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Fundamentals of Nursing > Final Review > Flashcards

Final Review Flashcards

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1
Q

What are the initial manifestations of low oxygen?

A
  1. tachypnea
  2. tachycardia
  3. restlessness from panicking
  4. pale skin, mucous membrane
  5. elevated BP
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2
Q

What are the last manifestations of low oxygen?

A
  1. stupor
  2. cyanosis
  3. bradypnea
  4. bradycardia
  5. hypotension
  6. cardiac dysrhythmias
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3
Q

What are some factors that affect urinary elimination?

A
  1. age
  2. stress
  3. meds
    4, preggerz
  4. diet
  5. mobility
  6. pain
  7. psychosocial factors
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4
Q

What is the most common cause of UTIs?

A

E. coli

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5
Q

What are the types of incontinence? Which is the most common?

A
  1. stress- most common
  2. urge
  3. overflow
  4. reflex
  5. functional
  6. total
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6
Q

Describe crackles or rales

A

fine to coarse bubbly sounds as air passes through fluid or re-expands collapsed small airways

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7
Q

Describe wheezes

A

high-pitched whistling, musical sounds as air passes through narrowed or obstructed airways

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8
Q

Describe rhonci

A

coarse, loud-low-pitched rumbling sounds

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9
Q

What is a pneumothorax?

A

air in the thoracic cavity

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10
Q

What is atelectasis?

A

collapsed alveoli

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11
Q

What are Si/Sx of atelectasis?

A

uneven chest and diminished lung sounds

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12
Q

What items are included in PPE?

A

gown, masks, gloves

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13
Q

What are the 3 most common reactions to latex products?

A
  1. irritant contact dermatitis
  2. latex allergy
  3. allergic contact dermatitis
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14
Q

What is the average time to wash your hands?

A

15-30 sec.

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15
Q

When you should you wash your hands with soap and water vs. just geling?

A

Always wash your hands after coming in contact with a C. dif patient or if your hands are visibly soiled otherwise it is okay to gel.

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16
Q

When should you perform hand hygiene?

A
  1. before and after caring for a patient
  2. touching blood, bodily fluids, secretions, excretions, and contaminated items
  3. between tasks and procedures
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17
Q

List the transmission-based precautions

A
  1. contact
  2. droplet
  3. airborne
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18
Q

Describe contact precautions

A

requires gloves and gown. Pt is in a private room to prevent cross-contamination.

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19
Q

Example of contact precautions

A

VRE, MRSA, C. dif, wound infxns, and herpes simplex

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20
Q

Describe droplet precautions

A

used when a disease is transmitted by large droplets.

requires a surgical mask within 3 ft of the pt, gown and gloves

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21
Q

Examples of droplet precautions

A

influenza, pneumonia

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22
Q

Describe airborne precautions

A

used with pts who have diseases that are transmitted by smaller droplets. isolation requires negative airflow.
N95 respirator, gown and gloves

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23
Q

Examples of airborne precautions

A

TB, MMR

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24
Q

What is the primary method to reduce infection?

A

handwashing

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25
Q

Normal Blood pressure

A

120/80

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26
Q

What is the approx. value for low BP

A

90/60

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27
Q

What is the approx. value for high BP

A

175/90

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28
Q

Normal heart rate (adult)

A

60-100 bpm

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29
Q

Tachycardia

A

> 100 bpm

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30
Q

Bradycardia

A

<60 bpm

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31
Q

Normal respiratory rate

A

12-20 breaths/min

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32
Q

Tachypnea

A

> 20 breaths/min

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33
Q

Bradypnea

A

<12 breaths/min

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34
Q

Normal Temp

A

98.7 F

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35
Q

If a UAP reports an unusual VS do we take their word for it? If no, then what?

A

No, I assess the patient myself. If VS are same, then assess the patient by asking how they are feeling and about recent activities

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36
Q

When I am taking HR what am I also assessing?

A

strength, rhythm, abnormalities

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37
Q

If HR should abnormality on the radial pulse, what is the next step?

A

Check the apical pulse for full 60 s

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38
Q

How should you assess pain?

A

by using the pain scale (0-10) and PQRST

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39
Q

What is PQRST?

A 
Precipitating factors
Quality 
Region
Severity 
Timing
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40
Q

According to PQRST, what kind of questions would you ask to assess S?

A

Severity. What is your pain level on a scale of 0-10? Does it interfere w/ activities? Does it force you to sit dow, lie down?

