Final Exam Study Guide Flashcards
is this order correct?
Humalog 2 units SQ
No, must be Sub-Q
which is correct?
mL
q4h
PO
mL
all of the above
before administering insulin, do you need another nurse to verify the dose, a 3cc syringe, or have another nurse draw up the dose?
another nurse to verify
should also get a BG prior to administration
best protein for vegan client?
greek yogurt
peanut butter
multigrain toast
soy milk
soy milk
what are signs of late hypoxia?
- hypotension
- cyanosis (check conjunctiva in pt with darker skin)
- bradycardia
someone just lost their friend and is going out drinking every night,
what type of grief is this?
Masked
use of maladaptive behavior
client is approaching death, family asks what they should expect?
- warm skin
- facial muscles tense
- breathing shallow, rapid, and irregular
- may become incontinent
- breathing shallow, rapid, and irregular
- may become incontinent
(cool extremities, muscle relaxation, mucous in the airways, and unconsciousness)
movement of arm in a circle?
circumduction
movement of arm lifting away from the body?
abduction
movement of arm moving arm toward the body?
adduction
client with diabetes feels fatigued and has difficulty getting ready for the day,
what is the best nursing diagnosis?
- activity intolerance
- risk for falls
- knowledge deficit
- impaired physical mobility
- activity intolerance
how do you keep a client with macular degeneration safe?
- keep glasses nearby
- keep room lit
- use large font on handouts
- call light and belongings within reach
- keep pathway to bathroom clear
what are modifiable risk factors?
- stress
- obesity
- lifestyle
what are nonmodifiable risk factors?
- gender
- age
- genetics
which client is at risk for aspiration?
- patient with colon cancer
- one with diabetic foot disease
- a client who overdosed on drugs?
a client who overdosed (OD)
which patient would have fluid volume deficit?
- right sided heart failure
- kidney failure
- vomiting and diarrhea for days
- chest pain
vomiting and diarrhea for days
what should you monitor in a patient with hyperkalemia?
cardiac system
can cause dysrhythmias
when administering enema, what position should patient be in?
left sims position
which patient should be seen first?
- one with a 6/10 on the pain scale
- a client trying to get out of bed
- a client getting discharged and their ride is here
- a patient that just got back from surgery and complaining of nausea
patient trying to get out of bed
- fall risk for injury, incident report, needs xrays, etc.
what are important points of foot care for patients with DM?
- prevent infection/pain
- professional should perform foot care
- inspect feet daily especially between the toes
- use lukewarm water
- apply moisturizer
- avoid over the counter products with alcohol
- wear cotton socks
- cut nails straight across
- don’t self treat corns/calluses
- wear comfortable shoes
- do not apply heat
non-blanchable erythema of intact skin
Stage 1 pressure ulcers
partial thickness skin loss with exposed dermis
Stage 2 pressure ulcers
full-thickness skin loss visible adipose tissue with possible granulation tissue
Stage 3 pressure ulcers
full-thickness skin and tissue loss with exposed bone muscle or ligaments
Stage 4 pressure ulcers
what are important points of hand hygiene?
- use warm, NOT hot water to maintain skin integrity
- use 4 - 5mL of soap
- hands should be lower than elbows so water flows from contaminated to clean area
- scrub hands for at least 15 seconds and up to 2 minutes when soiled
it is important for which clients to evaluate their feet and prevent injury?
DM and PVD
unpleasant emotion, feeling, thought, condition, or behavior related to lack of sleep and increasing anxiety d/t financial issues
Distress
positive form of stress having a beneficial effect on health, motivation, performance, and emotional well-being
Eustress
what are healthy coping mechanisms for stress?
- exercise
- journaling
- yoga
- meditation
- spending time with family
- eating a balanced healthy diet
- doing a hobby
- taking vacation days or a mental health day
what are signs of effective coping with stress?
during relaxation should experience a decrease in BP, HR, RR, and oxygen consumption
what are the stages of general adaptation syndrome?
- alarm stage
- resistance
- exhaustion or recovery
stages of general adaptation syndrome:
fight or flight
- tachycardia, tachypnea, hyperglycemia
alarm stage
stages of general adaptation syndrome:
maintain homeostasis
- use of coping mechanisms
resistance
stages of general adaptation syndrome:
coping ineffective
- ends in disease or death
exhaustion
what does a healthy stoma look like?
- red
- shiny
- moist
- small amount of blood
- if purple: notify surgeon - could indicate ischemia
what are signs of a UTI in an older adult?
- confusion
- new onset of incontinence
what are good sources of fiber?
- grains
- oatmeal
- beans
- veggies
(not white rice, waffles, rice like cereal)
canned peaches < beans
what are important considerations with buddhist clients?
