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NUR 501 > Final Exam Blueprint > Flashcards

Final Exam Blueprint Flashcards

1
Q

Nonrebreather mask (low flow)

A

Amount delivered FIO2:
- 10-15 L/min - 80-95%

nursing interventions:
- maintain flow rate so reservoir bag collapses only slightly during inspiration
- check valves and rubber flaps are functioning properly (open during expiration and closed during inhalation)
- monitor SaO2 w/ pulse ox

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2
Q

stress management techniques (class notes)

A
  • relaxation
  • meditation
  • anticipatory guidance
  • guided imagery
  • biofeedback
  • humor
  • crisis intervention
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3
Q

Transmission precautions

A

used in addition to standard precautions for pts with suspected infection that can be transmitted by: airborne, droplet, or contact routes

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4
Q

Sepsis (IV) s/s

A
  • red, tender insertion site
  • fever, malaise, other vital changes
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5
Q

Delegating pain management to UAP’s

A

Do not delegate:
Pain assessment
Monitoring of patient’s response to pain management
Evaluation of pain management plan
(everything else we can delegate)

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6
Q

Hypotonic fluid: what is it? example?

A

Lesser concentration of particles than plasma

  • should be administered slowly to prevent cellular edema
    – causes cells to swell
  • used for dehydration
  • definition: solutions that are more dilute or have a lower osmolality than body tissues

Example: 0.45% NSS

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7
Q

Air embolus s/s

A
  • respiratory distress
  • increased HR
  • cyanosis
  • decreased BP
  • change in level of consciousness
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8
Q

Causes of hypoxia?

A

Often caused by hypoventilation, atelectasis

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9
Q

Foley catheter

A

needs to be sterile

Female:
- sterile gloves
- graps corners of drape and unfold without touching nonsterile areas
- sterile tray on drape between patient thighs
- open all supplies; attach syringe to inflation port for balloon
- antiseptic swabs or cotton balls: prepare
- lubricate 1-2 inches of catheter tip
- spread labia and identify meatus – keep one hand there until catheter is inserted
- use dominant hand to pick up swaps or cotton balls and clean one labial fold top to bottom, discard, and use clean one for each following stroke
- slowly insert catheter into urethra with dominant hand and advance until return of urine
- once urine drains, advance catheter another 2-3 inches
- rotate slightly if needed
- use dominant hand to inflate catheter balloon with sterile water from syringe attached to port
- pully gently after inflation to make sure in place
- attach catheter to drainage bag if not preattached
- remove gloves; secure catheter tubing to patient’s inner thigh with securing device
- secure drainage bag below level of bladder; ensure tubing is not kinked or clamped

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10
Q

What is the reticular activating system (RAS)

A
  • basically your drive
  • is a poorly defined network
  • extends from hypothalamus to medulla
  • mediates arousal
    – optimal arousal state of RAS: general drive
  • monitors and regulates incoming sensory stimuli
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11
Q

Chronic stress

A

exercise helps to lessen stress

from internet:
Chronic stress can lead to a range of negative effects on both mental and physical health,
- including increased risk of anxiety,
- depression,
- heart disease,
- high blood pressure,
- digestive issues,
- headaches,
- muscle tension,
- sleep problems,
- weakened immune system,
- memory impairment,
- and difficulty concentrating,

essentially impacting nearly every system in the body due to prolonged elevated stress hormones

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12
Q

What is the therapeutic action of a drug

A

The intended effect of the drug; the physical effect

Can have more than one

6 actions: palliative, curative, supportive, substitutive, chemotherapeutic, restorative

Ex: giving antihypertensive -> therapeutic effect is lower BP

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13
Q

What are stressors

A

anything perceived as challenging, threatening, or demanding; anything that causes a person to experience stress

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14
Q

What is oliguria

A

low urine output, or when someone is producing less urine than normal

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15
Q

Care of a patient with an indwelling foley catheter

A
  • keep bag below bladder
  • have it strapped
  • check for kinks; move tubing if not draining
  • make sure everything is connected
  • make sure with placement that it is correct and balloon accurately inflated
  • replace catheter and urine bags that become disconnected
  • cleaning with soap and water
  • empty collection bag
  • make sure sterile technique

how long can it be in there?

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16
Q

Complications of IV therapy (list)

A
  • phlebitis
  • thrombus
  • infiltration
  • sepsis
  • fluid overload
  • air embolus
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17
Q

Respiratory medications

A

Expectorants, suppressants, nebulizer, inhaler, bronchodilators, corticosteriods???