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41
Q

According to PQRST, what kind of questions would you ask to assess R?

A

Region. Where does it hurt? Does it radiate?

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42
Q

According to PQRST, what kind of questions would you ask to assess Q?

A

Quality. What does it feel like? Stabbing? Dull? Sharp?

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43
Q

According to PQRST, what kind of questions would you ask to assess T?

A

Timing. When does it start? How long does it last? Frequency?

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44
Q

According to PQRST, what kind of questions would you ask to assess P?

A

What brings about the pain? What are you doing when the pain starts? What makes it better?

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45
Q

What are the 4 physiologic responses to pain?

A

transduction, perception, transmission, and modulation

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46
Q

What is the difference between pain threshold and pain tolerance?

A

threshold is when one begins to feel pain while tolerance is how much pain one can endure or accept

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47
Q

Acute pain

A

temporary, typically less than 6 mos, limited tissue damage with an identifiable cause

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48
Q

Chronic pain

A

long-lasting, longer than 6 mos, leads to great personal suffering

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49
Q

What are some factors that affect pain?

A

age, genetics, religion or spirituality, coping style, culture, and previous experience

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50
Q

What is the common effective method for pain?

A

analgesics

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51
Q

If an analgesic is given PO how long does it take to be effective?

A

30-45 mins

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52
Q

If an analgesic is given IV how long does it take to be effective?

A

3-5 mins

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53
Q

What are 2 types of analgesics?

A

NSAIDS & opioids/narcotics

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54
Q

What are some examples of NSAIDS?

A

motrin, aspirin, naproxen (aleve)

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55
Q

What are the common side effect of NSAIDS?

A

GI bleeding, heartburn, nausea, and upset stomach

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56
Q

What is the trade name for acetaminophen?

A

tylenol

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57
Q

What are some examples of narcotics?

A

Diladud, vicodin, oxycontin, norco, tramadol

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58
Q

What are some common effects on narcotics?

A

dry mouth, constipation, and drowsiness

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59
Q

What is an effective communication style from nurse to physician?

A

SBAR

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60
Q

What does SBAR stand for?

A

Situation, Background, Assessment and Recommendation

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61
Q

If you tell the physician that the patient is diabetic and admitted to the hospital for dehydration 2 days ago at 0700, what part of SBAR is this?

A

Background

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62
Q

If you tell the physician that he should come see the patient in 2 hours after pain meds were administered to speak with the patient and you recommend they move to telemetry, what part of SBAR is this?

A

Recommendation

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63
Q

If you tell the physician, hi my name is Nurse Nelson, and I am calling about David Cartell in Rm 214, what part of SBAR is this?

A

Introduction

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64
Q

If you tell the physician, that David Cartell just had a glucose check and it was 232 mg/dL before meals, and needs an insulin prescription STAT, what part of SBAR is this?

A

Situation

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65
Q

If you tell the physician that the pt’s VS, pain level, and HR, what part of SBAR is this?

A

Assessment

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66
Q

Wha should you do before calling a physician?

A
  1. Assess the patient
  2. Review the chart
  3. Know admitting Dx
  4. Keep info concise
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67
Q

What is the nursing process?

A

ADPIE

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68
Q

What does ADPIE stand for?

A 
Assess
Dx
Planning 
Implementation 
Evaluation
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69
Q

If I identify the patient’s problem, what part of the process am I doing?

A

Dx

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70
Q

If I perform nursing actions, delegate tasks, supervise other health care staff, and document, what part of the process am I doing?

A

Implementation

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71
Q

If I ask myself if the pt meet the planned outcomes, were interventions effective and appropriate, and modification is needed, what part of the process am I doing?

A

Evaluate

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72
Q

If I set priorities, determine pt goals with the pt, and select nursing interventions, what part of the process am i doing?

A

Planning

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73
Q

If I am gathering information on the pt such VS, lab values, medical history and validating, interpreting and clustering data, what part of the process am I doing?

A

Assessment

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74
Q

Say your ABCs

A 
Airway 
Breathing 
Circulation
Disability- LOC 
Exposure
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75
Q

What are some factors that affects wound healing?

A

age
loss of skin turgor
slower tissue regeneration
decrease in collagen

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76
Q

Serous drainage

A

portion of serum is watery and clear

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77
Q

Sanguineous drainage

A

contains RBCs and thick

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78
Q

Serosanguineous drainage

A

contains both serum and blood

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79
Q

Purulent drainage

A

pus (WBCs) with foul smell, result of infection

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80
Q

Purosanguineous drainage

A

pus and blood (newly infected wound)

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81
Q

What is the difference between evisceration and dehiscence?

