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z_NUR112: MIDTERM_LAST LEG > Final Midterm Review > Flashcards

Final Midterm Review Flashcards

1
Q

What is the acceptable temperature range for adults?

A

96.8-100.4

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2
Q

Average oral/tympanic temp in adults is…

A

98.6

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3
Q

Average rectal temp in adults is…

A

99.5

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4
Q

Average axillary temp in adults is…

A

97.7

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5
Q

Temperature control is regulated by…

A

the hypothalamus

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6
Q

The anterior hypothalamus controls heat _____.

A

loss

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7
Q

The posterior hypothalamus controls heat _____.

A

production

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8
Q

Radiation is the transfer of…

A

heat from one surface to another

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9
Q

Convention is the transfer of heat by…

A

air

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10
Q

A fan blowing on a surface promotes…

A

heat loss.

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11
Q

Conduction is the transfer of heat from…

A

one molecule to another of lower temperature

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12
Q

Dispursion of heat through air current is known as…

A

convection.

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13
Q

Name 5 methods of assessing temperature and the cautions of each.

A
  1. Orally; wait 20-30 mins after eating/drinking 2. Temporal; Forehead, not reliable due to variables 3. Tympanic Membrane; Watch for cerumen, eardrum and redness (indicating possible infection) 4. Axillary; Surface reading, caution of seat, add 1 degree to reading 5. Rectal; Contraindictions (should be used with those who have diarareah, rectal surgery, etc. Could effect cranial nerve 10
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14
Q

A pt presenting a temp of 104°F with no diaphorisis may be symptomatic of

A

heatstroke

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15
Q

A pt presenting with high temp and profuse diaphoresis may be symptomatic of

A

heat exhaustion

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16
Q

Someone who is hypovolemic needs…

A

water & electrolytes (Sugar/salt water)

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17
Q

What is cardiac output and how is it calculated?

A

• Total amount of blood pumped in 1 minute • HR x SV (Heart Rate x Stroke Volume)

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18
Q

What is arythmia?

A

This is when the heart beats too quickly, too slowly, or with an irregular pattern

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19
Q

What is dysrhythmia?

A

An abnormal heartbeat

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20
Q

Where are all the places you can take a pulse?

A
  1. Temporal (temples of head) 2. Carotid (at neck) 3. Apical (on chest surface) 4. Brachial (at bend of elbow) 5. Radial (wrist at thumb) 6. Femoral (where leg meets torso, toward groin) 7. Popliteal (behind knee) 8. Posterior tibial (inside of ankle bone) 9. Dorsalis pedis (top of foot)
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21
Q

When listening to the “lub, dub” of the heartbeat, the “lub” is known as __ and represents the closure of the ___ valves known as the _____ and the _____.

A

S1, AV, Tricuspid, Mitral/bicuspid

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22
Q

When listening to the “lub, dub” of the heartbeat, the “dub” is known as __ and represents the closure of the ___ valves known as the _____ and the _____.

A

S2, Semilunar valves, pulmonic, aortic

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23
Q

The five points at which to listen to the heart are represented by what acronym? Describe each point

A

All Patients Take Medicine • A= Aortic; Right sternal border at 2nd intercostal space • P= Pulmonic; Left sternal border at 2nd interncostal space • T= Tricuspid; Left sternal border at 4th intercostal space • M= Mitral; Left sternal border at 5th intercostal space at midclavicular line

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24
Q

Orthostatic hypotension is defined as a decrease in systolic blood pressure of __ mm Hg or a decrease in diastolic blood pressure of __ mm Hg within __ minutes of standing when compared with blood pressure from the sitting or supine position

A

20, 10, 3

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25
Q

How are pulse strengths documented and describe each.

A

0 = abscent, not palpable +1 = pulse diminished, barely palpable +2 = normal/expected +3 = full pulse, increased +4 = bounding pulse

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26
Q

When does exercise increase pulse rate?

A

during short-term exercise

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27
Q

Do positive chronotropic drugs increase or decrease pulse rate?

A

increase

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28
Q

Do negative chronotropic drugs increase or decrease pulse rate?

A

Decrease

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29
Q

A pulse deficit can indicate…

A

• The thrust of blood from heart is too feeble for wave to be felt at peripheral site • May indicate vascular disease is preventing impulses from being transmitted • Can also result from dysrhythmia

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30
Q

How is A/O assessed?

