Fundamentals Exam October 12 Flashcards
What does a nurse do after/while taking a telephone order?
Read it back to the physician
Record the orders in patient’s medical record
Read orders back to practitioner to verify accuracy
Date and note the time orders were issued
Record telephone orders, and full name and title physician or nurse practitioner who issued orders
Sign the orders with name and title
Before administering a sublingual or buccal drug offer the patient ___
a drink if water or oral care. This ensures that the tablet will dissolve appropriately.
What is the primary purpose of outcome identification and planning in the nursing process
Establish priorities
Identify expected patient outcomes
Select evidence based nursing interventions
**Develop a plan of care and with the client
Communicate the plan of care
What activities do we carry out during the implementation step?
REASSESS the patient for changes in status that might dictate a different set of interventions
be sure that RESEARCH supports the interventions you have selected and be open to better ways of addressing patient problems and issues
always MONITOR RESPONSE to your interventions so that you can modify the plan of care if needed
Alfaro’s Rule: “assess, reassess, revise, record”
How do you locate the spot to give a deltoid injection?
Three fingers down from the acromion process
How do you locate the spot to give a vastus lateralis injection?
Outer middle third of tic-tac-toe box
How do you locate the spot to give a ventrogluteal injection?
find greater trochanter and iliac crest
If you have a hypoxic patient what will you symptoms be?
Dyspnea (trouble breathing), elevated B/P with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis
CAN CAUSE CONFUSION/ DISORIENTATION
Patient that has pneumonia- what are the assessment signs?
Listening for decreased breath sounds (diminished breath sounds) Lung collapse (atelectasis) will cause the trachea to deviate to the side
What is a parental medication
injectable- it does not use the mouth or alimentary canal
Diagnoses are best developed from ____.
clusters of significant data
what are the levels in maslow’s hierarchy of needs?
Level 1: Physiological needs Level 2: Safety and security needs Level 3: Love and belonging needs Level 4: Self-esteem needs Level 5: Self-actualization needs
pt. presents with 4 fractured ribs from a motor vehicle accident. You watch for ____
a rib possibly puncturing a lung, the broken ribs causing a hematoma, and possible pneumonia
put the parts of a nursing diagnosis in order. A) related to B) etiology C) as evidence by D) pt problem
problem, related to, etiology, as evidenced by(optional)
Secondary sources include
Medical record, primary provider, home health nurse, family member
low pulse oximetry means
there has been changes in alveolar capillary membrane and diffusion
enteric coating does what?
prevents gastric irritation
Term for greatest efficacy without toxicity
therapeutic range
what is the nursing diagnosis for hypoxia?
ineffective airway clearance or anxiety
Identify 5 types of nursing diagnoses
Actual: Risk: Possible: Wellness: Syndrome
pt Outcomes and goal are derived from
the problem statement of the nursing diagnosis
Describe 6 variables that influence the way a plan of care is implemented.
Patient variables: Developmental stage, Psychosocial background
b. Nurse variables: Resources, Current standards of care, Research findings, Ethical and legal guides to practice
4 types of outcomes specified in the plan of care.
**Cognitive-Increase patient’s knowledge, **Psychomotor-Patient’s outcome of new skills, **Affective-Changes in patient’s values, beliefs and attitude, **Physiological-Physical changes in patient.
NF means
national formulary