A

An dehiscence partial or total rupture of a sutured wound usually with separation of underlying skin layers and evisceration involves protrusion of visceral organs through a wound opening

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82
Q

What are risk factors for pressure ulcer development?

A

shearing, friction, altered LOC, impaired sensory perception, friction and moisture, neglect, nutrition

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83
Q

Describe a Stage I pressure ulcer

A

skin is not broken, nonblanchable redness, may feel warm or cool to toucj, tissue is swollen and congested, possible discomfort

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84
Q

Describe a Stage II pressure ulcer

A

skin is broken, down to epidermis to dermis, reddish-pinkish bed without slough or bruising, superficial and can appear an abrasion, blister or shallow crater, scant drainage, edema persists

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85
Q

Describe a Stage III pressure ulcer

A

skin is broken- down to SQ fat, damage or necrosis can extend down to but not through underlying fascia, deep crater w/o exposed muscle or bone. Drainage and infection are common

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86
Q

Describe a Stage IV pressure ulcer

A

skin is broken- down to bone or muscle. sinus tracts, deep pockets of infxn, tunneling or undermining eschar (black) or slough (tan, yellow or green) not painful anymore

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87
Q

Describe an unstageable pressure ulcer

A

actual depth is unknown w/ no determination of stage bc eschar or slough obscures the wound

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88
Q

If evisceration occurs what should you do?

A

cover area with sterile towels and call physician immediately

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89
Q

What is the depth measurement for mild edema (1+)?

A

2mm

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90
Q

What is the depth measurement for moderate edema (2+)?

A

4mm

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91
Q

What is the depth measurement for moderate-severe edema (3+)?

A

6mm

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92
Q

What is the depth measurement for severe edema (4+)?

A

8mm

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93
Q

What is the Braden Scale?

A

Measurement tool for pressure ulcer risk

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94
Q

What are some nursing interventions for preventing pressure ulcers?

A
  1. Rotating a pt q2h
  2. Keep skin clean, dry, and intact
  3. Ambulate patients
  4. Use pressure supportive devices
  5. Inspect skin frequentlt
  6. Clean the skin with a mild cleansing agent and pat it dry immediately following urine and stool incontinence
  7. Bathe with tepid water and avoid scrubbing
  8. Do not massage bony prominences
  9. Provide adequate hydration
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95
Q

When changing a dressing how we do we assess the wound?

A

TACO

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96
Q

What does TACO stand for?

A

Texture- thick, watery
Amount- scant, copious
Color- purulent, serous, etc.
Odor- foul

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97
Q

How should you go about a physical assessment?

A

assess the body by systemd

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98
Q

When observing the eyes what are we looking for?

A

PERRLA: Pupil, Equal, Round, Reactive and Accommodation

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99
Q

Which CN are we observing during eye examination?

A

CN II & III

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100
Q

How should you assess LOC?

A

ask if they know where they are, why they are there, who is the president, and their name

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101
Q

Which 3 step method should you use during assessment?

A

inspect, palpate, and auscultate

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102
Q

What is the purpose of an assessment?

A

baseline data and plan of care

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103
Q

When assessing the lungs, how many sounds should I listen to anterior? Posterior?

A

Anterior: 6
Posterior: 8

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104
Q

What are the auscultatory sites for the heart in order?

A

Aortic, Pulmonic, Erb’s Point, Tricuspid, and Mitral/ Apical

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105
Q

What are the 2 sounds expected when listening to the heart?

A

lub (S1 sound)-dub (S2 sound)

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106
Q

What is happening during lub? dub?

A

lub- ventricular systole (contraction) and dub- ventricular diastole (relaxation)

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107
Q

What is an S3 sound?

A

Ventricular gallop

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108
Q

What is an S4 sound?

A

atrial contraction

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109
Q

Which groups of people experience S3 sounds?

A

pregnant women and CHF

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110
Q

What does a ventricular gallop sound like? When does it occur?

A

Ken-tuck-y and occurs after S2

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111
Q

What does an atrial gallop sound like? When does it occur?

A

Ten-es-see and occurs before S1

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112
Q

What are audible when blood volume in the heart increases or its flow is impeded or altered?

A

Murmurs

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113
Q

What is the difference between infiltration and phlebitis?