A

If the patient can name • person (who they are) • place (where they are) • time (date) You can also add • Current event

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31
Q

How do the following effect pulse rate?

A
  1. Sort-term Exercise 2. Long-term Exercise 3. Fever and Heat 4. Hypothermia 1. Sort-term Exercise = increases hr 2. Long-term Exercise = Decreases hr 3. Fever and Heat = Increase hr 4. Hypothermia = Decreases hr
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32
Q

How do the following effect pulse rate? 1. Hemorrhage 2. Standing or sitting 3. Lying down 4. Acute pain and anxiety 5. Diseases causing poor oxygenation such as asthma, COPD

A
  1. Hemorrhage = Increase 2. Standing or sitting = Increase 3. Lying down = Decrease 4. Acute pain and anxiety = Increase 5. Diseases causing poor oxygenation such as asthma, COPD = Increase
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33
Q

Orthostatic hypotension signs and symptoms include:

A

• Feeling lightheaded or dizzy after standing up • Blurry vision • Weakness • Fainting (syncope) • Confusion • Nausea

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34
Q

Pulse deficit is indicative of

A

vascular disease that is preventing impulses from being transmitted

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35
Q

Involuntary respiration is controlled by…

A

the brain stem

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36
Q

Ventilation rate is regulated by…

A

CO2 and O2 and hyrdogen ion concentration in arterial blood

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37
Q

What is the typical volume of air inhaled?

A

500mL

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38
Q

What are the three processes of respiration?

A
  1. Ventilation 2. Diffusion 3. Perfusion
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39
Q

Define ventilation.

A

• The movement of gases in and out of the lung • Inhalation/exhalation

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40
Q

Define Diffusion.

A

Movement of O2 and CO2 between the alveoli and red blood cells

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41
Q

Define Perfusion.

A

The distribution of red blood cells to and from the pulmonary capillaries

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42
Q

Respiration Vital measurements include:

A

• Respiratory rate • speed of breathing • Pattern • regular, labored, etc • Depth • shallow, deep, etc • SpO2 • Pulse oxymetry should read 95%-100%

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43
Q

Define: 1. Eupnea 2. Tachypnea 3. Bradypnea 4. Dyspnea

A
  1. Eupnea is normal, good, unlabored breathing, sometimes known as quiet breathing 2. Tachypnea is abnormally rapid breathing (over 20bpm) 3. Bradypnea is an abnormally slow breathing rate. 4. Dyspnea is difficult or labored breathing
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44
Q

Define: 1. Apnea 2. Orthopnea 3. Hyperpnea 4. Hypopnea

A
  1. Apnea is temporary cessation of breathing for several seconds. Persistent cessation results in respiratory arrest. 2. Orthopnoea is shortness of breath (dyspnea) that occurs when lying flat 3. Hyperpnea is increased depth and rate of labored breathing. (>20bpm, normal while exercising) 4. Hyperpnea is decreased depth and rate of breathing
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45
Q

Define: 1. Hemoptysis 2. Hyperventilation 3. Hypocarbia 4. Hypoventilation 5. Hypercarbia

A
  1. Hemoptysis is the coughing up of blood 2. Increased rate and depth (similar to hyperpnea) Hypocarbia may occur. 3. Lower than normal levels of CO2 in blood (can effect blood pH) 4. Decreased rate and depth (similar to hypopnea). Hypercarbia may occur. 5. Higher than normal levels of CO2 in blood (can effect blood pH)
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46
Q

Define Cheyne-Stokes respiration

A

• Respiratory rate and depth are irregular • alternating periods of apnea and hyperventilation • Cycle: slow, shallow breaths that gradually increase to abnormal rate/depth. Pattern reverses, breathing slows and becomes shallow, climaxing in apnea before respiration resumes • Sign of “impending doom” as it is common when approaching death

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47
Q

Define Kussmaul’s respiration

A

• Abnormally deep, regular at increased rate

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48
Q

Define Biot’s respiration

A

• Abnromally shallow for two or three breaths • followed by irregular period of apnea

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49
Q

What are some factors that influence BP?

