Fundamental Nursing Flashcards
Glasglo Coma Scale
Eye opening (E) – The best eye response, with responses ranging from 4 to 1 4 = Eye opening occurs spontaneously. 3 = Eye opening occurs secondary to voice. 2 = Eye opening occurs secondary to pain. 1 = Eye opening does not occur.
Verbal (V) – The best verbal response, with responses ranging from 5 to 1
5 = Conversation is coherent and oriented.
4 = Conversation is incoherent and disoriented.
3 = Words are spoken, but inappropriately.
2 = Sounds are made, but no words.
1 = Vocalization does not occur.
Motor (M) – The best motor response, with responses ranging from 6 to 1
6 = Commands are followed.
5 = Local reaction to pain occurs.
4 = There is a general withdrawal to pain.
3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present.
2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present.
1 = Motor response does not occur.
Responses within each subscale are added, with the total score quantitatively describing the client’s level of consciousness. E + V + M = Total GCS
A nurse is caring for a client who has been prescribed furosemide. Which of the following foods should the nurse encourage this to include in his diet?
Clients prescribed potassium-wasting diurectics should be encouraged to eat foods high in potassium. Table salt is not a good source of potassium.
What interventions should the nurse take to prevent aspiration?
Position the client in Fowler’s position., Instruct the client to tuck his chin when swallowing., Keep the client in semi-Fowler’s position for at least 1 hour after the meal., Support client’s upper back, neck and head during feeding.
How does dehydration affect a clients electrolytes, etc?
Dehydration is the loss of water from the body without the loss of electrolytes. This hemoconcentration results in increases in HCT, serum electrolytes, and urine specific gravity.
What is the correct BMI for underweight, healthy, overweight, and obese?
Healthy weight is indicated by a BMI of 18.5 to 24.9.
Overweight is defined as an increased body weight in relation to height. It is indicated by a BMI of 25 to 29.9.
Obesity is an excess amount of body fat. It is indicated by a BMI greater than or equal to 30.
What are some ways to promote sleep include
Exercise regularly; limit exercise at least 2 hr before bedtime.
- Establish a bedtime routine and a regular sleep pattern.
- Arrange the sleep environment for comfort.
- Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime.
- Limit fluids 2 to 4 hr before bedtime.
- Engage in muscle relaxation if anxious or stressed.
How to care for hearing aids?…
- Hearing Aid Nursing Considerations
- Use the lowest setting that allows hearing without feedback.
- To clean the ear mold, use mild soap and water while keeping the hearing aid dry.
- When the hearing aid is not in use, turn it off or remove the batteries to conserve battery power. Keep replacement batteries on hand.
What are some recommendations that a nurse should provide a client in management of their heart failure?
It is encouraged to stop smoking, reduce sodium intake, monitor fluid intake, restricting intake to 2 L per day. It is also encouraged to increase protein intake to 1.12 g/kg and consume small, frequent meals that are soft, easy-to-chew foods. There are no recommendations on calcium intake associated with heart failure.
What types of food restrictions do patients with celiac disease have?
Celiac disease is a gluten-sensitive enteropathy. It is a chronic, inherited, genetic disorder with autoimmune characteristics. Clients who have celiac disease are unable to digest the protein gluten.
Latex Allergies may also be allergic to:
Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well.
Order of assessment:
I-inspection
P-palpation
P-percussion
A-auscultation
Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate.
Cane walking:
C-cane
O-opposite
A-affected
L-leg
Crutch walking:
Remember the phase “step up” when picturing a person going up stairs with crutches. The good leg goes up first followed by the crutches and the bad leg. The opposite happens going down the stairs….OR “up to heaven…down to hell”
Delegation:
RNs DO NOT delegate what they can EAT–evaluate, assess, teach
AIRBORNE precautions:
AIRBORNE: “My Chicken Hez TB”
- Measles
- Chicken pox
- Herpes zoster
- TB
Management: neg. pressure room, private room, mask, n-95 for TB.