A

infiltration- cold in temp, edema, and blanching

phlebitis- red in color and hot in temp

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114
Q

Who is most at risk for falling?

A
  1. elderly
  2. those w/
    - decreased visual acuity
    - generalized weakness
    - urinary frequency
    - gait and balance problems
    - cognitive dysfunction
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115
Q

What are some ways to prevent falls?

A
  1. Make sure the call light is within reach
  2. Place bed alarms
  3. Keep table or nightstand within reach
  4. Bed is in its lowest position
  5. Fall Risk alerts
  6. Place those confused and fall risk closer to the nurse’s station
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116
Q

For an adult on restraints when should they be given a break?

A

q2h

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117
Q

When can seclusions and restraints be used?

A
  1. with physician’s order
  2. the pt at harm to themselves or others
  3. signed within 24 hours
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118
Q

When should a restraint prescription renewed?

A

q24h

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119
Q

What are a nurse’s responsibilities for a pt on restraints?

A
  1. assess skin integrity q2h
  2. Monitor VS
  3. Explain the need for the restraints
  4. Ask client for consent
  5. Use a quick-release knot
  6. 2 finger fit
  7. Never leave the client alone w/o restraints
  8. Remove to ensure good circulation
  9. Tie restraints to the bed frame where they will not tighten when bed lower or heightens
  10. Evaluate regularly to determine if restraints are needed.
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120
Q

What is the most common sleep disorder?

A

insomnia

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121
Q

What is the inability to get an adequate amount of sleep and to feel rested?

A

insomnia

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122
Q

Sleep apnea

A

more than 5 breathing cessations lasting longer than 10 s/ hr during sleep

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123
Q

Narcolepsy

A

sudden attacks of sleep or excessive sleepiness during waking hours

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124
Q

Nocturnal enuresis

A

bed-wetting

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125
Q

What does the sleep cycle consist of?

A

4 stages of NREM and a period of REM

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126
Q

Describe Stage 1 NREM

A
  1. very light sleep
  2. only lasts a few mins
  3. VS and metabolism beginning to decrease
  4. awakens easily
  5. feels relaxed and drowsy
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127
Q

Describe Stage 2 NREM

A
  1. deeper sleep
  2. 10-20 mins long
  3. VS and metabolism continuing to slow
  4. requires slightly more stimulation to awaken
  5. increased relaxation
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128
Q

Describe Stage 3 NREM

A
  1. Initial stages of deep sleep
  2. 15-30 mins long
  3. VS continue to decrease but remains regular
  4. difficult to awaken
  5. relaxation with little movement
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129
Q

Describe Stage 4 NREM

A
  1. delta sleep
  2. deepest sleep
  3. 15-30min long
  4. VS low
  5. Very difficult to wake up
  6. physiologic rest and restoration
  7. enuresis, sleepwalking, sleeptalking
  8. repair and renewal of tissue
130
Q

Describe REM sleep

A
  1. vivid dreaming
  2. about 90 mins after falling asleep
  3. longer with each sleep cycle
  4. varying VS
  5. very difficult to awaken
  6. cognitive restoration
  7. avg length 20 min
131
Q

What are some factors that can affect sleep?

A
  1. illness
  2. current life events
  3. emotional stress or mental illness
  4. exercise
  5. fatigue
  6. sleep environment
    7, medication
132
Q

Exercise promotes sleep is at least how many hrs. before bedtime?

A

2 hrs

133
Q

What are the 3 parts to a NANDA nursing diagnosis?

A

Diagnostic label, related to and as evidenced by

134
Q

What are some influential factors that affect bowel elimination?

A
  1. stress
  2. diet/nutrition
  3. exercise/ activity
  4. age
  5. hydration/fluid
  6. pain
135
Q

Define incontinence

A

inability to control defecation, often caused by diarrhea

136
Q

Define diarrhea

A

loose or watery stool

137
Q

Define constipation

A

difficult or infrequent evacuation of hard, dry feces

138
Q

What are some interventions for constipation?

A

increase liquid intake, ambulation or activity, and increase fiber

139
Q

What is the normal range of diet one should consumer per day?

A

25-30 g/ day

140
Q

If a patient exhibits red stool, what is your thoughts? Do you presume it is blood?

A

No, I do not immediately think it is blood, but ask about the patient’s diet. Specifically ask if they have been consuming any beets, which may cause stool to be red. Also it can be the result of hemorrhoids

141
Q

If a patient exhibits black tarry stool, what are your thoughts?

