Final Exam Review Flashcards

Question

Acute pain

Answer 1

Typical manifestations are guarding, let's say if someone's abdomen hurts they are going to come in with their arms across their abdomen. If they’re diaphoretic their vital signs are going to be increased so tachycardia, rapid respirations, hypertension.

Answer 2

Vital signs can level out so you might not be able to tell just based off of their vitals signs that they are having this immense amount of pain it can cause a lot of patients to go into depression, fatigue from the chronic pain. These patients are on around the clock pain medications instead of just as needed.

Answer 3

Choose baked potato! This has more potassium than bananas or avocados

Answer 4

Yogurt and orange juice - so if there is a patient on a potassium restricted diet it is good to avoid these

Answer 5

Polystyrene sulfonate

Answer 6

Anticholinergic - this is because these drugs are very drying - also anticholinergics block nerves that control the bladder's muscle contractions, which cause urine to be released. -decreases urine and the urge to void

Answer 7

- Patient may complain of urinary frequency, or they can’t go - Can get a bladder scan (do not need a drs. Order)

Answer 8

- The nurse should instruct the client to urinate 10 minutes before the scanning procedure - Pt. Should be in supine position with head slightly elevated - The scanner head should be about 1-1.6 inches above the symphysis pubis.

Answer 9

Metabolic alkalosis

Answer 10

the first action to take is to elevate the clients head, this will promote effective breathing and chest expansion Following then it is good to monitor spo2

Answer 11

Flush the first void then collect all urine following the nurse will instruct the client that the urine is to remain refrigerated between collection.

Answer 12

Client must first wash hands with soap and water. Female clients are instructed to wipe from front to back. Client will start to urinate to flush out any contaminates and then stops. Client holds the urine cup under then will continue to urinate until the appropriate amount of urine is collected.

Answer 13

secure the catheter upper thigh or lower abdomen

Answer 14

Used to determine if blood is present or absent. ** Foods such as beets, red meat, broccoli can give a false positive result.** Nurse should also instruct the client to avoid medications such as aspirin, ibuprofen, and vitamin C supplements.

Answer 15

Promotes elimination This intervention is intended to prevent blood clots from forming in the bladder or remove any clots that may be present. Can be uncomfortable. **Pain is not an expected finding and should be reported immediately to the provider**

Answer 16

• Sets a schedule to use the bathroom. • Focuses on accident avoidance in clients with overactive bladders by gradually increasing the time between bathroom visits to urinate. • Attempting to set times with or without the urge and slowly increasing the time between these sessions. • Record times for each bathroom visit. • First attempt to extend the time between bathroom visits by 15 minutes then advancing the time slowly.

Answer 17

Clients with paraplegia will utilize **intermittent catheters** in conjunction with bladder training to avoid urinary accidents due to lack of bladder sensation.

Answer 18

Difficulty swallowing Actions- Sour foods can be given to stimulate saliva production which can assist a client with dysphagia

Answer 19

Taut skin and cool to the touch. -Nursing actions: stop the infusion, elevate the extremity, and apply a warm moist compress or a cold compress.

Answer 20

Erythema (redness surrounding skin)

Answer 21

Ventrogluteal site because it doesn’t have any major nerves or blood vessels.

Answer 22

Manifestation of hypocalcemia - facial muscle twitching when touched.

Answer 23

It is good to hold packages above by 6 inches before opening the package then dropping them into the sterile field Hold sterile drape above the waist and away from the body Anything within one inch border of sterile field is considered non sterile

Answer 24

Sit in front of the client not next to them Assume an open position (legs crossed suggest a defensive posture) Maintain direct eye contact Lean towards the client to convey interest and involvement

Answer 25

Wash for at least 15 seconds normally and up to 2 minutes when hands are more soiled.

Answer 26

o Examples: Measles, Tuberculosis, Varicella o A private room o Use an N95 or HEPA o Negative airflow room (at least 6 to 12 exchanges per hour)

Answer 27

o Example: C. Difficile, RSV, shigella, MRSA - a private room or room with other clients with the same infection -gloves and gowns worn by the caregiver and visitors -disposal of infectious dressing material into single non porous bag without touching the outside of the bag

Answer 28

How it should look and how many times it should be changed Should change when less than ¾ full so about ½ to ¼ full. Good to change colostomy bag before a meal so drainage is less likely to occur. Clean around the stoma with warm water (soap can leave residue). Know about the 1/8 bigger for the border You don’t want the pouch to be too full

Answer 29

- Patients are going to be on humidified air Rationale: For a patient with a lot of mucous, dried air would make it hard to eliminate mucous from the mucous membrane. - Suction the patient 10-15 seconds and maximum is 3 passes within 5 minutes.

Answer 30

-polyuria -polydipsia (extreme thirst) -lethargy -headaches -polyphagia (hungry) -blurred vision

Answer 31

With abdominal pain and they are receiving tube feedings You wanna slow down the rate until their pain goes away.

Answer 32

- Can be clear diet plus diary - **Can be liquid at room temperature** - Example is yogurt

Answer 33

Send the patient back to their room. Help him or her return to bed or to a chair, whichever is closer to the patient.

Answer 34

Sanitize the injection site Roll vials Aspirate the amount for the cloudy vial, inject into the vial. Aspirate the amount for the clear vial, inject into the vial. Then aspirate from the clear vial, remove needle Aspirate from the cloudy vial, remove needle. Inject into the client subcutaneously.

Answer 35

With death rituals someone often stays with the body until burial Practice a kosher diet: foods with scales and fins They cannot have meat and dairy together.

Answer 36

**Dietary Rituals** Clients often avoid alcohol and pork Clients can fast during Ramadan **Health and Illness** Avoid organ transplantation Make decisions with family Might permit withdrawal of life support Have a belief in faith healing

Answer 37

**Health and illness** Clients might not accept blood transfusions even in life threatening situations **Dietary Rituals** Avoid foods having or prepared with blood **Death** Clients can choose burial or cremation

Answer 38

Over hydration: too much fluid ABG: respiratory alkalosis — due to dyspnea (slow breathing aka shortness of breath) — increased pH > 7.45 — decreased CO2 <35 mmhg

Answer 39

ABG: respiratory alkalosis — increased pH > 7:45 — decreased CO2 <35 mm Hg

Answer 40

Metabolic alkalosis — this is because you’re losing a lot of hydrogen ions causing the GI to become more basic.

Answer 41

Metabolic acidosis - this is because the kidneys excrete acid from body through urine if the kidneys aren’t functioning properly then acid is getting built up

Answer 42

Cells are over hydrated. Administer hypertonic IV

Answer 43

Increased sodium causing the cells to be dehydrated Administer hypotonic OR isotonic solution

Answer 44

3% Saline. 5% Saline. 10% Dextrose in Water (D10W) 5% Dextrose in 0.9% Saline. 5% Dextrose in 0.45% saline. 5% Dextrose in Lactated Ringer's

Answer 45

0.9% Saline 5% dextrose in water (D5W)**also used as a hypotonic solution after it is administered because the body absorbs the dextrose BUT it is considered isotonic) 5% Dextrose in 0.225% saline (D5W1/4NS) **Lactated Ringer’s**

Answer 46

0.45% Saline (1/2 NS) 0.225% Saline (1/4 NS) 0.33% saline (1/3 NS)

Answer 47

Wanna report any urine output less than 30 mL/ hr And check the clients weight each morning

Answer 48

Taken 30 minutes before medication is given.