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18
Q

Deep Tissue Pressure Injury

A

purple or maroon intact skin or blood-filled blister

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19
Q

Types of assistive devices in activity

A

patient confined to bed:
- wedges and pillows
- mattresses
- adjustable beds
- trapeze bar
- high-top sneakers
- hand splints

assistive devices in activity:
- walker
- cane
- crutches

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20
Q

T or False: A urine specimen from a patient with an indwelling catheter should be obtained from the collection receptacle.

A

False-should be obtained from the sampling port on the catheter tubing, not the collection receptacle (drainage bag) to ensure a fresh, uncontaminated sample.

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21
Q

Provider order interpretation

A
  • be sure to compare meds to original order

medication orders:
- standing order (routine)
- prn: as needed
- single order (one time)
- stat order: immediately given, emergent
- standing protocols - like diabetic and sugar levels; based on number values or symptoms like chest pain
- telephone/verbal/faxed

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22
Q

Work-life balance

A

no idea; try to have a good work life balance? make sure to make time for yourself to do things like exercise, see family

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23
Q

Sources of stress (4)

A
  • developmental stressors (childhood, adolescence)
  • situational stressors (car accident, exams)
  • physiologic stressors (medical)
  • psychosocial stressors (bullying, breaking up)
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24
Q

HIPAA

A

All information about patients written on paper, spoken aloud, saved on computer
Name, address, phone, fax, social security
Reason the person is sick
Treatments patient receives
Information about past health conditions

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25
Q

Types of isolation

A

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

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26
Q

Pain with GI/GU/Peri-op (CA means colon cancer)

A

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

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27
Q

Alternatives for drugs for comfort/pain

A

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

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28
Q

What are some things you can recommend to a spouse that is a caregiver and has symptoms of chronic stress

A

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

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29
Q

safety: prioritization

A

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

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30
Q

What is role overload

A

unmanageable expectations and responsibility of that role

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31
Q

Intradermal injection: gauge, angle, length, sites

A

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)

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32
Q

What do you want to accomplish with teaching after a teaching session

A

want to evaluate goals and learning objectives

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33
Q

Types of Urine specimen collection

A
  • Routine urinalysis
  • Clean-catch or midstream specimens
  • Sterile specimens from indwelling catheter
  • urinary specimen from urinary diversion
  • 24hr urine specimen
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34
Q

Droplet precautions

A
  • 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
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35
Q

TPN

A

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.

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36
Q

REM sleep and vital signs

A

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

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37
Q

Sleep apnea

A

impaired Gas
Exchange
- high BMI
-snoring
-diabetes

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38
Q

Fluid overload s/s

A
  • increased BP
  • distended jugular veins
  • rapid breathing
  • dyspnea
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39
Q

What is airborne transmission

A

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

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40
Q

What is somatic pain

A

tendons, ligaments,
muscles, bones,
blood vessels

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41
Q

What is the expected response of vital signs to infection? **not sure what she wants here tbh

A

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)

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42
Q

Susceptible Host

A

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

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43
Q

Who would you be worried about using a nonrebreather mask

A

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

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44
Q

What are the 3 checks of medication administration

A

when you reach for container
before pouring
upon replacing container

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45
Q

What should you do after a general acute injury-RICE

A

Rest
Ice
Compression
Elevation

First 48 hours you do ice for acute injury and then switch or alternate

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46
Q

What is adaptation

A

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

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47
Q

Joint Commission guidelines for pain management

A

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

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48
Q

24 hour urine

A

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

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49
Q

Devices for oxygen therapy

A

nasal cannula
simple mask
nonrebreather mask
partial rebreather
venturi mask

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50
Q

Stage 1 pressure ulcer

A

non-blanchable erythema of intact skin

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51
Q

Stage 2 pressure ulcer

A

partial-thickness skin loss - shallow, open ulcer

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52
Q

Simple mask (low flow)

A

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

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53
Q

DVT prevention

A
  • compression socks
  • keeping patients mobile; not resting in bed too long
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54
Q

Values and beliefs in culture

A
  • can influence type of health care received
  • can influence medications receive
  • can influence hygiene practices
  • can influence dietary practices
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55
Q

Cold applications for skin - effects?

A

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

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56
Q

What are the 11 rights of medication administration

A

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

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57
Q

GI/GU/Peri-op: male hygiene

A

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

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58
Q

Stage 3 pressure ulcer

A

full-thickness skin loss - subcutaneous fat may be visible

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59
Q

Hoyer lift (2 types)

A

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

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60
Q

Techniques for assessing vital signs (temperature)

A

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

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61
Q

What are factors contributing to pulmonary disease?