A

Assess the patient and ask if the patient is taking any iron supplements

142
Q

When is okay to say one has a diarrhea or constipation?

A

3x/day or 3x/week

143
Q

Straining while defecation is an indication of what?

A

diarrhea

144
Q

If a patient isn’g getting enough fiber, what is a fiber supplement?

A

metamucil

145
Q

Sierra a patient is experiencing severe diarrhea, what medication helps?

A

lomotil

146
Q

If you tell the physician about lab and diagnostics, what part of SBAR is this?

A

Recommendation

147
Q

If a patient has pneumonia what are some nursing interventions?

A

twisting, deep breathing and coughing

148
Q

If a patient is having diarrhea and has infection or bacteria in stool, can you still give lomotil?

A

no because you want them to get rid of the infxn or bacteria

149
Q

Supine

A

laying on back “spine”

150
Q

Prone

A

laying on stomach

151
Q

Semi- Fowler’s

A

45 degrees sitting up

152
Q

Full-Fowlers

A

90 degrees sitting up

153
Q

Sim’s

A

on the side with one leg bent

154
Q

What is an example of a stool softner?

A

colace

155
Q

Define impaction

A

stool hardening and will not pass

156
Q

What can impaction lead to?

A

obstruction

157
Q

What are the 4 types of enemas?

A
  1. cleansing
  2. return-flow
    3, medicated
  3. oil-retention
158
Q

Na

A

136-145

159
Q

Ca

A

8.6-10

160
Q

Cl

A

99-109

161
Q

K

A

3.5-5.5

162
Q

Mg

A

1.5-2.5

163
Q

PaCo2

A

35-45

164
Q

PaO2

A

80-100

165
Q

HCO3

A

22-28

166
Q

Actual act of having a bowel movement

A

defecation

167
Q

What are the 7 rights of medication?

A

Right:

  1. patient
  2. medication
  3. dosage
  4. time
  5. time
  6. refusal
  7. documentation
168
Q

How do you know you have the right patient?

A

2 patient identifers: name, medical record number and date of birth. never the patients room number

169
Q

When do you do your 3 medication checks?

A
  1. when you get the order
  2. when you prepare the medication at the pixis
  3. patient’s bedside
170
Q

What are the 11 routes for medications

A
  1. PO
  2. IV
  3. IM
  4. IVPB
  5. Buccal
  6. SQ/SC
  7. PR
  8. IVP
  9. SL
  10. MDI
  11. ID
171
Q

What are the routes for enteral medications?

A
  1. PO
  2. SL
  3. PR
172
Q

What are the routes for parenteral meds?

A
  1. SC/SQ
  2. IV
  3. IM
173
Q

What meds are given SQ?

A
  1. anticoagulants

2. insulin

174
Q

What degrees should you give SQ/SC?

A

30-45

175
Q

What are the sites to give SQ injection?

A
  1. abdomen
  2. back of the arm
  3. back of the thigh
  4. buttocks
176
Q

what angle should you give an IM injection?

A

90

177
Q

If you aspirate an IM injection and get blood with a narcotic what do you do? regular meds?

A

you discard the med with another nurse witnessing you in both scenarios

178
Q

What are some sites for IM injection?

A
  1. deltoid
  2. vastus lateralis
  3. ventrogluteak
179
Q

What is the important about MDI?

A

Make sure the lips are sealed

180
Q

What is important aspect of a spacer?

A

spacer allows more of the medication to enter into the lungs

181
Q

If Jane has a patch, what is important teaching information?

A

alt. sites and can never wear more than one patch at a time

182
Q

What med is given ID?

A

TPPD

183
Q

What is stat?

A

within 15 mins

184
Q

What is now?

A

within 90 minutes

185
Q

At what degree do you give ID? How should needle be placed?

A

10-15 degrees and the bevel of the needle should be up

186
Q

BID

A

Twice per day

187
Q

TID

A

three times per day

188
Q

QID

A

four times per day

189
Q

QD

A

every day

190
Q

PRN

A

as needed

191
Q

NPO

A

nothing by mouth

192
Q

What is the onset time for SQ and IM?

A

3-20 mins

193
Q

If a patient refuses to take their meds, what do you do?

A
  1. Assess and ask why don’t you want to the medication.

2. then document the patient refused and gave you the medication and time

194
Q

If Sue is getting meds at 0800, what time range do you have to give her meds?