A

S.A.M.S. A.G.E.D • Stressed • Activity/Weight • Medications • Smoking • Age • Gender • Ethnicity • Daily Variation

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50
Q

What are some Symptoms of Hypotension

A

• Pallor (paleness) • Skin mottling (spots or smears of color) • Clamminess • Confusion • Increased heart rate • Decreased Urine output

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51
Q

What is the BP range indicating Prehypertension?

A

• Systolic: 120-139 • Dyastolic: 80-89

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52
Q

What is the BP range indicating Stage 1 hypertension?

A

• Systolic: 140-159 • Diastolic: 90-99

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53
Q

What is the BP range indicating Stage 2 hypertension?

A

• Systolic: 160 and above • Diastolic: 100 and above

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54
Q

Orthostatic Hypotension may be related to

A

• fluid volume deficit • medications (diuretics or anti-hypertensive)

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55
Q

Orthostatic Hypotension symptoms include

A

• Dizziness • Light-headedness • Falling

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56
Q

Describe the effect of the following BP assessment errors: 1. Bladder/cuff to wide 2. Bladder/cuff to narrow/short 3. Cuff wrapped too loosely/unevenly

A

Effects 1. Bladder/cuff to wide = False Low Reading 2. Bladder/cuff to narrow/short = False High Reading 3. Cuff wrapped too loosely/unevenly = False High Reading

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57
Q

Describe the effect of the following BP assessment errors: 1. Deflating cuff to slowly 2. Deflating cuff to rapidly 3. Arm below heart level 4. Arm above heart level 5. Arm not supported

A

Effects 1. Deflating cuff to slowly = False High Diastolic 2. Deflating cuff to rapidly = False Low Systolic and False high Diastolic 3. Arm below heart level = False High BP 4. Arm above heart level = False Low BP 5. Arm not supported = False High BP

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58
Q

What does hypertension damage?

A

• Brain • Heart • Vessels • Kidneys

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59
Q

What are two types of Pain?

A
  1. Acute 2. Chronic
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60
Q

Define Acute Pain

A

• Patient is protective of the area • Identifiable cause, short duration • Limited tissue damage

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61
Q

Define Chronic Pain

A

• Prolonged pain associated with cancer or another long term ailment

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62
Q

What is the PQRST Pain Assessement?

A

• P: Precipitating or palliative - what makes it better/worse • Q: Quality - aching, shooting, stabbing, sharp, dull • R: Region - location of pain • S: Severity - 1-10 • T: Timing - when is it worse

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63
Q

What are the factors to report associated with Pain?

A

COLDSPA • Character • Onset • Location • Duration • Severity • Pattern • Associated Factors

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64
Q

What scale is used to assess pain for someone who is non-verbal?

A

FLACC • Face • Leg • Arm • Sudden reactionary movements to the above • Consolability • Crying

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65
Q

What are the three drug groups?

A
  1. Non-opiods 2. Opioids 3. Adjuvants (chemo, radiation)
66
Q

NSAID stands for

A

Non Steroidal Anti Inflammatory Drug

67
Q

NSAIDS are highly effective as _____, _____, and _____ agents.

A

analgesic, antipyretic and anti-inflammatory

68
Q

What is the difference between selective and nonselective NSAIDS?

A

• NSAIDs (nonselective) can cause gastrointestinal bleeding • NSAIDs (selective) causes less gastrointestinal reactions

69
Q

What are four side effects of opioids?

A
  1. Respiratory depression 2. Sedation 3. Nausea/vomiting 4. Constipation
70
Q

What are the Six Rights of Medication Administration?

A
  1. Right Patient 2. Right Drug 3. Right Dosage 4. Right Route 5. Right Time 6. Right Documentation
71
Q

What are the three checks for Medication Administration?

A
  1. Order to MAR 2. Medication to MAR 3. Patient to MAR
72
Q

Name and detail the first check of Medication Administration

A

• First step is compare Order to MAR • When you do this, apply the six rights • Patient • Drug • Dosage • Route • Time • Documentation (confirms that all match)

73
Q

Name and detail the second check of Medication Administration

A

• Second check is comparing the medication to the MAR • Confirm that the medication, dosage, route, and time are match • At this point note any special conciderations for the drug such as vitals/allergies, etc • ex. special direction to not give drug if BP is <60. Must check pulse and if lower, withhold, if above, proceed • Confirm that the medication is sealed • Confirm that it is not expired

74
Q

Name and detail the third check of Medication Administration

A

• The third check is Patient to MAR • Confirm that the patient is correct w/ Bracelet IDx2 • Ask for allergies (Do you have any allergies to any medication, food, latex or anything else?)

