neuropathic

Answer 161

Legally, it didn’t happen because it wasn’t documented. You can document late - remember to go back to document; it is your only defense

Answer 162

Provides comfort with oxygenation protects against irritation and infection

Answer 163

- use stages of cognitive development - consider that health care crisis can lead to regression as common response - be alert to nonverbal behaviors older adults: - pace appropriately - may need increased response time to process - physical limitations considerations when interviewing people with special needs overcome communication barriers consider health literacy; help clients understand

Answer 164

inadequate amount of O2 available to cells

Answer 165

From internet: Kegel exercises are a way to strengthen the pelvic floor muscles, which can help with bladder control

Answer 166

Avoid these “traps” to effective interviewing: 1. Providing false assurance or reassurance 2. Giving unwanted advice 3. Using authority 4. Using avoidance language 5. Engaging in distancing 6. Using professional jargon 7. Using leading or biased questions 8. Talking too much 9. Interrupting 10. Using “why” questions assist the narrative - patient leads and reactions obtained from interviewer -- facilitation, silence, reflection, empathy, clarification - interviewer leads and expression of own thoughts based on obtained information -- confrontation, interpretation, explanation, summary

Answer 167

Use the nursing process to document: ADPIE Formats for nursing documentation: - nursing care plans (NANDA) - critical/collaborative pathways - patient care summary (kardex) - flow sheets/graphic records Conferring - consultation - referral - conference - nursing care rounds Nursing informatics - specialty integrating nursing science, computer science, information science - developing and implementing cutting age tech - providing more knowledge to nurses to improve patient safety and quality of care

Answer 168

Gait belt Sit-to-stand Lateral assist (mechanical) Transfer chair

Answer 169

expectations of how one should behave when sick, not likely to be reality, different for each person

Answer 170

Produce analgesia by attaching to opioid receptors in the brain ----- Common Side Effects: Sedation, nausea, and constipation -Sedation usually precedes opioid-induced respiratory depression -Must assess level of sedation and take action if necessary: .....If asleep, but easily arousable – no action necessary .....If frequently drowsy and drifts off to sleep mid-conversation then dose should be decreased ......If somnolent with minimal or no response to stimuli then discontinue opioid and consider reversal agent (narcan)

Answer 171

(thinking of in hygiene with self care) patient able to do everything themselves

Answer 172

-assess skin daily -cleanse skin routinely and as needed -moisturize dry skin avoid massage of bony prominences -minimize friction and shearing -use appropriate support surfaces -administer nutritional supplements as needed -improve mobility/activity and use ROM -frequent position changes -document prevention measures and results

Answer 173

vitamins, minerals, water

Answer 174

sleep deprivation lowers ability to adapt immobility: sleep pattern disturbance Good mobility: better sleep factors affecting sleep - developmental considerations - motivation to be awake - culture - physical activity - shift work - stimulating activities - dietary habitrs - tobacco use - alcohol use - environment - psychological - health condition - meds insomnia most common sleeping disorder

Answer 175

Change bowel pattern Blood in stool Rectal/abdominal pain Change in stool Sensation of incomplete emptying p bowel movement

Answer 176

carbohydrates, protein, lipids, vitamins, minerals, water

Answer 177

R - rescue A - alarm C - contain E - extinguish/evacuate - have a fire plan - fire alarm and CO alarm - check electrical equipment and cords - no smoking in hospitals

Answer 178

Greater concentration of particles than plasma. causing water to move out of the cells and to be drawn into the intravascular compartment, causing the cell to shrink. Definition: solutions that are more concentrated or have a higher osmolality than body fluids - concentrate ECF and cause movement of water from cells into ECF by osmosis - monitor for fluid overload, but used to treat hypovolemia and replace fluid and electrolyte don’t want to dehydrate cells - they can shrivel Example: 5% dextrose in 0.9% normal saline Example: 5% dextrose in LR

Answer 179

Prolonged expiration to slow down path way resistance. Good for COPD

Answer 180

-Infectious Agent- Pathogen -Reservoir Place- where the organism can grow and multiply, natural habitat -Portal of Exit- Route of escape -Means of Transmission- Route of movement from reservoir -Portal of Entry - Point where the organism enters another host -Susceptible Host- Person that is acceptable to the pathogen