A

factors affecting oxygenation:
-sedentary activity patterns
-exercise
-smoking

Smoking!!! (have to offer smoking cessation to any patient that smokes)
Environmental - pollution
Working with chemicals

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62
Q

Safety with oxygen therapy

A

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

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63
Q

Sterile gloves - how to put on and off?

A

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.

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64
Q

Cold applications for skin - types?

A

Moist
- cold compresses

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

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65
Q

Priority nursing issue/nursing diagnosis (unsure)

A

ADPIE
safety first

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66
Q

UTI - signs, symptoms, how to treat

A

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

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67
Q

Stool specimen collection

A

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

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68
Q

Factors affecting learning

A
  • 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

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69
Q

Types of responses to pain (voluntary..involuntary..)

A

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

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70
Q

Long-term stress (class notes)

A

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

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71
Q

Stages of Infection #2

A

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

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72
Q

Fatigue in hygiene/ADL

A
  • patient can get tired or unable to complete hygiene for themselves or able to do ADLs
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73
Q

Adult learning

A
  • 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

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74
Q

Incontinence and skin

A
  • fecal incontinence
  • urinary incontinence

watch for skin breakdown due to moisture exposure

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75
Q

What is neuropathic pain

A

Nerve pain

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76
Q

Some effects of NREM sleep

A

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

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77
Q

Pulse oximetry - normal values, when to take

A

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

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78
Q

Metabolic rate

A

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

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79
Q

Means of Transmission (5)

A

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

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80
Q

What is drug toxicity

A
  • 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
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81
Q

Thrombus s/s

A
  • IV infusion sluggish or may cease
  • heat, redness, tenderness at site
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82
Q

Sterile field

A
  • 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.

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83
Q

Diet for clients based on bowel health

A

high or low fiber diets
idk eat fruits and veggies

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84
Q

What is vehicle transmission

A

transmitted through food or water

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85
Q

Assisting patients with sensory deficits

A
  • use clock face language to tell a patient where something is.
  • making sure they dont trip on the IV line
  • clearing paths
  • clear communication
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86
Q

Normal and abnormal values: RR

A

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

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87
Q

Heat application for skin - effects?

A

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

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88
Q

Documentation/reporting/informatics - pain

A

Ask on scale 0-10
PQRST or OLDCARTS

Unsure on this just guessing

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89
Q

Clear vs Full Liquid

A

Clear liquid: juice, broth, water, coffee

Full liquid:
“Clears” plus:
- milk
- pudding and custard

want pourable
liquid supplements

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90
Q

What are complications with tube feedings

A

aspiration

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91
Q

Types of restraints

A
  • wrist restraint (cloth, leather)
  • jacket or body restraint
  • geriatric chairs
  • bed rails
  • medications as well
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92
Q

Bacterial Reservoir
(Common reservoirs)
What does bacterial need?

A

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

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93
Q

Powered full body lift

A

designed for patients who cannot bear any weight

94
Q

Older adult comfort/pain

A

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

95
Q

What is vector transmission

A

transmitted through insect or fomite

96
Q

Confidentiality with documentation/reporting

A

Cannot have any identifying information in writing yourself notes

Do not speak about patients in common, public areas

97
Q

What is something you should always check for patients as general safety

A

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

98
Q

7 components of a medication order

A
  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
99
Q

What is pneumonia? When does it develop? How to prevent? idk

A

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

100
Q

Alcohol vs soap and water for hands

A

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.

101
Q

Portals of Exit

When the human body is the reservoir

A

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

102
Q

Powered Stand lift (can patient assist)

A

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

103
Q

Venturi mask (high flow)

A

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

104
Q

Central venous sites

A

Subclavian, jugular, PICC line

she noted: IV in hand is not a central line

105
Q

How to use crutches

A

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.”