A

0730-0830. You have an half hour window before and after

195
Q

If a patient is vomiting and has PO med due, what do you do?

A

call the doctor to see if you can get another order, if another med can be given IV or another route

196
Q

What are high alert medications?

A
  1. heparin
  2. insulin
  3. K+
197
Q

What do you do before you administer high alert medications?

A

you have another nurse check it for you independently

198
Q

Black-box warning

A

what the FDA puts out about med that can be potential harmful (ex. Ritalin )

199
Q

Complementary alt. therapy

A

eastern meds.

200
Q

Types of complementary therapies

A
  1. accupuncture
  2. oils
  3. herbs
  4. chakras
  5. reflexology
  6. visualization
  7. distraction
  8. reflection
201
Q

What is the difference between Eastern and Western meds?

A

Eastern do not use meds they use herbs and more of a holistic method

202
Q

Holistic

A

body, mind and spirit

203
Q

AC

A

Before meals

204
Q

HS

A

at bed time

205
Q

BC

A

after meals

206
Q

When should do accu-chek?

A

ac and hs

207
Q

hyponatremia

A

low NA level <136. causes cells to swell

208
Q

Hypernatremia

A

high Na level >145 causes swell to shrink

209
Q

Respiratory acidosis

A

lungs are unable to excrete CO2

210
Q

Respiratory alkalosis

A

lungs are excreting too much CO2

211
Q

What is the result of respiratory alkalosis?

A

hyperventilating

212
Q

What is the result of respiratory acidosis?

A

hypoventilating

213
Q

Metabolic acidosis

A

increase acid

214
Q

Metabolic alkalosis

A

increase bicarbonate

215
Q

How do you assess Acid Base with lab values?

A
  1. look at pH
  2. look at CO2 and HCO3- values
  3. Use Rome
216
Q

What does ROME stand for?

A

Respiratory Opposite Metabolic Equal

217
Q

So how do determine if alkalosis and acidosis for respiratory?

A

If pH value and PCO2 values are opposite: if pH is up and CO2 is down= alkalosis if pH is down and CO2 is up= acidosis

218
Q

So how do you determine if alkalosis and acidosis for metabolic?

A

If pH value and HCO3 values are the same: if pH is down and HCO3- is down= acidosis and if pH is up and HCO3- is up= acidosis

219
Q

Common Si/Sx of respiratory acidosis

A

oversedation, cardiac arrest and CHF

220
Q

Common Si/Sx of respiratory alkalosis

A

hyperventilation and pulmonary embolus

221
Q

Common Si/Sx of Metabolic acidosis

A

renal failure, poisonings, and diarrhea

222
Q

Common Si/Sx of metabolic alkalosis

A

excessive antacids, NG suctioning and vomiting

223
Q

Hypovolemia

A

low volume of blood, H2O

224
Q

What kind of patient is hypovolemic?

A

dehydrated, burns

225
Q

Common Si/Sx of hypovolemia

A
  1. tenting or poor skin turgor, dry mouth
  2. increase thirst
  3. fatigue
  4. decreased urine output
  5. flat veins
  6. high HR (tachycardia)
  7. low BP
  8. headache
  9. dizziness
226
Q

Common Si/Sx of hypervolemia

A
  1. edema
  2. distended neck veins
  3. high BP
  4. low HR (Bradycardia)
  5. SOB
  6. strong pulse (bounding)
  7. crackles in the lungs
  8. increased urine output
  9. weight gain
227
Q

What is the best indicator of hypervolemia? How do you assess?

A

the best indicator is weight gain and you assess by weighing the patient t daily

228
Q

Interventions for hypervolemia

A
  1. low Na+ diet
  2. decrease H20 intake
  3. check input and output
  4. check VS
  5. check lab values
  6. elevate HOB
  7. elevate extremities or reposition
  8. check weight
229
Q

What is the normal intake of fluids/day?

A

2500-3000

230
Q

How do we get nutrition?

A
  1. diet

2. IV

231
Q

What is considered intake?

A

anything you take PO, IV and TPN

232
Q

What is considered output?

A

anything this is coming out your body: vomiting, suctioning, drain, diarrhea

233
Q

What is the difference between PPN and TPN?

A

TPN goes directly to the heart

234
Q

What direction does the fluid move in a hypertonic solution? hypotonic solution?

A

hypertonic into the cell and hypotonic out of the cell

235
Q

What type of solution is a lactated ringer?