Answer 181

- when verbal and nonverbal messages are congruent: verbal message reinforced -- when incongruent: nonverbal is viewed as truer nonverbal skills: - physical appearance - posture - gestures - facial expression - eye contact - voice - touch

Answer 182

female assessment - color, lesions, masses, swelling, excoriation, tenderness, discharge cleaning front to back perineal care: - spread labia - wash from pubic area toward anal area (front to back) - rinse well - plain soap and water for vaginal water

Answer 183

- risk factors - fall risk - psychosocial health state -- stress -- depression - physical health state -- health and disease process -- chronic illness (MI, stroke) -- acute illness (braces, casts, crutches)

Answer 184

letting fluid run through the line and getting all the air out before connecting to the patient

Answer 185

increased HR and RR

Answer 186

Infection: - immune system fails to control the growth of microorganisms - microorganisms can invade at the time of trauma, during surgery, or any time after - usually apparent 2-7 days after injury or surgery - can lead to other complications HARPS (heat, affected part loss of function, redness, pain, swelling) Presence of infection: - purulent and increased drainage - pain, redness, swelling - increased body temperature - increased WBCs - delayed healing - discoloration of granulation tissue

Answer 187

pain when urinating; difficulty

Answer 188

Acute - Rapid onset - Varies in intensity: mild to severe - After cause resolved it disappears Chronic - May be limited, intermittent, or persistent - Lasts beyond the normal healing period - Can have remission or exacerbation

Answer 189

Past experience Cultural/Ethnic variables Family Gender Age Religious beliefs Environment Support people Anxiety/Stress

Answer 190

on- gown, then mask, then goggles, then gloves doff-remove gloves, then gown, then goggles, then mask, then hand hygiene

Answer 191

(thinking of partial bath in hygiene) nurse assists with some thinks, like untying gown and getting hard to reach areas

Answer 192

Identity/Introduction Situation Background Assessment Recommendation

Answer 193

(thinking of complete bath in hygiene) patient unable to do activity; nurse does everything

Answer 194

high fiber? good fluid intake

Answer 195

medication exercise at least 2-3 hours before bed don't drink water before bed keep screens off avoid caffeine - coffee, tea, chocolate, some sodas

Answer 196

physiologic adaptation - managing and providing care for those w acute, chronic or life-threatening physical health conditions - knowledge in body systems, f&e imbalances, hemodynamics, infectious diseases, medical emergencies, pathophys, radiation therapy, respiratory care, unexpected response

Answer 197

chronic illness sleep deprived person

Answer 198

- physician order required - continuous or very frequent monitoring - offer use of bathroom or bedpan - maintain hydration - maintain nutrition -> feeding patient - encourage ROM and movement - assess skin and circulation - remove ASAP - be aware of state and hospital guidelines/protocols

Answer 199

NEED 2 NURSES Stay with the patient for 15 minutes to watch for reaction Check blood type and patient band Can be out of fridge max 4 hours; infuse over 1-4 hours Consider: *Typing and cross-matching *A, B, AB, and O type blood *Rh factor *Selecting blood donors *Initiating transfusion *Transfusion reactions

Answer 200

Patient’s verbalization and description of pain: Duration Location Intensity Quality Chronology Aggravating factors Alleviating factors

Answer 201

- precautions who have infections that spread through the air such as tuberculosis, varicella (chicken pox), and rubeola (measles) - Place pt in a private room that has monitored negative air pressure in relation to surrounding areas -- 6-12 air changes per hours and appropriate discharge of air outside, or monitored filtration if air is recirculated -- Keep door closed and patient in room - Wear an N95 respirator when entering room of pt with known or suspected tuberculosis -- If pt has known or suspected rubeola (measles) or varicella (chicken pox), respiratory protection should be worn unless the person entering room is immune to these diseases - Transport pt out of room only when necessary and place a surgical mask on the patient if possible - Consult CDC guidelines for additional prevention strategies for tuberculosis - use of N95 respirator mask; negative pressure room

Answer 202

No kink in tubing Iv tower is tall enough Vein is good condition

Answer 203

hoyer? friction sheet and board? gait belts?

Answer 204

Stage 1: light sleeping. woken easily , Stage 2: light sleeping. HR will slow, body temp will drop, Eye movement stops, brain waves slow down. 50% of sleep is spent here. . Stage 3: deeper phase of sleep. Breathing will be deeper, body will regrow and repair tissues, immune system will strengthen. (could feel disoriented if awoken at this time)