75
Q

Define Generic drug name

A

The manufacturer who first develops the drug assigns the name, and it is then listed in the U.S. Pharmacopeia

76
Q

Define Trade drug name

A

• Known as the brand or proprietary name. • Name a manufacturer markets the medication

77
Q

What are the four phases of pharmacokinetics?

A
  1. Absorption 2. Distribution 3. Metabolism 4. Excretion
78
Q

Define pharmacokinetic absorption.

A

The ability of a drug to be absorbed by cells, tissues, organs, systems and alter physiological functions

79
Q

What are five factors that influence absorption?

A
  1. Route of administration 2. Ability to dissolve 3. Blood flow 4. Body surface area 5. Lipid solubility of medication
80
Q

Pharmacokinetic distribution depends on what four factors?

A
  1. Chemical properties of the drug 2. Circulation 3. Membrane permeability 4. Protein binding
81
Q

What are four factors to consider in drug metabolism?

A
  1. Medications are metabolized into a less potent or an inactive form 2. Biotransformation occurs under the influence of enxymes that detoxify, break down and remove active chemicals 3. Most biotransformation occurs in the liver 4. Kidneys, blood, intestines and lungs all play a role
82
Q

What is drug excretion?

A

The method the body uses to rid the body of a drug.

83
Q

Medications are excreted through:

A

• Kidney • Liver • Bowel • Lungs • Exocrine glands

84
Q

What are the 7 types of medication action?

A
  1. Therapeutic effect 2. Side effect 3. Adverse effect 4. Toxic effect 5. Idiosyncratic reaction 6. Allergic reaction 7. Synergistic
85
Q

Define: Therapeutic effect

A

Expected or predicted physiological response

86
Q

Define: Side effect

A

Unavoidable secondary effect

87
Q

Define: Adverse effect

A

Unintended, undesirable, often unpredictable drug effect

88
Q

Define: Toxic effect

A

• Accumulation of medication in the bloodstream • Frequent use can cause accumulation

89
Q

Define: Idiosyncratic reaction

A

• Over-reaction or under-reaction or different reaction from normal • Will require further follow up to discover why (mixed with other drugs, etc)

90
Q

Define: Allergic reaction

A

Unpredictable response to a medication

91
Q

Define: Synergistic effect

A

The combined effect of two medications is greater than the effect of the medications given separately.

92
Q

What six factors make up a medication dose response?

A
  1. Onset 2. Trough 3. Plateau 4. Peak 5. Duration 6. Biological half-life
93
Q

Define: Onset

A

Time it takes for a medication to produce a response

94
Q

Define: Trough

A

Minimum blood serum concentration before the next scheduled dose

95
Q

Define: Plateau

A

Point at which blood serum concentration is reached and maintained

96
Q

Define: Peak

A

Time at which a medication reaches its highest effective concentration

97
Q

Define: Duration

A

Time medication takes to produce greatest result

98
Q

Define: Biological half-life

A

Time for serum medication concentration to be halved

99
Q

What are the 5 routes fo medication administration?

A
  1. Oral 2. Topical 3. Inhalation 4. Parenteral 5. Intraocular
100
Q

What are three methods of administration for inhalation?

A

• Inhale/sniff • Nebulizer (drop in vapor) • Endotracheal

101
Q

What are the four parenteral methods of administration?

A
  1. ID; Intradermal 2. Sub-Q; Subcutaneous 3. IM; Intramuscular 4. IV; Intravenous
102
Q

Name the sites and angle for an IM injection. Sites:

A

• Ventrogluteal (side of butt) • Vastus Lateralis (top of thigh) • Deltoid (shoulder) Angle: • 90°

103
Q

entrogluteal site is is recommended for volumes greater than __ mL

A

2

104
Q

Sub-Q injections are are absorbed more _____ than IM injections. slowly

A

due to low blood supply

105
Q

Where are the sub-q injection sites located?