A

isotonic solution

236
Q

What do you typically use to check a patient’s nutritional status?

A

BMI (Body mass index)- height (m2) and weight (kg)

237
Q

BMI OF 25-30 is considered what?

A

overweight

238
Q

What is the BMI for an obese patient?

A

more than 30 kg/m2

239
Q

What are you at risk for if you are obese?

A

at risk for diabetes, CAD, hypertension

240
Q

dysphagia

A

difficulty swallowing

241
Q

If a person has dysphagia or aspiration precaution what type of liquids would you give them?

A

thick liquids

242
Q

If a person is malnourished what do you observe?

A 
dehydration 
lab values- low albumin (plasma protein)
dry skin or puzzling
brittle hair and nails
decayed teeth 
lips cracked or die
243
Q

Clear liquid diet

A 
things you can see through: 
water
cranberry juice
chicken broth 
jello 
apple juice
244
Q

high fiber diet

A

whole grains, raw and dried fruit

245
Q

mechanical soft diet

A

clear and full liquids plus diced or ground foods

246
Q

full liquid

A

clear liquids plus diary products all juice, pureed vegetables

247
Q

NG

A
  1. Assess the nares- inflammation
    back of throat- ensure they have a gag reflex and no obstruction
  2. measure tip of the nose to the ear to the xiphoid process
  3. lubricate the tip
  4. start insertion while drinking water and chin to chest
248
Q

What verifies an NG tube placement?

A

X-ray

249
Q

What is the actual act of peeing called?

A

micturition

250
Q

dysuria

A

difficulty peeing

251
Q

nocturia

A

peeing at night (children, preggerz, diuretics)

252
Q

oliguria

A

diminished output

253
Q

hematuria

A

blood in the urine

254
Q

polyuria

A

excessive urination

255
Q

What kind of patients have difficulty urinating?

A

patients with UTIs

256
Q

Si/Sx of UTI

A
  1. burning
  2. color (dark)
  3. excessive urinating but its scanty
  4. urgency to pee
  5. hematuria
  6. foul smelling
257
Q

What can make urine foul smelling?

A
  1. bacteria
  2. asparagus
  3. blueberries
  4. B12
  5. beets
  6. medications
258
Q

pyridium

A

make urine turn orange (ozo has pyridium in it )

259
Q

Si/Sx of UTIs mimic what kind of diseases?

A

STIs

260
Q

What kind of test do you order to check for WBCs in urine?

A

culture and sensitivity urine test

261
Q

What are some preventions for UTIs?

A
  1. cranberry juice
  2. wipe front to back
  3. no tight jeans
  4. no bubble baths
  5. increase H2O (>3000 ml)
262
Q

What are the 2 types of urinary diversions?

A
  1. continent urinary reservoir- ureters imbedded in the reservoir
  2. orthotopic neobladder- ileal pouch replaces the bladder
263
Q

Cystectomy

A

removal of the bladder

264
Q

What are the types of urinary specimens?

A
  1. dipstick- change colors determining on the color
  2. urinalysis
  3. C&S- looking for infection
265
Q

Once the urine leaves the body is it considered sterile?

A

no

266
Q

When you want to get a C&S how do you get sterile urine?

A

midstream or clean-catch

267
Q

What are the 2 types of catheters?

A
  1. indwelling/ folley- held by a 10 ml water balloon

2. in and out

268
Q

How do you know if a catheter is in the bladder?

A

urine will come out, if not drops come out immediately, massage or push on the bladder

269
Q

How many ml can the bladder hold?

A

600-1000 ml

270
Q

How do you remove a folley?

A

take a 10 ml syringe and aspirate on the port of the balloon so the balloon will just fall out

271
Q

What are you look at when you are assessing the urine?

A
  1. color- anything dark is abnormal
  2. smell
  3. amount
  4. transparency/ clarity
272
Q

How many ml/hr should we be voiding?

A

30ml/hour

273
Q

What happens if your patient is urinating less than 30ml/hour?

A

inform the physician after assessing the patient

274
Q

What are some nursing dx for urinary elimination?

A
  1. urinary continence
  2. risk for infection
  3. altered urine function
275
Q

During a head-to- toe when do we assess urinary elimination?

A
  1. assess the bladder for distention
276
Q

alveoli

A

gas exchange

277
Q

ventilation

A

processing of moving gases in and out (inhalation and exhalation)

278
Q

Hemaothorax

A

blood in the thoracic cavity

279
Q

Anpea

A

absence of breathing

280
Q

Hypoxia

A

no oxygen in the lungs

281
Q

What factors can influence oxygenation?