- brain death is not considered a requirement for death
- patient on ventilator is considered dead even without brain death
what are important considerations with islamic clients?
client prays 5x/day facing Mecca
what are important considerations with jehovah’s witness clients?
might not accept blood transfusion
what are important considerations with christian clients?
may fast during lent
what are important considerations with jewish clients?
death practices involve burial within 24 hrs
what are causes of constipation?
- frequent laxative use
- holding bowel movements
- iron supplements
- opioids
what are ways to prevent constipation?
- exercise
- walking
what should you do with a client in isolation when they need to leave their room?
have them wear a mask
what are protective precautions for a patient following a stem cell transplant?
- private room
- HEPA filter
- positive pressure airflow
- no fresh fruit or flowers d/t fungi
clients in isolation are at high risk for what?
- depression and loneliness
- be aware of this risk and encourage client to voice feelings and concerns
- be active in their care
what is OSA?
obstructive sleep apnea
- obstruction caused by structures in the mouth and throat relax during sleep and occlude the upper airway (could be adipose tissue)
what are symptoms of OSA?
- snores
- snorts
- grunts or thrashes about during sleep
- exhausted during the day
what medications can be administered through an NG tube?
- liquid
- chewable
- crushed tablets
- nothing enteric coated, sublingual, or extended release
what are foods for osteoporosis?
- high calcium diet (broccoli, kale, milk)
- not meat or black beans
flow rate for nasal cannula
up to 6 L/min
flow rate for venturi mask
deliver 4 - 12 L/min (best for COPD)
flow rate for simple face mask
minimum flow rate of 5 - 6 L/min up to 10 L/min
flow rate for non-rebreather
10 - 15 L/min
when is humidification required when using a nasal cannula?
O > or equal to 4 L/min
- will help to thin secretions
what are important points of home oxygen therapy?
- system should be kept 6 - 10 feet away from a heat source
- no smoking, petroleum jelly in nares or increasing rate
- wool fabric can generate static electricity - cotton okay
- teaching client about how to use/check oxygen tank and regular delivery service
- throw rugs are a fall hazard
- tubing can be distracting and be a high fall risk
- check ears for skin breakdown
- do not to adjust oxygen without calling provider
- check the equipment daily
- oxygen should be stored vertically
what are early signs of hypoxia?
- tachypnea
- tachycardia
- hypertension
- restlessness
- accessory muscles usage
- pale skin and mucous membranes
- anxiety
- confusion
what vaccine is recommended for COPD patients?
PNA vaccine
what are the 5 stages of grief?
- denial: difficulty believing diagnosis
- anger: lashes out at people or things
- bargaining: negotiate for more time or a cure
- depression: overwhelmingly sad by inability to change the situation
- acceptance: plan for the future and moving forward
what are interventions to prevent falls?
- apply nonskid footwear
- hold the client by the transfer belt
- apply a safety belt (gait belt)
- have the client dangle feet at the bedside to ensure they do not feel dizzy
- do not use the IV pole for stability
- never grab the client under the arms (could cause skin tears)
- keep room well lit
how do you determine a client’s pain?
ask them
- what they tell us
what are nonverbal signs of pain?
- facial expressions/posture (grimacing, lowering the brow, wincing, clenching jaws, closing eyelids, guarding a painful site or maintaining a tense position)
- elevated vital signs (tachycardia, tachypnea, hypertension)
- using laughter, distraction, or even sleep to cope
- withdrawn/stoic
what should you monitor after giving pain medication?
respirations
list 4 nonpharmacological pain control techniques?
- oral sucrose
- immobilization
- cutaneous stimulation (transcutaneous electrical nerve stimulation TENS, percutaneous electrical nerve stimulation PENS, spinal cord stimulator SCS, acupuncture, acupressure, massage, use of heat and cold), contralateral stimulation
- cognitive-behavioral interventions (distraction, sequential muscle relaxation, guided imagery, diaphragmatic breathing, hypnosis, therapeutic touch, humor, writing, animal assisted therapy)
what are important things to remember when communicating with a client with hearing loss?
- speak slowly and clearly
- write down what the client doesn’t understand
- minimize background noise
- turn off the TV
- stand in front of the client
- lower your voice if possible
- nurse should not speak loudly or raise the pitch of their voice
how should you care for hearing aids?
- alcohol use can break down the mechanism of the hearing aids
- follow the manufacturer’s instructions, usually include using a soft cloth to remove cerumen and other debris and never immersing them in water
activities to prevent or slow onset of disease
- healthy diet, exercise, sunscreen, immunization, handing out condoms
- used after returning home like limiting salt intake
primary prevention
stopping disease from progressing and returning to pre-illness phase - rehab is main intervention during this level
- recover from surgery
- prevent sx complication
- regain strength
- cardiac stent
- physical therapy
- speech therapy
tertiary prevention
screening activities and education detecting illness early
- self-breast exam
- testicular exam
- regular physicals
- BP
- TB test
- bone density scan
- colonoscopy
- pregnancy test
secondary prevention
what are the goals of “Healthy People 2030”?
identify top preventable health risks in the US and establish 10 - year goals to reduce preventable health risks
what clients are at risk for aspiration?