106
Q

Phlebitis s/s

A
  • local acute tenderness
  • warmth, redness, edema above insertion site
107
Q

Oxygenation: positioning

A

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

108
Q

How to use walker

A

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

109
Q

How to use cane

A

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

110
Q

Stages of infection #4

A

Convalescence: period when acute symptoms disappear

111
Q

What nutrients provide energy

A

Protein, fat, carbs

112
Q

What is an adverse reaction

A

effects that are not intended

113
Q

Portals of Entry

A
  • Often the same as exit routes
    ** Gain entrance into host
    Skin & mucous membranes
    Respiratory tract
    Genitourinary tract
    Gastrointestinal tract
    Blood & tissue
114
Q

Subcutaneous injection: gauge, angle, length, sites

A

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

115
Q

How do you describe to a patient what PRN pain controlled meds mean

A

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

116
Q

What is role strain

A

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

117
Q

Vital signs: delegation of tasks to UAP, best practice

A

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

118
Q

How do you test for food poisoning

A

stool sample culture is only official way to diagnose

119
Q

COPD considerations

A

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

120
Q

Diet orders (therapeutic, modified)

A

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)

121
Q

Normal values and locations you can take: pulse ox

A

ear, finger, toes

normal range: 95-100%

122
Q

Enteral nutrition

A

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

123
Q

What is the expected response of vital signs to exercise?

A

core temp increase
pulse rate increase
RR increase
bp increase

124
Q

Communicating with a patient who is confused

A
  • 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
125
Q

Heat applications for skin - types?

A

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

126
Q

Direct vs indirect contact

A

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).

127
Q

Stages of infection: #1

A

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

128
Q

Prior knowledge in client/patient teaching (unsure)

A

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

129
Q

How to use an incentive spirometer? What is it good for?

A

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

130
Q

What is sensory overload

A
  • 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
131
Q

Intramuscular injection: gauge, angle, length, sites

A

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

132
Q

Exercise - effects on sleep? how long to do before going to bed?

A

2 hours before

133
Q

CDC guidelines for handwashing

A

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.

134
Q

What is the teach-back method

A

patient literally teaches if back to you after you teach them

135
Q

What are side effects of a drug

A

effects from medication, but are not the desired effect

some are expected like headache, weight loss, hair growth

136
Q

What is dermatomal pain (?? had to google)

A

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.

137
Q

If you’re teaching someone, what is one of the first things you should do before teaching

A

assess prior knowledge (what they already know)

138
Q

What is metabolic syndrome

This was pulled from my prereq notes

A

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

139
Q

What is visceral pain

A

body organs in thorax,
cranium, and abdomen

140
Q

Emotional responses to stress: defense mechanisms

A
  • compensation
  • denial
  • displacement: taking stress out on others
  • rationalization: trying to rationalize what’s happening
141
Q

Stages of infection #3

A

Full stage of illness: the presence of specific
disease symptoms

142
Q

Patient assisted moving devices

A

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

143
Q

prolonged stress effects (class notes)

A
  • 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)
144
Q

Patient getting tired during ADLs - what can you recommend?

A

Taking breaks; doing it in steps

145
Q

Symptoms of hypoxia?

A

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

146
Q

Infection prevention (cleaning)

asepsis, cleansing, disinfecting

A

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

147
Q

Stage 4 pressure ulcer

A

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

148
Q

When do you have to use an electronic pump for IV?

A

medication that has to be controlled on a pump like TPN

149
Q

Contact precautions

A
  • 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
150
Q

What is droplet transmission

A

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

151
Q

Infiltration s/s

A
  • edema, pain and coolness at site
  • significant decrease in flow rate
152
Q

What is polyuria

A

Frequent urination

153
Q

Interpretation of vital signs

A

(im gonna add ranges in the next cards)

154
Q

What is anuria

A

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

155
Q

Isotonic fluid: what is it and example

A

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

156
Q

What is tolerance?

A

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

157
Q

Unstageable Pressure Ulcer

A

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

158
Q

Pump vs gravity infusions

A

pump can be set to a ml/hr

gravity - set to specific height

159
Q

Using a gait belt

When to avoid using them?

A

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

160
Q

When getting a medication history, you should check if they are also taking…

A

OTCs, herbal meds, supplements

161
Q

What is referred pain

A

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

162
Q

Focused assessment in oxygenation (just typing from memory from studying exam 3 so flagging this in case wrong)

A

Pattern of respirations
Meds
Health history
Recent changes
Lifestyle and environment

163
Q

Interpreting orders/conferring verbal orders

A

Repeat verbal orders back

164
Q

Effects of stress (class notes)

A

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

165
Q

Medication administration: health history

A
  • 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

166
Q

Healthy vs. unhealthy adaptation/coping

A
  • 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

167
Q

nasal cannula (high flow) - was asked specifically if this was on exam and it was not

A

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

168
Q

Insomnia (3 types)

A

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

169
Q

Personal factors affecting adapatation

A
  • physiologic makeup
  • genetic inheritance
  • very young
  • very old
  • altered physical or mental health
  • inadequate nutrition
  • sleep deficits
  • poor support systems and relationships
170
Q

