ibis final Flashcards
urine specific gravity lab value
1.010-1.030
would a patient with fluid volume deficit have a high or low urine specific gravity?`
high
safety measures for a patient with increased confusion?
place patient in room closest to nursing station
magnesium normal lab values
1.3-2.1
sodium normal lab values
135-145
potassium normal lab values
3.5-5
chrloride normal lab values
98-106
BUN normal range
10-20
what does a high BUN indicate
patient dehydrated
Physiological findings of a pt with N/V/D
dehydration poor skin turgor fluid volume deficit flat neck veins tachycardia low BP (hypotension) electrolyte imbalance
fluid volume deficit means?
dehydration
Aspiration prevention for patient with NG tube?
30-45 degree bed elevation
flush
aspirate for gastric secretions (ph testing)
abdominal x-ray
instructions for flushing meds down NG tube
15-30 ml
put meds once at a time
explanation for why patient needs IV access even though they are drinking by mouth
for medications
for emergency access
Who do you refer a patient with pain and crepitus out of Temporomandibular joint (TMJ?
oral surgeon
signs of TMJ disorder
pain
popping
crepitus
who is responsible to obtain patient informed consent?
the surgeon (person performing surgery)
What tasks can you delegate to an AP for a post op patient
vitals
feeding
ambulation
Can an AP change dressings
No
Isolation precautions for airborne
N95 mask
TB
measles (rubeola)
varicella zoster
what precautions are there for rubella?
droplet
where do you put linen that has been soiled by feces
biohazard
proper linen handling
dont put on floor dont double bag wrap inward or use a tie dont shake dont leave extra linen inside room
what do you put at the foot of isolation patient bed
plastic bag
isolation patient will have their own?
linen disposal hamper
how to keep a sterile field
dont reach over
keep hands over elbows
open outwards
wash hands for 20 secs
Response for when family asks why you dont put restraints on patient who keeps pulling out IV
lowest form of restraints have to be used before
wrap IV site with acrylics
place IV in non-reachable area
try to resolve patient confusion if they are confused
what do you do before obtaining wound culture
irrigate site
difference between speaking to male patient and female patient
male patients are more direct
home safety for fall risk patient
bars in shower non slip bathmat no carpet no clutter night light non slip rug med alert shower chair
nursing actions for patient with partial hearing issues
make sure hearing aid is working
speak to patient face to face
clean hearing aid w/ non alcohol wipes or damp cloth
what does cold therapy do
constricts (less blood circulation)
what does hot therapy do
dilates (more blood circulation)
clean under patient nail with
orange stick
can a CNA cut a patients nail?
no
who cuts diabetic patients nails
podiatrist
clear liquid diet includes
black coffee jello apple juice orange juice chicken broth
is sherbert included in a clear liquid diet?
no
what kind of liquid is apple sauce
full liquid
what do you ask a patient to do if they have adventitious lung sounds (abnormal)
cough (could be congestion)
interventions for patient with low o2 saturation
raise head of bed (opens up airways)
what is the limit of O2 COPD patient can receive?
