INP 2 Final Review Flashcards
The correct sequence when doing an abdominal assessment
1) inspection
2) Auscultation
3) percussion &
4) Palpation
Another name for pressure ulcer
Decubitus ulcer
What may contribute to medication errors 5
1) Duplicate last name
2) incorrect MAR
3) pre-pouring medications
4) poor lighting
5) distractions
Which order is written correctly
A) Digoxin 0.25mg po qid
B) Digoxin 0.25mg po daily
C) Digoxin 0.25mg po qod
B) Digoxin 0.25mg po daily
Before administering Lasix, what electrolyte levels should the nurse know, the periodic table of said electrolytes
Sodium and potassium, Na and K
The difference between a vial and an ampule
Ampule contains a single dose, vial multiple doses eg. B12
Normal adult urine output
1500 to 1600ml/day
Localized infection
Confined to one area of the body
One purpose of the use of the standard formal nursing diagnostic statement
Facilitate understanding of client problems among health care professionals
Know your periodic table for; sodium, potassium, bicarbonate and chlorine
Na, K, Cl, HCO3
What to place between the legs of a patient post-op hip surgery
An abductor pillow
What should you do if a patient with moderate dementia tends to wander
A) Tell him about safe areas for wandering
B) Make sure the door alarms are turned on
C) Keep him on bed rest and give him comfort care
B) Make sure the door alarms are turned on
Lewy body dementia is characterized by progressive cognitive decline plus three specific features
1) recurring visual hallucination
2) motor rigidity
3) fluctuations in levels of alertness
Have a patient sitting upright during meal and 1 hour after is good for someone who has _________.
Dysphasia
A gastrotomy tube
A tube inserted surgically into the colon
Patient with orthostatic hypotension; what is the best technique to prevent a fall
Sit the patient up slowly; use pre-handling check prior to ambulation
Fall risk factors
-vertigo
-benzodiazepine (medications)
-nocturia
-poor fitting shoes
The ten rights
Person, time, dose, med, route, reason, refuse, educate, evaluation, documentation
What do you do immediately before administering Digoxin
Assess apical pulse, withhold med if heart rate is below 60 beats/min
What is the usual gauge of a needle for an IM
22 g
What do you do when choosing a site for a diabetic insulin shot in a LTC facility
Consult the diabetic record to see where the latest injection was administered
Do you draw up from a vial or ampule first when mixing two compatible meds?
Withdraw med from vial first
Purpose of a client assessment is to _______.
Collect information to compile an individual database
The correct sequence for administering an IM
Landmark
clean injection site
Quickly insert needle
Aspirate the plunger
Slowly inject medication
The body defenses against infection
Normal flora
Inflammation
Immune response
What is a nursing diagnosis
A clinical judgement about individual, family or community respinses to actual and potential problems or life processes
Know what NOT to do when recapping a needle
Never recap a used needle with your hands
The most common alteration in blood pressure
Hypertension
Signs and symptoms of heat stroke
Patient is Dizzy, confused and unable to talk
What to do for collecting a urie sample with someone with a catheter
Clamp the catheter tubing for 15-30 minutes
Patient with diarrhea will have ____ bowel sounds
Hyperactive
What info is collected following administration of morphine sulfate
Rate and depth of respirations
Sundowning
Behaviours become worse in the late afternoon and evening hours
Picks disease
Early symptoms result from frontal lobe involvement, so the disease manifests as social and emotional issues rather than memory impairment
The appropriate steps to take before administration of morphine sulfate
-Ausultate bowel sounds
-check for gastric residual
-prepare the feeding
-administer feeding
When performing a cardiovascular assessment what should be performed
1) Measuring blood pressure
2) Observing capillary refill
Bradycardia
Pulse is less than 60 beats/min
Norms for vitals
BP 120/80
P 60-100
O2 95-100%
Resp 12-20
T 36-38 C
Patient with hiatal hernia-comains of indigestion after eating. How long should they wait before they lie down after eating?
Not to lie down for at least 2 hrs after eating
Pt. Is interested in improving her diabetes management, what steps could she take
-Regular check ups monitor for S&S of complications
-Mild to moderate exercise
-3 times a week 20 minutes
-Check feet daily for any changes
-Healthy diet
The signs of diabetic acidosis
Sweet fruity smelling breath
Diagnosis of hypothermia is an example of a/an _________
Actual nursing diagnosis
Who would you use the clock method on?
Visually impaired client
The goals of ostomy care
-Promoting self-care of the ostomy -Maintaining a healthy stoma
-Limiting skin irritation around the stoma
Pt. Has an advanced directive, for no aggressive treatment, dr’s order for pain med every 3-4 hrs. How often do you give med to maintain maximum comfort?