What is role conflict

A

a person must assume opposing roles with incompatible expectations

Ex: adult daughter now caregiver and medical decision maker for elderly parent

171
Q

Normal values and locations: temperature

A

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

172
Q

Patient teaching about oxygenation

A

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

173
Q

What is sensory deprivation

A
  • environment with decreased/monotonous stimuli
  • impaired ability to receive stimuli
  • inability to process stimuli
174
Q

Who is at higher risk for toxicity

A

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

175
Q

What is stress

A

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

176
Q

Priority patient

A

Acute vs chronic
ABC
Emergent > urgent

177
Q

Objectives/goals in client/patient teaching

oral, written, interview

A

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

178
Q

Cultural competence

A
  • 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
179
Q

Infectious Agent - 3 types

A

*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

180
Q

Diets for clients with diarrhea

A

BRAT: banana, rice, applesauce, toast

181
Q

Nasal cannula (low flow)

A

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%

182
Q

Normal and abnormal ranges: BP

A

=

<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

183
Q

What patients are most susceptible to opioid effects like decreased respirations, constipation and nausea

A

very young and very old

184
Q

What are the types of pain?

A

Referred
Visceral
Somatic
Dermatomal
neuropathic

185
Q

Legal issues with documentation/reporting/informatics

A

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

186
Q

Humidification with oxygenation

A

Provides comfort with oxygenation
protects against irritation and infection

187
Q

Patient reliability in communication

A
  • 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

188
Q

What is hypoxia?

A

inadequate amount of O2 available to cells

189
Q

Kegel exercises

A

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

190
Q

Verbal communication

A

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

191
Q

Nursing documentation - documentation/reporting/informatics

formats, conferring, nursing informatics

A

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

192
Q

Patient transfers types

A

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

193
Q

What is the sick role

A

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

194
Q

Opioid use (sedation)

A

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)

195
Q

Concepts of types of ADL: self care

A

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

196
Q

Skin: pressure prevention

A

-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

197
Q

What nutrients regulate body processes

A

vitamins, minerals, water

198
Q

Sleep and adaptation

Discussing adaptation Monday too

A

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

199
Q

CA (colon cancer) warning signs

A

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

200
Q

Nutrients: six classes

A

carbohydrates, protein, lipids, vitamins, minerals, water

201
Q

Fire safety - RACE?

A

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
202
Q

Hypertonic fluid: what is it and example

A

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

203
Q

What is pursed lip breathing? What is it good for?

A

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

204
Q

What are the stages of infection (infection cycle)

A

-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

205
Q

Nonverbal communication

A
  • 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

206
Q

GI/GU/peri-op: female hygiene

A

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

207
Q

Patient safety

idk things can prob be added to this? idk specifically what

A
  • 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)
208
Q

T or F: Normal fresh urine has an ammonia odor?

A

False

209
Q

Priming IV bags

A

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

210
Q

What would you expect from someone with increased temperature

A

increased HR and RR

211
Q

Infection and skin

A

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

212
Q

What is dysuria

A

pain when urinating; difficulty

213
Q

Types of pain

acute vs chronic

A

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

214
Q

Patient experience in comfort/pain
(not sure if this is right)

A

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

215
Q

PPE - what are they? order to don and doff?

A

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

216
Q

Normal and abnormal values: HR

A

60-100

217
Q

Concepts of types of ADL: partial care

A

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

218
Q

SBAR and patient handoff

A

Identity/Introduction
Situation
Background
Assessment
Recommendation

219
Q

Concepts of types of ADL: complete care

A

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

220
Q

Diet for clients with constipation

A

high fiber? good fluid intake

221
Q

What are some things you can do for insomnia

A

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

222
Q

Normal adaptation responses - literally dont know what this is (found a slide on physiologic adaptation in cultural competence ppt)

i think we’re doing this on Monday

A

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

223
Q

If you’re adapting to a change or illness, what conditions would have more trouble adapting

A

chronic illness
sleep deprived person

224
Q

Safety - restraints

A
  • 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
225
Q

Blood transfusions: what to consider, what is different, how long can they be out of fridge

A

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

226
Q

Assessment in comfort/pain
OPQRST essentially

A

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

227
Q

Airborne precautions

A
  • 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
228
Q

Troubleshooting an IV infusion

A

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

229
Q

Activity: patient transfers

A

hoyer? friction sheet and board? gait belts?

230
Q

NREM sleep and vital signs

A

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)

NUR 501 (6 decks)

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