A
  1. positioning
  2. obstruction
  3. asthma
  4. exercise
  5. smoking
  6. Medication
  7. stress
  8. allergies- pollen, abstesis
  9. environmental
  10. age
  11. substance abuse
282
Q

How do we know the difference between respiratory distress and choking?

A

if choking they cannot talk, respiratory distress they can talk

283
Q

Assessing chest

A
  1. ensure chest symmetrical
284
Q

Trache suctioning

A

suction on the way up or your way out

285
Q

What are the 3 types of chest physiotherapy? Who can do this?

A
  1. postural drainage
  2. percussion
  3. vibration
    Nurse or RT can do this
286
Q

What is the purpose of chest physiotherapy?

A

loosening up chest secretions

287
Q

What is our main concern after surgery regarding respiratory system?

A

pneumonia

288
Q

What are some interventions for post-op patients regarding respiratory?

A

ambulation and lung exercises

289
Q

What are lung exercises for post op patients?

A

deep breathing and coughing using incentive spirometer

290
Q

How do you use an incentive spirometer?

A

5-10 breaths/hour

291
Q

How do we prevent pneumonia for post op patients who are bed-ridden?

A

TCDP- turn cough and deep breath and repositioning them to prevent pneumonia

292
Q

Factors that influence bowel elimination

A
  1. stress
  2. age
  3. exercise
  4. hydration/fluids
  5. diet- high fiber diet
  6. pain
  7. activity/inactivity
293
Q

How many g of fiber do you need daily?

A

25-30 g

294
Q

What is an example of a stimulant?

A

ducolax and caffeine

295
Q

What are basic interventions to promote bowel elimination?

A
  1. ambulation,
  2. increase liquid intake
  3. increase fiber
  4. increase activity
296
Q

What are the interventions after basic ones for bowel eliminiation?

A
  1. stimulant
  2. stool softner
  3. Digital disimpaction
  4. enema
297
Q

A what height should you hang a soapsuds bag?

A

12-18 in above the anus

298
Q

What position is the patient in for enemas?

A

left side sim’s

299
Q

How far you going to into the anus for an enema? adult?

A

3-4 in

300
Q

What are hemorrhoid?

A

enlarged blood vessels that can be itchy and uncomfortable

301
Q

What kind of patient has diarrhea?

A

C. diff

302
Q

When can you get hemorrhoids?

A

straining with constipation

women with multiple pregnancies

303
Q

What are the 2 types of hemorrhoids?

A
  1. internal

2. external

304
Q

What kind of baths do patients with hemorrhoids or vaginal labor get?

A

Sitz bath

305
Q

Fecal Occult Blood Test or Guaiac

A

determines if there is hidden blood in a stool specimen

306
Q

How do you collect a stool softner?

A

by using a hat

307
Q

What is O&P test for stool?

A

ova and parasite

308
Q

What is an ostomy?

A

surgical incision in small intestines outside the body. Patient move their bowels into the bag. Also relieves gas, so bag will become full of air

309
Q

Nursing Dx for bowel elimination

A
  1. constipation
  2. diarrhea
  3. altered body image
  4. knowledge deficit
310
Q

When do we use NG Intubation?

A
  1. GI bleed

2. nutritional reasons

311
Q

If you test the pH of gastric secretions, what pH do you expect?

A

3-4

312
Q

What position do you put a patient in to place a bed pan?

A

Fowler’s

313
Q

How often do we need to reposition a patient?

A

q2h

314
Q

What are the interventions for Stage I pressure ulcer?

A

repositioning, pillows, and heel protectors

315
Q

What are the interventions for Stage II pressure ulcer?

A

Transparent dressings

316
Q

What are the interventions for Stage III pressure ulcer?

A

Specific dressings prescribd by doctor

317
Q

How do we measure a pressure ulcer?

A

width, length, and depth

318
Q

What type of aphasia is the inability to name common objects or express simple ideas in words or writing?

A

expressive aphasia

319
Q

What type of aphasia is the inability to understand written or spoken language?

A

receptive aphasia

320
Q

How do you care for a patient with aphasia?

A

greet and call them by name
speak clearly and slowly using short sentences
Do not shout
ask simple questions

321
Q

What cranial nerves are involved with PERRLA?

A

3, 4,6

Fundamentals of Nursing (4 decks)

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