2 L (they retain CO2)
patient with cardiac issues should be instructed not to do what when defecating
straining
what is the issue with a patient straining during defecation
can cause cardiac syncope (passing out)
stimulates cranial nerve 10
why dont you let cardiac patients go to the bathroom by themselves
morphine they were given for pain can cause constipation which could cause them to strain while defecating
what do you give patient with constipation
stool softeners
use a gait belt if patient is
unbalanced
weak
what should you assess before ambulating a patient
if they can bear weight
aspiration precaution for patient at home
sit up in chair (fowlers position)
what to assess when patient is immobile for long period of time to see if theyre ready to ambulate
able to move all extremities
what do you remove first
gloves (most dirty)
first thing you put on
gloves
next step if patient is still pulling out IV
put on mittens
restraint process
get order within 24 hrs
easy tie knot
dont tie to side rails
how often do you assess a restrained patient
every 2 hrs
what do you assess when assessing restrained patient
circulation
ROM (remove restraints & perform ROM exercises)
if they need to use bathroom
what is your priority assessment for a patient in vest restraints
respiration
priority assessment for patient in mittens
skin integrity
circulation
how do you prevent patients nails from digging into their palms when in mittens
place towel or cotton in hands
where do you document a telephone order
in patients chart
what do you do with left over medication
throw away
how to prevent skin breakdown in immobile patient
barrier cream
clean & check often
reposition every 2 hrs
best solution to use when inserting IV into patient
chlorhexidine
phlebitits is
blood vessel inflammation
signs of phlebitis
warmth
burning sensation
redness
tenderness
what is infiltration
medication leaking into tissue
infiltration makes skin
cold
swollen
discolored
physiological changes in old people
lower metabolic rate increased pain threshold decreased cardiac output decreased gastric motility decreased skin turgor
first thing to do when removing NG tube
check order
recommendation for patient with circulation issues, cold feet and trouble sleeping
put on socks
is suction input or output
output
proper way to put anti embolic stockings on
no wrinkles (preserve skin integrity) make sure theyre not too tight
where to put padding on restraints
over bony prominences
patients that are at risk for aspiration
NG tube pts dysphagia pts throat cancer pts (head and neck) stroke pts post op pts on general anesthesia
low sodium/fat/cholesterol patients cant have
packaged food (high sodium) cheese (high fat and sodium) red meat dairy products (cant have low fat milk either) chicken skin animal products (high cholesterol)
high calcium food
salmon (high in calcium)
milk
oranges
citrus products
TUMS are also called
calcium carbonate antacid
what do calcium carbonate antacids cause
constipation
antacids
milk of magnesia
aluminum hydroxide
what does milk of magnesia cause
diarrhea
what does aluminum hydroxide cause
constipation
what do you give for constipation
fluids and fiber
where do you test skin turgor on young patients
on hand
where do test skin turgor on old patients
on collar bone
vitamin d production gets triggered by
the sun
foods high in vitamin c
oranges
cabbage
green pepper
strawberries
you risk breaching EHR & EMR confidentiality when
some else documents for you
you give your password out
leave computer open
going into chart you arent assigned to
patient statements are
subjective
is vomiting subjective or objective
objective (you see i.t)
is nausea objective or subjective
subjective
what do you do first after collecting a stool sample
send to lab immediately
patient needs to be catheterized if
incontinent immobile going to surgery urinary retention open perineal wound residual urine (unable to empty bladder even after urinating)
wipe from front to back to prevent
ecoli contamination
first step if patient hasnt urinated after catheter is removed
assess with bladder scan
normal gastric secretion ph
1-3
can you use gastric tube if ph is near range (ex. ph of 4)
yes
proper action for patient with cleansing enema
sims position
bag 12-18 in (30-45 cm)
hold solution to help gravity flow
insert 2 in to anus (lubricate tip)
orthodox jewish patient diet
kosher
meat and dairy eaten hrs from each other
no pork
islamic patient diet
no pork
what kind of liquid is grape juice
clear liquid
sublingal medication for patient that has NG tube what do you do?
place under patients tongue (always give med how i.ts supposed to be given)
education for patient who has difficulty swallowing or stroke
soft foods
nectar liquids
sit up to eat and lean forward
pulses locations
- temporal
- carotid
- brachial
- radial
- apical/pmi/mitral
- femoral
- popliteal
- dorsalis pedis
- posterior tibial
what to do if patient has irregular heart beat
assess for full minute
why dont you assess both carotid pulses at same time
could drop BP
steps if patient has infiltration
assess stop infusion remove IV put sterile dressing elevate extremity (fluid gets reabsorbed) apply warm (if fresh) apply cold (after 24 hrs)
during BP reading patients arm should be
at level of heart
instructions for patient getting BP reading
no talking
keep legs uncrossed
keep feet flat
sit upright
what gender is more likely to have scoliosis
female
should incident reports be put in patients chart?
no
fall risk patient care plan should include
in reach call bell
lowered bed position
fall mats
what to do if ambulating patient and they begin to fall
help patient slide down or help fall against wall with gait belt