- altered level of alertness
- decreased cough or gag reflexes
- motor deficits may require close observation while eating
- a client who is obtunded is altered therefore at risk for aspiration
what can a patient eat who is on a mechanical soft diet that required minimal chewing?
- egg salad
- tuna salad
- mashed potatoes
how do you prioritize which patient needs to be seen first?
- prioritization falls under organization
- use prioritization to decide which problem to address first and which are safe to address later
- can use Maslow’s hierarchy, future consequences, and ABCs
- give high priority to problems patient thinks are most important as long as it does not conflict with basic/survival needs or treatments
what are important points to teach a client who is using a cane?
- keep cane on OPPOSITE side of injury
- always maintain two points of contact on ground for stability
- move cane forward 6 - 10 inches
what should the nurse remember when performing oral care on an unconscious client?
- turn head to the side
- use suction
- use padded tongue depressor
- head of bed is flat (not in high fowlers position)
what are appropriate indications for a foley catheter?
- obstruction
- hematuria
- decubitus ulcer in pelvic region
- strict I&Os
- SCI/neurogenic conditions
- not incontinence
- ICU
- pressure ulcer on the heel
- post-op cholecystectomy
what are interventions to prevent pressure ulcers?
- turn the patient every 2 hours
- maintain hydration
- keep skin dry
- float the heels
- keep the HOB less than 30 degrees
- diet rich in protein and vitamin C
- PROM exercises
- therapeutic mattress
- do not place client in high fowlers
what are contact precautions and examples?
- pathogen spread by direct contact
- wounds, secretion, supplies (c-diff, wound infections, MRSA, VRE)
- private room, clean gown and glove, disposal of contaminated items, double bag linen
what are droplet precautions and examples?
- coughing, sneezing, talking, touching contaminated objects - large droplets that travel 3-6 feet
- flu, one type pneumonia, meningitis, rubella, pertussis (whooping cough)
- same as contact (private room, clean gown and glove, disposal of contaminated items, double bag linen), addition of mask and eye protection within 3 ft of client
what are airborne precautions and examples?
- ventilation system, shaking sheets, sweeping - aerosolized small droplets smaller than 5 mcg
- TB, covid, VARICELLA (CHICKEN POX/SHINGLES), measles
- same as those for contact (private room, clean gown and glove, disposal of contaminated items, double bag linen), special negative pressure room, special mask (n95 or respirator), and mask for patient when transported
who is responsible for regulating the practice of nurses in each state?
state board of nursing
what does ADPIE stand for?
nursing process:
- assessment
- diagnosis
- planning
- intervention
- evaluation
what are signs that an infection has become systemic?
- fever
- tachycardia
- positive blood culture for microorganisms
- lymphadenopathy
what is fidelity?
fulfill a promise to the patient
what is beneficence?
provide best quality care to patient
what is non-maleficence?
commitment to do no harm
what is veracity?
being honest with patients
what causes neuropathic pain?
damage to the nerves
- viral infection
- diabetes
what are the 6 rights of medication administration?
- right drug
- right dose
- right time
- right route
- right patient
- right documentation
what are examples of artificial airways?
- tracheostomy
- ET
- nasopharyngeal tube
what are examples of oxygen delivery systems?
oxygen delivery systems:
- nasal cannula
- venturi mask
- ventilator
signs/symptoms of hypovolemia?
- tachycardia
- hypotension
- weak thready pulse
- furrowed tongue
- sunken eyes
- increased skin turgor
- tacky MM
- increased temperature (body cant sweat)
- sudden weight loss 5 - 15%
- caused by loss of fluid, electrolytes, and decreased blood volume
signs/symptoms of hypervolemia?
- hypertension
- pulse is bounding
- respirations are increased and shallow
- distended neck veins
- orthopnea
- EDEMA
- skin is pale and cool
- rapid weight gain
what is involved with therapeutic communication?
- avoid “why” questions
- express empathy - names a feeling and allow its expression
- don’t give advice
- avoid close ended questions
- sit eye level when speaking with them
why do we monitor albumin levels?
nutritional status
what should you do if you witness a client having a seizure?
- positioning the client laterally facilitates airway patency
- the client should not be restrained or have anything placed in the mouth as this could cause further injury
- stay with the client during a seizure
what is the effect of vitamin K on Warfarin?
- vitamin K decreases effectiveness of Warfarin
- must limit greens like broccoli and spinach that are high in Vitamin K
how can you promote optimal respiratory function for a client with chronic lung disease?
- PNA vaccine
- stop smoking
- elevate head of the bed
- incentive spirometer use (inhale)