Every 3 hrs
Types of wound drainage
(1) Serous; clear, watery plasma
(2) serosanguineous (containing blood; may also be present in a healthy, healing wound),
(3) sanguineous (primarily blood), or
(4) purulent (thick, white, and pus-like; may be indicative of infection and should be cultured)
Dementia caused by a series of small strokes
Vascular dementia
Data is collected during assessment to be used as _____
Baseline information to be used in evaluating pt’s progress
How does a nurse integrate her holistic assessment while providing care?
Notes bruising and skin tears on the client while providing AM care
Monitoring respirations, auscultating lung sounds, and observing nasal flaring, what are you assessing
Pt’s ventilations
Pt. 4 days post-op hip surgery, is restless and labored breathing noted all afternoon. She is irritable and you hear gurgling sounds. What is the best course of action to take.
A) check her gag reflex to see if she may have aspirated
B) perform oral suctioning to help clear the airway as per standing post-op orders
C) administrater O2 at 2L/min via face mask as per standing post-op orders
B) perform oral suctioning to help clear the airway as per standing post-op orders
What the expected outcome should be when developing a nursing care plan?
Person-centered care based on the client’s values, beliefs and cultural preferences, realistic and measurable, focused on the short term or long term needs of the client
How to administer ear drops in an adult.
Up and back
Preparing chemotherapy medication what should the nurse do first?
Wear disposable gloves
The process and preferred positioning of a needle when giving a subcutaneous injection
Bevel up, pinch skin, insert at 45 degrees and pierce skin quickly
Pt. Is requesting morphine 2hrs after receiving his last dose. Morphine is ordered q4hrs. He is mumbling and disoriented to time, what should you do.
A) Put up the side rails on his bed
B) Assess his vital and neuro signs
C) Inform him it is too early to give him his next dose.
A) Assess his vital signs and neuro status
The usual length of needle for an IM into the ventral gluteal muscle
1 1/2 inches
When do you sign the MAR?
After administering medications to the patient/resident
Who is responsible for performing natcotics counts?
One nurse from each shift
Why is it important to do narcotic counts, besodes protecting yourself?
To provide tracking of controlled substances
Bacteria
Simple unicellular organism
Handwashing or immunizations are an ecample of _____ (primary, secondary, tertiary) prevention
Primary
Which cues indicate an underlying respiratory disease
A)fluid intake for 8hrs is 800ml
B) the client has drainage from a surgical wound
C) client is restless
C) client is restless
How to locate the apical pulse?
Using a stethoscope place it to the pt’s left side of the sternum
Oxygen flow meter regulates the _______ of O2 delivered to pt.
Concentration
Why we collect a urine sample for C&S
Important so the Dr can order the correct meds
The stages of pressure ulcers
1) skin intact, blanchable
2) skin not intact
3) adipose fatty tissue may be noticeable
4) muscle and bone may be noticeable
Which type of pain arises from internal organ structures?
Visceral pain
What assessment data should include?
Subjective data from the client, use of interpersonal and cognitive skills, detailed physical examination
A focused or selective assessment is a/an ______
Modified assessment using knowledge of the client’s own history and chief complaint
Can failure to landmark cause muscle or adipose tissue damage, scarring of underlying tissue and nerve or bone damage
Yes
The abbreviations for the following:
A) intramuscular injection
B) sublingual
C) intravenous
D) subcutaneous
The med is delivered fastest by what route
IM
SL
IV
SC
IV delivered fastest
Pt’s is receiving Lasix 80mg po, BID, potassium levels are low at 2.7, what should the nurse do.
A) Hold med and administer KCL
B) Give the med, phone Dr. And ask to d/c order
C) Hold the med, call the Dr. Inform him of potassium levels and ask for order of KCL
C) Hold the med, call the Dr. Inform him of potassium levels and ask for an order of KCL (potassium chloride)
How can you help a pt. Improve O2 and ventilation. With what technique?
Have the patient seates with arms supported while leaning over a table
How is insulin measured?
In units
Mark the following with Y if still used or N if not used.
PO _____
OD _____
qd _____
q4-6hrs _____
q by itself _____
BID ______
TID _____
Yes
No
No
Yes
No
Yes
Yes
Know if the following is correct the way thry are written.
I.m. _____
Qid _____
And
SQ _____
IM
QID
SC
Rewrite the following med orders correctly
1) Humulin R insulin 10 mg SQ, q PM
2)Timolol 20 MG, BED
3)Tylenol #2, 1-2 tab, q4-6h, PRN, know what Tylenol #2 is used for
4)Hydromorphone 4, PO, OD know what hydromorphone is and what is missing from this order
5)Amoxicillin 500mg, i.m. Qid = Amoxicillin 500mg, IM, QID
1)Humulin R 10 units SC every PM
2)Timolol 20 mg, BID
3)Tylenol #2, 1-2 tabs, q4-6h, PRN for pain
4)Hydromorphone 4mg, PO daily (missing the measurements) (not OD, just write daily)
5)Amoxicillin 500mg, IM, QID
