Fundamentals Flashcards
who needs to be monitored closely for fluid imbalances
infants and older adults
normal osmolarity
275-295
patient with diarrhea is at high risk for
fluid and electrolyte issues
who are at high risk for fluid volume overload
AKI, CKD, HF
where and why is the safest location of K replacement
central line due to infiltration
hyponatremia can predicate what toxicity
lithium
chovstek and troussea
hypocal
what is anidont for mag overdose
cal gluconate
S/S of acidosis
lethargy, confusion, coma, headache, decreased blood pressure, dysrhythmias, muscle weakness
airway ob needs to be monitored for what acid base imbalance
resp acid
S/S of alkalosis
Confusion, headache, low blood pressure, tachycardia, tetany, tingling of extremities, seizures
severe diarrhea needs to be monitored for
met acidosis
excessive vomiting needs to be monitored for
met alk
covert F to C
degrees fahrenheit - 32 x 5/9 = degrees celsius
no rectal temps in who
cardiac patients, rectal surgery, diarrhea, fecal impaction, or rectal bleeding or who is at risk for bleeding (thrombocytopenia)
what meds do you count apical
dig
beta blocker
elevated BP
120-129/less than 80
stage 1 BP
130-139/80-89
Stage 2
> 140/>90
hypertensive crisis
> 180/>120
small cuff
high
large cuff
low
major concern with Tylenol
hepatotoxicity
fat sol vit
A D E K
how to monitor hydration status
assessing intake and output, assessing weight, monitoring for edema, and monitoring for signs of dehydration. Each kilogram (2.2 lb) of weight gained or lost is equal to 1 liter of fluid retained or lost.
who may get fluid restrictions
hyponatremia, severe extracellular volume excess, and renal disorders.
CN I
Olfactory: smell
CN II
Optic: vision
CN III
Oculomotor: extraocular eye movement
CN IV
Trochlear: extraocular eye movement
CN V
Trigeminal: Chewing, sensation
CN VI
Abducens: extraocular eye movement
CN VII
Facial: face movement and taste sensation
CN VIII
Acoustic: hearing
CN IX
Glossopharyngeal: swallowing, salivation
CN X
Vagus: Swallowing, phonation, abdominal viscera
CN XI
Spinal: neck and shoulder strength
CN XII
Hypoglossal: swallowing, and speech
who is babinski abnormal in
anyone older than 2
- CNS disease
RACE
rescue
activate
confine
extinguish
PASS
pull
aim
squeez
sweep
what is the priority for posion
call posion control
airborne diseases
measles
chicken pox
disseminated varicella zoster
tuberculosis
COVID
airborne precautions
negative pressure room
N95/respirator
if a patient has airborne precautions and they are leaving the room place what on them
surgical mask
droplet precautions
surgical mask
contact precuations
gloves and gown
If the nurse has any questions about or sees inconsistencies in the written prescription, the nurse must contact
the person who wrote the prescription immediately and must verify the prescription.
after gastric surgery do not do what
irrigate NG tube
what to do about positioning for spinal anesthesia
do not elevate the legs any higher than placing them on the pillow; otherwise, the diaphragm muscles needed for effective breathing could be impaired.
what may be s/s of paralytic ileus
Postoperative vomiting, abdominal distention, and absence of bowel sounds
diabetic foot care
the feet would not be soaked and the nails would not be trimmed, and the primary health care provider or a podiatrist would be consulted for foot care if needed.
what razor should we use for anticoagulant or antiplatlet
electric razor
stage 1
Non blanchable redness, skin is intact
stage 2
Particle thickness, exposed dermis
stage 3
Full thickness, exposed subq tissue, may have eschar or slough present
stage 4
Full thickness, exposed underlying structures such as bone, muscle, tendon, ligaments, may have eschar or slough present
unstageable
Full thickness, extent cannot be confirmed because of eschar and slough, need to debride to stage
ureteral or nephrostomy
monitor output closely; urine output of less than 30 mL/hr or lack of output for more than 15 minutes should be reported to the primary health care provider immediately.
CVA tenderness firs priority
bladder distention
Neprolithiasis
uric acid crystals
nephrolithiasis decrease consumption of
purine
red meat, alcohol