A

• Lateral surface of the upper arm • Upper back at the lower end of the scapula and down about 6” • upper ventral/dorsal gluteal areas (top of butt) • Belly under naval area

106
Q

What are the angles of entry for IM, Sub-Q, and ID shots?

A

• IM = 90° • Sub-Q = 45° - 90° • ID = 5 - 15°

107
Q

Regarding IM and Sub-Q injections, which do you pinch and which to you spread?

A

Sub-Q = pinch IM = spread

108
Q

Give the typical volume amounts for the following injections: ID IM

A

Sub-Q • ID = < 0.5mL • IM = < 2mL for small muscles, <5mL for large muschles • Sub-Q = < 1mL, (but up to 2mL is safe)

109
Q

What are the 6 types of orders MD’s use for medication administration?

A
  1. Standing/Routine 2. Single 3. Now 4. PRN 5. STAT 6. Prescriptions
110
Q

Define: Single order

A

One time administration given for a specific reason

111
Q

Define: Now order

A

• When a medication is needed right away, but not STAT • w/in 90 minutes

112
Q

Define: PRN order

A

• Given when a patient requires it • Will still need to refer to timing to see when it can be administered

113
Q

Define: STAT order

A

Given immediately in an emergency

114
Q

What is a pressure ulcer?

A

A local injury to the skin over a bony prominence due to pressure and other factors

115
Q

How does pressure result in an ulcer forming?

A

• If pressure over a capillary exceeds normal capillary pressure and the vessel is occluded (obstructed) for a prolonged time, tissue ischemia (shortage of blood supply/O2) occurs which can cause tissue death.

116
Q

What is “blanching”

A

Normal red tones of skin are abscent when area is pressed and released.

117
Q

What is “non-blanching”?

A

When an reddish area is pressed and released and no blanching occurs. Indicative of an ulcer/pressure issue.

118
Q

What are the 6 risk factors for pressure ulcer development?

A
  1. Impaired sensory perception - unable to feel pressure or pain 2. Alterations in LOC - Confused and unable to verbalize 3. Impaired mobility - unable to change position independently 4. Shear (sliding of skin) 5. Friction (dragging of skin) 6. Moisture
119
Q

How many stages are there in the classification of pressure ulcers?

A

4 only

120
Q

Describe a Stage 1 pressure ulcer.

A

Intact skin with non-blanchable redness

121
Q

Describe a Stage 2 pressure ulcer.

A

Partial-thickness skin loss involving epidermis, dermis, or both

122
Q

Describe a Stage 3 pressure ulcer.

A

Full-thickness tissue loss with visible fat

123
Q

Describe a Stage 4 pressure ulcer.

A

Full-thickness tissue loss with exposed bone, muscle, or tendon

124
Q

What is the term for an ulcer that defies clear indentification of the 4 stages of pressure ulcer classification?

A

Non-stageable

125
Q

Define unstabeable ulcer.

A

Pressure ulcer with full-thickness tissue loss in which the depth is obscured by slough and/or eschar in the wound bed.

126
Q

What are the colors of slough?

A

• yellow • tan • gray • green • brown

127
Q

What are the colors of eschar?

A

• tan • brown • black

128
Q

Define a suspected deep tissue injury

A

A purple or marron localized area of discolored intact skin or blood-filled blister caused by damage to underlying tissue from pressure and/or shear.

129
Q

Wound healing occurs by _____ or _____ intention.

A

Primary, secondary

130
Q

When checking on wound healing, what are the items we are assessing? REEDA

A

• Redness • Ekymosis • Edema • Drainage • Approximation

131
Q

Define the primary intention healing process

A

• This occurs when the would edges are approximated • ex. surgical incision is sewn up and winds up with minimal to no scarring

132
Q

Define the secondary intention healing process

A

Secondary intention occurs when the would heals with non-approximated edges and leaves a scar

133
Q

A surgical incision heals by _____ intention.

A

primary

134
Q

A burn, pressure ulcer, or severe laceration heals by _____ intention.

A

secondary

135
Q

Describe tertiary intention.

A

• occurs when the wound is left open for several days • while open, it is observed for signs of infection • closure is delayed until infection is resolved

136
Q

What are the 4 types of wound drainage?

A
  1. Serous 2. Sanguineous 3. Serosanguineous 4. Purulent
137
Q

Describe Serous wound drainage.

A

• This type of drainage is plasma that’s thin, clear and watery • During the inflammatory stage, a small amount of this bloody leakage is natural. • When this type of exudate occurs during other wound healing stages, it may be an indicator that the wound bed has undergone trauma, such as during dressing changes, which can hinder healing.

138
Q

Describe Sanguineous wound drainage.

A

Drainage that is fresh blood and prevalent among deep wounds of full and partial thickness

139
Q

Describe Serosanguineous wound drainage

A

• Leakage is thin and watery, and it’s pink in color (it can also be a darker red). • The pink tinge is the effect of red blood cells in the fluid, which is a sign that there is damage to the capillaries. • Such damage generally occurs during wound dressing changes and can disrupt the healing process.

140
Q

Describe Purulent wound drainage.

A

• Wound appears milky • It’s generally gray, green or yellow • Most commonly thick in consistency, though some purulent exudate can be thin. • This may be a sign that the wound has an infection

141
Q

What are five types of wound complications?

A
  1. Hemorrhage 2. Hematoma 3. Infection 4. Dehiscence 5. Evisceration
142
Q

The Braden Scale is used for…

A

predicting pressure ulcer risk

143
Q

What are the six categories used in the Braden Scale Score?

A
  1. Sensory perception 2. Moisture 3. Activity 4. Mobiility 5. Nutrition 6. Friction and shear
144
Q

A Braden Scale Score of 23 indicates what level of risk for developing a pressure ulcer?

A

No Risk

145
Q

A Braden Scale Score of 15-18 indicates what level of risk for developing a pressure ulcer?

A

At risk

146
Q

A Braden Scale Score of 13-14 indicates what level of risk for developing a pressure ulcer?

A

Moderate Risk

147
Q

A Braden Scale Score of 10-12 indicates what level of risk for developing a pressure ulcer?

A

High Risk

148
Q

A Braden Scale Score of ≤ 9 indicates what level of risk for developing a pressure ulcer?

A

Very High Risk

149
Q

How do we check for overall tissue perfusion?

A

• At the peripheral pulse • If pulse week, perfusion will be low • If pulse strong, perfusion will be high

150
Q

On the Braden Scale, the higher the number the _____ the risk.

A

lower

151
Q

What are four other factors (not on the Braden Scale) that can influence pressure ulcer formation?

A
  1. Tissue perfusion 2. Infection 3. Age 4. Psychosocial impact of wounds
152
Q

What is the Jackson-Pratt Drainage Device?

A

A closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites.

153
Q

What are the nursing responsibilities regarding the JP Drainage Device?

A

• Measure output • Assess T.A.C.O • Check tubing to make sure its not kinked or dislodged • If its coming apart call MD

154
Q

What are the three types of Nursing Implementation?

A
  1. Independent 2. Dependent 3. Collaborative
155
Q

How does the Nurse know what kind of dressing to use on a wound?

A

The doctor will indicate

156
Q

What are five types of wound dressings?

A
  1. Dry/Moist 2. Film Dressing 3. Hydrocolloid 4. Hydrogel 5. Vacuum assisted closure (VAC)
157
Q

Describe a film dressing. What stage ulcer is it used for?

A

• transparent to permit viewing of wound without opening it • adheres to undamaged skin • does not require secondary dressing • traps moisture over wound • Used for stage I and II ulcers

158
Q

Describe a hydrocolloid dressing. What stage ulcer is it used for?

A

• Wafer dressing • protects wound from surface contamination • Used for Stage II and III ulcers

159
Q

Describe a hydrogel dressing. What stage ulcer is it used for?

A

• gel-based wound care dressing • protects and provides a moist wound-healing environment • helps remove dead tissue from the wound bed during the healing process. • used for stage III and IV ulcers

160
Q

How does a VAC work?

A

• uses a negative pressure to support healing

161
Q

What are the Nurse responsibilities when a VAC is in use?

A

• Tell patient not to pull on it • Checked tubing to make sure its not dislodged • Beeping is a leak, call surgical team

z_NUR112: MIDTERM_LAST LEG (11 decks)

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